Nathaniel Stoikes

Mediastinal pancreatic pseudocyst with acute airway obstruction.

Pancreatic pseudocysts are usually located in the peripancreatic area, but on rare occasion a pseudocyst can reach the mediastinum. The natural history of mediastinal pseudocysts is poorly understood and seldom reported in the literature. We treated a patient who presented with an acute airway obstruction from a mediastinal pancreatic pseudocyst. Initial acute airway management and stabilization proved successful. A staged cyst decompression via a cervical and abdominal transhiatal approach was ultimately required. The natural history, potential complications, and management of pancreatic mediastinal pseudocysts are reviewed.

Impact of Intracranial Pressure Monitor Prophylaxis on Central Nervous System Infections and Bacterial Multi-Drug Resistance

BACKGROUND Routine intracranial pressure monitor (ICP) prophylaxis is not practiced at our institution. Nevertheless, some patients receive de facto prophylaxis as a result of the use of antibiotics for injuries such as open or facial fractures. We tested the hypothesis that prophylactic antibiotics do not reduce the incidence of central nervous system (CNS) infections but instead are associated with the acquisition of multi-drug resistant (MDR) bacterial infections. METHODS Patients admitted to the trauma intensive care unit (TICU) from January, 2001 through December, 2004 with blunt, non-operative traumatic brain injury who were managed solely with an ICP monitor were identified from our trauma registry and divided into two groups: (1) Those receiving no antibiotics prior to or during ICP monitoring (NONE; n = 71); and (2) those already receiving antibiotics at the time of ICP monitor insertion (PRO; n = 84). Groups were stratified on the basis of age, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) Score, base excess (BE), ICP days, transfusions in 24 h, ICU days, ventilator days, head Abbreviated Injury Score (AIS), and chest AIS. The study groups did not differ with respect to age, ISS, GCS, BE, ICP days, 24-h transfusions, ICU days, ventilator days, head AIS, or length of stay. In all, 183 patients were identified, of whom 28 died within seven days and were excluded from the analysis. All patients were followed until discharge for both CNS infections and subsequent infectious complications. RESULTS Only two patients, both in the PRO group, developed CNS infection. Both infectious complications (0.7 vs 1.4 per patient; p < 0.05) and infections secondary to MDR pathogens (0.03 vs. 0.33 per patient; p < 0.01) were significantly more common in the PRO group. Twenty-nine percent of the ventilator-associated pneumonias and 33% of the blood stream infections in the PRO group were MDR, whereas only two blood stream infections in the NONE group (4% of the total infections) were MDR. CONCLUSIONS The routine use of prophylactic antibiotics for ICP monitor insertion is not warranted. This practice does not reduce the CNS infection rate and is associated with more MDR pathogens in any subsequent infectious complications.

Fixation in Laparoscopic Inguinal Hernia Repair

There is a broad spectrum of fixation options for laparoscopic inguinal hernia repair. Categories of fixation include no fixation, adhesive fixation, and penetrating mechanical fixation. Given the confinements of the preperitoneal space, all forms of fixation are adequate with the exception of no fixation, which should be used in select scenarios where the patient has a small indirect defect. Understanding the biomechanics of each fixation type, however, enhances the surgeon’s ability to select appropriate fixation based on a patient’s hernia characteristics.

Chronic Groin Pain: Mesh or No Mesh

There are many factors that influence the incidence of chronic groin pain (CGP) after inguinal hernia repair. There is a perception that the use of synthetic mesh is one of the main factors creating CGP after surgery. Strong and opposite opinions exist supporting and condemning the use of mesh. The focus of this chapter is to objectively review the literature regarding mesh use for inguinal hernia repair and to understand the spectrum of existing opinions. To fully understand the scope of the topic, one must understand mesh and the foreign body response, the clinical data, and technique differences as they relate to mesh location, type, and fixation.

Onlay Ventral Hernia Repair

Recent data from the American Hernia Society Quality Collaborative (AHSQC) has shown comparable outcomes of onlay ventral hernia to other sublay techniques. Onlay ventral hernia repair was originally described by Chevrel in the 1970s. The focus of his original repair was recreation of the linea alba, and the use of a premuscular prosthesis to buttress the primary closure. Key features of onlay ventral hernia repair include creation of subcutaneous flaps, selective use of myofascial advancement flaps, mesh fixation with fibrin glue, and adequate drainage of the subcutaneous space postoperatively. Just as Chevrel indicated, the most important feature is recreation of a tension-free midline. In his large series of patients, he transitioned to the added use of fibrin glue fixation of the mesh over the midline closure coupled with suture fixation. The evidence for fibrin glue as a fixation method for mesh has been established in inguinal hernia literature and more recently has translated to onlay ventral hernia repair. Advantages include complete and immediate fixation of mesh, thereby theoretically taking tension off the midline closure. Clinically there may be advantages regarding less acute and chronic postoperative pain.