Need For Repeat Laparotomy Research Articles

Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection.

Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.

Characteristics of Combat-Associated Small Bowel Injuries.

Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries. The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications. One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively). We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.

Repeat laparotomy in a developing world tertiary level surgical service

BackgroundRepeat laparotomy is associated with significant morbidity and mortality; however, developing world data are scarce. This study reviews the spectrum and outcomes of relaparotomy in a developing world setting. MethodsProspectively collected data from adult patients needing repeat laparotomy over an 18-month period were analyzed. ResultsRelaparotomy rate was 24% and average age was 38 years with a male predominance (70%). Appendicitis and trauma were the most common diagnoses. Planned relaparotomy rate was high (41%); however, negative relaparotomy rate was only 9%. Need for intensive care unit admission (51%) and morbidity rate (64%) were both high, but overall mortality rate was 14%. Patients requiring multiple relaparotomies had further worsened outcomes. ConclusionsThe need for repeat laparotomy in the developing world is high and it is associated with significant morbidity and need for intensive care unit admission. However, mortality rates and negative repeat laparotomy rates were low.

Weekend hospitalisations and post‐operative complications following urgent surgery for ulcerative colitis and Crohn's disease

There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease [IBD; Crohn's disease (CD), ulcerative colitis (UC)] with frequent requirement for urgent surgery. To determine whether a weekend effect exists for IBD care in the United States. We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalisation database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalisation were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders. Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalisations in UC [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01-2.90]. The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, P = 0.04). The most striking difference between weekend and weekday hospitalisations was noted for needing repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions. Patients with UC hospitalised on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy and post-operative infections.

Repeat Laparotomy After Abdominal Hysterectomy

Objective: The purpose of this study was assessment of the incidence, indications, management, and outcome of repeat laparotomy after total abdominal hysterectomy in the early postoperative period. Design: This was a retrospective observational study. Materials and Methods: The study sample was a cohort of 4386 women who underwent total abdominal hysterectomy in a tertiary care university hospital during an 84-month period. Repeat laparotomy after abdominal hysterectomy in the early postoperative period was reviewed with regard to clinical, operative findings. Results: The incidence of repeat laparotomy after total abdominal hysterectomy was 0.52% (23/4386). Of these 23 women, 14 (60.9%) were operated on for hemorrhage, 3 (13%) for urinary complications, and 6 (26.1%) for intra-abdominal infections and eventration. One patient (4.3%) died. Conclusions: Repeat laparotomy after total abdominal hysterectomy in the early postoperative period is infrequent. Every precaution during hysterectomy must be taken to reduce the need for repeat laparotomy. Less-invasive hysterectomy alternatives should be an optional first line of treatment. (J GYNECOL SURG 28:197)

Drainage of Post-Operative Abdominal and Pelvic Abscesses Under the Guidance of Computed Tomography

BACKGROUND: Cross sectional imaging and specifically computed tomography (CT) has become the main radiological modality of detecting post-surgical abdominal collections and abscesses. Percutaneous abscess drainage (PAD) has revolutionized the treatment of abscesses, especially of post-surgical abdominal abscesses over the last 25 years; repeat laparotomy is a rare event due to the fact that the success rate of PAD is very high (90-95%) and complications are few (0-10%). OBJECTIVE: The aim of the study is to present our experience in the department of computed tomography of the percutaneous drainage of post-operative abdominal and pelvic abscesses. PATIENTS AND METHODS: During the last two and a half years, 93 post-operative patients were referred to the CT department for drainage of a post-surgical abscess in the abdomen or pelvis at 9-21 days post-operatively due to persistent fever. A total of 95 abscesses were drained; 84 were located in the abdomen and 11 in the pelvis. Abscess diameters ranged between 2 and 12 cm. A percutaneous drainage technique under CT-guidance was employed in all patients; 98 catheters were placed with use of the Seldinger technique. A transgluteal paracoccygeal approach was adopted in 11 patients. Aspiration of an intra-loop abscess was performed in 1 patient. The tilted gantry technique was utilized in 2 cases. RESULTS: Eighty-nine (95.7%) patients were successfully treated. In 4 (4.3%) patients the abscesses were partially drained, patients were stabilized and subsequently treated via laparotomy. Complications included inflammation of the skin at the entry site in 4 patients, pneumothorax in 1 patient, and displacement of the catheter in 12 patients, one involving catheter migration into the duodenum. Major complications did not occur. CONCLUSION: Percutaneous drainage of post-operative abdominal and pelvic abscesses was a safe and effective method of abscess management in our series with a 95.7% success rate and absent major complications. It is currently a widely used procedure, eliminating the need for repeat laparotomy in the majority of patients. Proper catheter management is essential for the successful outcome.

Surgical management and outcome of civilian gunshot injuries to the pancreas

Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds. This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed. A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I-II (111 patients) and grade III-V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19.6 per cent) required an initial damage control procedure. A total of 150 patients (68.5 per cent) had 407 postoperative complications (median 4, range 1-7). The 46 patients (21.0 per cent) who died had a median of 3 (range 1-7) complications. Median (range) intensive care unit and total hospital stay were 5 (1-153) and 11 (1-255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality. Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death.

Novel use of an air‐filled breast prosthesis to allow radiotherapy to recurrent colonic cancer

The authors present the novel and successful use of an air-filled breast prosthesis for extra pelvic exclusion of small bowel to facilitate adjuvant radiotherapy following resection of recurrent adenocarcinoma of the ascending bowel. The therapeutic use of radiotherapy in colon cancer can cause acute or chronic radiation enteropathy. Mobile small bowel can be sequestered in 'dead space' or by adhesions exposing it to adjuvant radiotherapy. A variety of pelvic partitioning methods have been described to exclude bowel from radiation fields using both native and prosthetic materials. In this case a 68 year old presented with ascending colon adenocarcinoma invading the peritoneum and underwent en bloc peritoneal resection. Thirty-seven months later surveillance CT identified a local recurrence. Subsequent resection resulted in a large iliacus muscle defect which would sequester small bowel loops thus exposing the patient to radiation enteropathy. The lateral position of the defect precluded the use of traditional pelvic partitioning methods which would be unlikely to remain in place long enough to allow radiotherapy. A lightweight air-filled breast prosthesis (Allergan 133 FV 750 cms) secured in place with an omentoplasty was used to fill the defect. Following well tolerated radiotherapy the prosthesis was deflated under ultrasound guidance and removed via a 7-cm transverse incision above the right iliac crest. The patient is disease free 18 months later with no evidence of treatment related morbidity. The use of a malleable air-filled prosthesis for pelvic partitioning allows specific tailoring of the prosthesis size and shape for individual patient defects. It is also lightweight enough to be secured in place using an omentoplasty to prevent movement related prosthesis migration. In the absence of adequate omentum a mesh sling may be considered to allow fixation. In this case the anatomy of the prosthesis position allowed for its removal without the need for repeat laparotomy. Pre-operative deflation of the air-filled prosthesis under ultrasound guidance also reduces the size of the incision required for removal. This technique may be valuable to prevent collateral small bowel irradiation following resection of renal or retroperitoneal malignancy.

Micropouch gastric bypass: indications for gastrostomy tube placement in the bypassed stomach.

Since 1994 we have performed the "micropouch" gastric bypass (MGB) procedure for morbid obesity. In our MGB operation, the transected gastric reservoir is limited to the cardia of the stomach. The Roux and biliopancreatic limbs measure 200 and 150 cm, respectively; radiographic or endoscopic access to the bypassed stomach is therefore excluded. A retrospective analysis of 1,120 MGB operations revealed that 33 patients (2.9%) developed a potentially life-threatening postoperative complication requiring emergency re-operation or prolonged hospitalization. Complications included anastomotic leaks, fascial dehiscence, gastro-enteric obstructions, peptic ulcers, and pancreatitis. Each complication was analyzed to determine if gastrostomy tube (G-tube) placement at the time of gastric bypass could have affected complication outcome or obviated the need for repeat laparotomy. In 19 patients (1.6% of total cohort), G-tube placement would have significantly affected complication outcome. In four instances, it would have prevented emergency re-operation. Routine gastrostomy tube placement at the time of gastric bypass is not necessary in all patients. For patients who are at high risk for a gastro-enteric obstruction or an anastomotic leak, G-tube placement is recommended and is often therapeutic.

EXTRAPERITONEAL ACCESS FOR KIDNEY TRANSPLANTATION IN CHILDREN WEIGHING 20 KG. OR LESS

We present our experience with kidney transplantation in children weighing 20 kg. or less. Surgery was done via extraperitoneal access while preserving the peritoneal cavity intact with special attention given to technical feasibility and the complication rate. Included in our study were 46 children with a median age of 7 years weighing 20 kg. or less (mean 16.6), of whom 16 weighed less than 15 kg. (median 13.2). The 25 boys and 21 girls underwent a total of 49 kidney transplants, including 2 in 3 during the study. Donors were living related in 44 cases and cadaveric in 5. Surgical access was obtained by making a J-shaped pararectal incision in a curvilinear fashion from the symphysis pubis to near the costal border. Mean hospital stay was 22.9 days (range 6 to 83) and mean followup was 55.8 months (range 12 to 131). All patients received water on day 1 and food on day 2 postoperatively. In 6 patients 7 surgical complications developed, including urinary fistula in 2, superficial wound infection in 2 and vascular complications in 3 (renal vein thrombosis, stenosis and renal artery kinking in 1 each). Only 1 graft was lost due to a surgical complication. There are many advantages to using extraperitoneal access without an increase in surgical complications or technical difficulty. Absent gastrointestinal complications, an easier way to perform percutaneous biopsy, treatment of any surgical complication with no need for repeat laparotomy and the possibility of using the peritoneal cavity when dialysis is needed postoperatively are attractive justifications for extraperitoneal access.

Surgical complications after pancreas transplantation with portal-enteric drainage

Background: Despite recent advances, surgical complications remain an important source of morbidity after pancreas transplantation (PTX). Several previous studies have delineated the surgical complications after PTX with systemic-bladder (S-B) drainage, but data are limited regarding the incidence and outcomes of surgical complications after PTX with portal-enteric (P-E) drainage. Study Design: We retrospectively studied surgical complications after 83 vascularized PTXs with P-E drainage in 79 patients (65 simultaneous kidney-PTXs [SKPT] and 18 solitary PTXs [SPT], 8 pancreas alone and 10 pancreas after kidney transplantation). Twelve (15%) were retransplants. A surgical complication was defined as the need for repeat laparotomy within the first 3 months after PTX. Results: A total of 53 surgical complications requiring repeat laparotomy occurred in 31 patients (37%). The incidence of surgical complications in SKPT and SPT was 38% and 33%, respectively. The most common indications for repeat laparotomy were: vascular thrombosis in 13% (SKPT 14% and SPT 11%), intraabdominal infection in 10% (SKPT 12% and SPT 0%), intraabdominal bleeding in 8% (SKPT 8% and SPT 11%), and duodenal allograft leak in 4% (SKPT 3% and SPT 6%). Patient survival rates at 1 and 3 years with versus without surgical complications were 84% and 80% versus 94% and 86%, respectively (p = NS). Pancreas graft survival rates at 1 and 3 years with versus without surgical complications were 48% and 44% versus 89% and 76%, respectively (p < 0.0001). The incidence of surgical complications was 45% in the first 42 P-E transplantations performed between 1990 and 1995, compared with 29% in the next 41 transplantations performed during 1996 and 1997 (p = NS). The mean number of repeat laparotomies per patient decreased from 1.2 in the former group to 0.5 in the latter group (p = NS). The incidence rates of vascular thrombosis, intraabdominal infection, and duodenal leak in the former and latter groups were 17% versus 10%, 12% versus 7%, and 2% versus 5%, respectively. Conclusions: Surgical complications after PTX are common, and their incidence and outcomes with P-E drainage are similar to those with S-B drainage. The complication rate does not vary according to the type of transplant (SKPT versus SPT). Increasing experience with P-E drainage results in a decreased incidence of surgical complications.

Diagnostic Ultrasound in the Evaluation of Patients with Gynecologic Cancer

In the early 1960's, obstetricians realized the usefulness of diagnostic ultrasonography and were largely responsible for much of the early development and advancement of the ultrasonic technique. Recently gray scale ultrasonography has resulted in the ability to conclusively differentiate solid from cystic masses. Research is currently underway regarding tissue identification based on ultrasonic patterns. The combined use of ultrasonic instrumentation and computers may some day enable the ultrasonographer to identify specific tissues within the body. Fine needle aspiration biopsy in combination with cross-sectional ultrasonic scanning in some cases circumvents the need for repeat laparotomy to obtain tissue for histologic diagnosis.