Abdominal Wall Closure Using Artificial Mesh for Patients with an Open Abdomen.

Purpose: After damage control surgery, abdominal wall closure may be impossible due to increased intraabdominal pressure (IAP), and primary closure may induce abdominal compartment syndrome. The purpose of this study was to investigate changes in the IAP and the feasibility of abdominal wall closure using artificial mesh. Methods: From July 2010 to July 2011, 8 patients with intra-abdominal hypertension underwent abdominal wall closure using artificial mesh. Medical data such as demographics, diagnosis, operation, IAP, postoperative complications, mortality and length of hospital stays were collected and reviewed, retrospectively. One patient was excluded because of inadequate measurement of the IAP. Results: Seven patients, 4 males and 3 females, were enrolled, and the mean age was 54.1 years old. Causes of operations were six traumatic abdominal injuries and one intra-abdominal infection. The IAP was reduced from 21.9±6.6 mmHg before opening the abdomen to 15.1±7.1 mmHg after fascial closure. Fascial closure was done on 14.9±17.5 days after the first operation. The mean lengths of the hospital and the intensive care unit (ICU) stays were 49.6 days and 29.7 days respectively. Operations were performed 3.1±1.5 times in all patients. Two patients expired, and one was transferred in a moribund state. Three patients suffered from complications, such as retroperitoneal abscesses, enterocutaneous fistulas, and bleeding that was related to the negative pressure wound therapy. Conclusion: After abdominal wall closure using artificial mesh, intra-abdominal pressure was well controlled, and abdominal compartment syndrome does not occur. When the abdominal wall in patients who have intra-abdominal hypertension is closed, artificial mesh may be useful for maintaining a lower abdominal pressure. However, when negative pressure wound therapy is used, the possibility of serious complications must be kept in mind.ope

Management of Traumatic Pancreas Injury in Multiple Trauma: Single Center Experience

PURPOSE: Pancreatic injury is rare in abdominal trauma patients (3%~12%). but it could result in significant morbidity and even mortality. Early and adequate decision making are very important in the management of patients with traumatic pancreatic injury. The purpose of this study was to assess the kinds of management and outcome through the review of our experience of pancreatic injury with multiple trauma. METHODS: We reviewed 17 patients with traumatic pancreas injury via electronic medical records from Jan. 2002 and April. 2011. We collected demographic findings; the type, location and grade of pancreas injury, the treatment modality, and patient's outcomes, such as complications, length of hospital stay (LOS), and mortality. RESULTS: Total 17 patients were reviewed, and man was 13 (88%). Traffic accident was the most common cause of injury. Pancreas neck was the most common injured site, and occured in 5 patients. Ductal injury was detected in 7 cases. Eleven patients were treated by surgical procedure, and in this group, 3 patients underwent the endoscopic retrograde pancreas drainage procedure coincidently. ERPD was tried in 8 patients, and failed in 2 patients. The major complications were post-traumatic fluid collection and abscess which accounted for 70% of all patients. The hospital stay was 35.9 days, and it was longer in patient with ductal injury (38.0+/-18.56 vs. 34.5+/-33.68 days). Only one patient was died due to septic shock associated with an uncontrolled retroperitoneal abscess. CONCLUSION: Early diagnosis is the most important factor to apply the adequate treatment option and to manage the traumatic pancreas injury. Aggressive treatment should be considered in patients with a post-operative abscessope

Development of a New Nutrition Screening Tool for Use in an Acute Care Hospital

Purpose: The objective of this study was to develop a new nutrition screening tool for quality improvement of the nutritional care process in an acute care hospital with a 2,000-bed capacity. Methods: To evaluate the current nutrition screening tool, we first examined 435 patients (274 men, aged 59.0±12.2 years). In the second step, the nutritional status of 387 patients (215 men, aged 57.5±13.3 years) was assessed by the scored patient-generated subjective global assessment (PG-SGA) tool. Variables such as age, body mass index (BMI), plasma albumin concentration, weight change, food intake change, and disease severity were analyzed to select indices for developing a new Severance nutrition screening index (SNSI). Results: The current nutrition screening tool had a poor correlation with the PG-SGA (κ=0.180, P＜0.0001). The SNSI was calculated as follows: SNSI = 1.5×albumin＋ 1.0×BMI＋4.5×intake change＋1.5×weight loss (for albumin＜ 3.0, BMI＜20, and decreased intake and weight loss＞5% of usual body weight). The SNSI showed a sensitivity of 90.5%, a specificity of 90.7%, and a high correlation (κ=0.628, P＜0.0001) with the PG-SGA. Conclusion: The SNSI appears to be a valid and useful nutrition screening tool to determine the nutritional risk of patients in acute care hospitals.ope

Management of Complicated Intra-abdominal Infection - Two Cases

Compared to uncomplicated intra-abdominal infection (IAI), complicated IAI extend beyond the source organ and into the peritoneal cavity through the perforated bowel. Most of intra-abdominal infection encountered in the surgical field is secondary or tertiary peritonitis. In this article authors report management experiences of unusual two cases about complicated IAI; the first case is abdominal wall abscess accompanied by perforation of ascending colon perforation from traumatic mesentery injury, and the second case is about liver abscess followed by pleural empyema. In the first case, abdominal wall abscess was drained by ultrasonography-guided incision and drainage, and negative pressure wound therapy (NPWT) was applied on the soft tissue defect site. In the second case, right pleural empyema was formed after percutaneous liver abscess drainage, and thoracoscopy-assisted pleural decortications and drainage of pleural effusion were performed. For the treatment of complicated IAI, source control is the most important and proper empirical antibiotic and susceptible therapeutic antibiotics are also neededope

Management of Traumatic Pancreas Injury in Korea:Literature Review

Purpose: Traumatic pancreas injuries are rare conditions that result in high morbidity and mortality. Thus, early diagnosis and intervention are very important to manage pancreatic injuries. The purpose of this study is to review the management and outcomes of the pancreatic injuries in the Korean population. Methods: Original articles published from January 2001 to December 2012 and addressing the Korean population were selected by using indices such as ‘pancreas injury’, ‘traumatic pancreas injury’, and ‘pancreatic trauma’ to search KoreaMed and PubMed. Nine reports were selected to review the management options for surgery or endoscopic retrograde cholangio-pancreatography. We assessed the injury mechanisms, injury severities, associated injuries, types of operation, and outcomes. Results: Two hundred fifty of the 332 patients included in the 9 selected reports were men, and the mean age of all patients was 36.4 years. The main injury mechanism was traffic accidents(65.6%). Most patients had grade II or III injuries(68.9%). The most common extra-pancreatic injury site was the liver, followed by the chest and spleen. Operative management, including distal pancreatectomies(129), drainage procedures(64), pancreaticoduodenectomies( 23), and others(60), was used for 276 patients. The reported mortality rate was 10.2%, and the morbidity rate ranged from 38% to 76.9%. The average length of hospital stay was 39.5 days. Risk factors for mortality were amount of transfusion, injury severity, base deficit, age, and presence of shock. Conclusion: In this study, we found neither significant data nor a consensus. If national guidelines are to be developed and established, a national data bank or registry, and nationwide data collection are required.ope

Experiences of Wet Beriberi and Wernicke’s Encephalopathy Caused by Thiamine Deficiency in Critically Ill Patients

Wet beriberi and Wernicke's encephalopathy (WE) are caused by thiamine deficiency and are potentially lethal and serious diseases. Thiamine deficiency occurs mainly due to poor oral intake or inadequate provision of thiamine in enteral or parenteral nutrition therapy. We report cases of wet beriberi and WE that developed after surgery in a surgical intensive care unit. The first patient, who was diagnosed with wet beriberi, underwent right total mastectomy and radical subtotal gastrectomy, simultaneously. The second was diagnosed with irreversible WE, respectively, due to long-term malnutrition. In both cases, intravenous replacement of thiamine was initiated after the admission to the surgical intensive care unit. However, comatose mentality of the second patient did not improve. As a result, we conclude that, if a patient's clinical feature is suspected to be thiamine deficiency, prompt intravenous thiamine replacement is needed.ope

Anterior Rectus Sheath Turnover Method for Abdominal Wall Reconstruction and Enterostomy Formation in Patient with Intra-abdominal Infection due to Anastomotic Leakage

Intra-abdominal infection due to perforation of upper gastrointestinal tract is sometimes a challenge to manage, especially a high output fistula or a perforation site that is difficult to approach. The authors present a case of anterior rectus sheath turnover method for abdominal wall repair in a patient with uncontrolled intra-abdominal infection and severe bowel ad-hesion to abdominal wall associated with prolonged application of negative pressure wound therapy.ope

Management of Open Abdominal Wound with Negative Pressure Wound Therapy

Negative Pressure Wound Therapy (NPWT) is very effective to not only simple wound but also such a complicated wound that can be observed in trauma patients. Herein, we introduce two experiences that the NPWT is used in surgical patient’s wound management effectively. One is a postoperative patient with abdominal wall defect and the other is a trauma patient with hip joint amputation and adjacent abdominal defect.ope

Definition and Pathophysiologic Mechanisms of the Sepsis

Sepsis is the overwhelming disease resulting serious outcome, and has the high morbidity and mortality rate. In surgical patient, many of them have septic condition, and consist of 8% of critically ill surgical patients. And postoperative sepsis is common complications result in 24∼44% of mortality. Understanding of definitions and pathophysiologic mechanisms of the sepsis is the mainstay to treat and manage the septic patient. In this section, we describe the definitions and pathophysiologic mechanisms of the sepsis, brieflyope

Prognostic Factors in Patients Who Performed Angiographic Embolization for the Bleeding from Injury of the Intraabdominal Organ and Pelvic Area.

PURPOSE: In patients with traumatic hemoperitoneum or pelvic bone fracture who underwent angiography and embolization, we want to find the prognostic factors related with mortality. METHODS: Patients(333 patients) who visited our hospital with traumatic injury from March 2008 to April 2012 were included in this study. Only 37 patients with traumatic hemoperitoneum or pelvic bone fracture underwent angiography and embolization. A retrospective review was conducted, and Glasgow coma scale (GCS), Revised trauma score (RTS), Injury severity score (ISS), initial laboratory finding and time interval, the amount of transfusion from the arrival at the ER to the start of embolization, and the vital signs before and after procedure were checked. Stastical analysis was conducted using the Chi square and Mann-Whitney U test. RESULTS: In univariate analysis, the amount of transfusion, the base deficit before procedure, the systolic blood pressure before and after the procedure, the GCS, the RTS and the ISS were significantly associated with prognosis. In the multivariate analysis, the ISS and the base deficit had significant association with prognosis. Of the 37 patients who underwent angiography and embolization, 31 patients needed not additional procedure (Group A) while the other 6 patients needed an additional procedure (Group B). After procedure, a statistically significant higher blood pressure was observed in Group A than in Group B. As to the difference in blood pressure before and after the procedure, a statistically significant decrease in systolic blood pressure was observed in Group B, but an increase was observed in Group A. CONCLUSION: In traumatic hemoperitoneum or pelvic bone fracture patients who underwent angiography and embolization, GCS, ISS, RTS, transfusion amount before the procedure, initial base deficit and systolic blood pressure were factors related to mortality. When patients who underwent angiography and embolization only were compared with patients who underwent re-embolization or additional procedure after the first embolization, an increase in systolic blood pressure after embolization was a prognostic factor for successful control of bleeding.ope