Primary Suture Closure Research Articles

Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections—report of 3 cases

Background Various allografts, xenografts, and synthetic materials are used in neurosurgery to repair dural defects when primary suture closure is impossible and autologous grafts are inadequate or inaccessible. When used in contaminated or infected wounds, however, nonautologous grafts promote chronic colonization and recurring infection. Recently, several resorbable dural substitutes that are broken down biologically and replaced by autologous tissues have been introduced. These include type 1 collagen matrix (DuraGen, Integra LifeSciences, Plainsboro, NJ) and a collagen implant derived from bovine skin (Durepair, Medtronic, Inc, Minneapolis, Minn), which can be applied as sutured or sutureless onlay grafts. The safety and efficacy of this material has not been reported in the setting of wound contamination or infection. Case Descriptions We present 3 cases in which these new collagen dural substitutes were successfully used to close dural defects in the presence of wound contamination and infection. In one case, a lumbar dural defect was closed with DuraGen in the presence of a subdural empyema. In the second case, maceration of the cranial dura mater from extensive compound depressed skull fractures was repaired with DuraGen in the presence of a subgaleal abscess. In the third case, a large dural defect in the setting of frontal osteomyelitis was successfully closed with sutured Durepair. In all cases appropriate antibiotic coverage was provided for the infection, and the tissues healed with excellent biologic incorporation and without evidence of further infection. Conclusions Resorbable collagen dural grafts appear to be effective alternatives to either primary dural closure or the use of autologous-harvested tissue grafts in the setting of grossly contaminated or infected wounds.

Use of a Prosthetic Patch for Laparoscopic Repair of Morgagni Diaphragmatic Hernia in Children

Morgagni hernias are well suited to laparoscopic repair. A primary suture closure may result in tension on the repair, thereby predisposing the patient to a recurrence. A prosthetic patch (PP) can be used to provide a tension-free repair. In this study, we reviewed our experience with the laparoscopic PP repair of Morgagni hernias in children. A retrospective chart review of all patients undergoing a laparoscopic Morgagni hernia repair using a PP was undertaken between November 2002 and January 2006. Outcome measures included age, gender, defect size, use of mesh, and outcome. The time of follow-up was from 6 to 37 months. Seven (7) patients (6 male, 1 female) underwent a laparoscopic repair of Morgagni hernia during this time period. Six (6) patients had a congenital hernia, and 1 patient was thought to have an iatrogenic hernia following a sternotomy for heart surgery. Defect size ranged from 4 to 7 cm in maximum dimension. All operations were completed laparoscopically, no patients presented with recurrence, and no PP complications were encountered. The laparoscopic repair of Morgagni hernia using a PP can be performed with relative ease and with a positive outcome, and may prevent future recurrence by effecting a tension-free repair.

Aortico???Left Ventricular Tunnel, an Unusual Congenital Cardiac Anomaly in Adult: Application of a New Operative Technique

Aortico-left ventricular tunnel is a rare congenital cardiac anomaly. A 45-year-old man was referred to our clinic with unstable angina pectoris. The patient had an aortico-left ventricular tunnel that had been operated on 15 years before and that now showed a recurrence. We performed a new surgical technique, including closure of orifices of the tunnel by resection of the aorta at the left coronary ostium, reconstruction of the aorta with patch plasty, and formation of a neo-left main branch by applying a saphenous magna vein patch at the noncoronary cusp. In this technique, the possibility of aortic regurgitation caused by stretching and distortion of the aortic ring and leaflets by primary suture closure of tunnel is eliminated. The postoperative 2-D colored Doppler echocardiography and cardiac MRI showed an excellent result of the procedure. Coronary flow could be restored, and thus anginal symptoms disappeared.

Rives-Stoppa retromuscular repair for incisional hernias

Background: Incisional hernias are a prevalent problem in abdominal surgery and occur in 11% of patients who undergo laparotomy. Primary suture closure of an incisional hernia results in a 31- 58% recurrence and the addition of a prosthetic mesh implant decreases recurrence rates to 8%-10%. Popularized in Europe by Rives and Stoppa, the sublay technique has proven to be very effective with low recurrence rates (0-23%) and minimal complications. The purpose of the study was to evaluate the experience of a single surgeon at a large tertiary care center performing a modified Rives-Stoppa repair for abdominal incisional hernias. Materials & Methods: The records of all patients undergoing a modified Rives-Stoppa incisional hernia repair between January 2000 and August 2003 were retrospectively reviewed. Outpatient clinic notes, discharge summaries, operative reports, and laboratory data were reviewed for patient demographics, surgical data and postoperative complications. All data was collected with previous written consent of the patient and approval by the hospital institutional review board. Statistical analysis was conducted using SPSS for Windows. Results: During the study period, 83 patients underwent a modified Rives-Stoppa incisional hernia repair. Nineteen patients were excluded due to incomplete medical records. The majority of incisional hernias were midline and supraumbilical, with several (n=3) flank hernias. Forty-five percent (n=29) of the incisional hernias were recurrent (mean 2, range 1-7, S.D.± 1.6). No patient required postoperative exploration for an intra-abdominal catastrophe. Follow-up information was available for 61 patients, with mean follow-up of 20 weeks (range 1-144 weeks, S.D.± 30.1) and mean number of follow-up visits of three (range 1-13, S.D. ± 2.9). Twenty-five percent (n=16) of patients had a complication as a result of the hernia repair. Six patients (9.4%) had superficial wound or deep mesh infections. None required removal of the prosthetic mesh and were successfully managed with antibiotics and/or drainage. One patient suffered a reaction to staples, four (6.3%) developed seromas, and three developed (4.7%) hematomas. Four patients (6.3%) were noted to have early postoperative small bowel obstructions and all of these were successfully managed conservatively. Only two patients (3.1%) developed recurrent incisional hernias. Conclusions: The results presented here confirm that the modified Rives-Stoppa retromuscular repair is an effective method for the repair of incisional hernias. The complication and recurrence rates compare favorably to published results for alternative techniques.

Surgical management of intrathoracic oesophageal rupture.

Intrathoracic oesophageal rupture is a life-threatening condition that requires early diagnosis and effective treatment if death or serious prolonged illness is to be avoided. Six consecutive patients with intrathoracic oesophageal rupture were treated by debridement and irrigation of the mediastinum and primary suture closure with reinforcement of the suture line by pedicled omentum. The cause of the rupture was Boerhaave's syndrome in five patients and compressed air injury to the oesophagus in one. All but one patient presented more than 24 h after onset of symptoms, with a mean of 38 (range 12-72) h. All the patients recovered well with no postoperative oesophageal leakage. The mean hospital stay was 11.5 (range 9-15) days. Irrespective of the duration of the oesophageal rupture, aggressive resuscitation and prompt primary suture closure with reinforcement of the suture line with a well vascularized pedicled tissue flap is required for optimal results.

Onlay Hiatal Reinforcement Utilizing Human Acellular Dermal Matrix: Three Case Series

Redo laparoscopic fundoplication and laparoscopic repair of large (>5cm) paraesophageal hernias have a high rate of recurrence after primary suture repair of the hiatal defect. As such, the use of mesh prosthesis as an interposition graft or onlay reinforcement is becoming more popular for the repair of larger, more complicated crural defects. We report three cases in which human acellular dermal matrix was used as an onlay reinforcement of the hiatus after primary suture closure. Two patients had large paraesophageal hernias (one type III and one type IV). The third patient became symptomatic after her second laparoscopic antireflux procedure and was found to have recurrent herniation of the fundus into the mediastinum. All three patients underwent successful laparoscopic repair. There were no intraoperative or postoperative complications. All three patients remain symptom free with follow-up ranging from 8 months to 10 months. Acellular dermal matrix appears to be a promising prosthetic for onlay reinforcement of the hiatus during redo laparoscopic fundoplication and repair of large paraesophageal hernias.

Defektverschluss mit Sklerainterponaten

Excessively draining fistulas may lead to enucleation when primary suture closure is not effective. In these cases preserved cadaver tissues such as sclera, fascia lata, dura mater and peritoneum have been used for patch graft repair with variable results. In this study, the clinical outcomes after transplantation of scleral patch grafts have been investigated. Twenty-eight eyes of twenty-seven patients underwent surgery with homologous scleral patch grafts for repair of excessively draining scleral fistulas after cataract surgery (n = 2), leaking filtering blebs following full-thickness filtration surgery (n = 7), large scleral perforations due to trauma (n = 7), corneo-scleral ulcerations due to severe eye burns (n = 9) or after radiotherapy of malignant melanoma (n = 3). The mean size of the rectangular grafts was 8.6 x 6.7 mm (+/- 2.8/3.1 mm). Clinical follow-up was up to 73 months (median 30 months). Twenty-three of 28 eyes (82.1 %) showed functional closure after initial surgery without any wound complication such as patch retraction or leakage and without evidence of inflammation. In five eyes surgical revision was necessary. Two of these eyes had to be enucleated due to uncontrollable dehiscence after the second operation. Two eyes were enucleated at the patient's demand due to pain. The fifth eye showed effective closure after the second operation. In our study scleral patch grafts were useful in adequately closing large corneo-scleral defects in 24 of 28 eyes (85.7 %). The antigen load and, therefore, the rejection of the scleral grafts is minimized due to the denaturation of proteins during the alcohol treatment before storage.

Laparoscopic Repair of Large Incisional Hernias

Incisional hernias after abdominal operations are a significant cause of long-term morbidity and have been reported to occur in 3 to 20 per cent of laparotomy incisions. Traditional primary suture closure repair is plagued with up to a 50 per cent recurrence rate. With the introduction of prosthetic mesh repair recurrence decreased, but complications with mesh placement emerged ushering in the development of laparoscopic incisional herniorrhaphy. The records of patients who underwent laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001 were reviewed. Patient demographics, hernia defect size, recurrence, operative time, and procedure-related complications were evaluated. Fifty patients (22 male and 28 female, mean age 57 years with range of 24-83) were scheduled for laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001. The average patient was obese with a mean body mass index of 35.8 kg/m2 (range 16-57 kg/m2). Two patients (4%) had primary ventral hernias. Forty-eight patients (96%) had incisional hernias with 22 (46%) of these previously repaired with prosthetic mesh. Mean defect size was 206.1 cm2 (range 48-594 cm2). The average mesh size was 510.2 cm2 (range 224-1050 cm2). Gore-Tex DualMesh and Bard Composite Mesh were used in 84 and 16 per cent of the repairs, respectively. Mean operating time was 97 minutes. There were no deaths. Complications were seen in 12 per cent patients (six occurrences) and included two small bowel enterotomies, a symptomatic seroma requiring aspirate, a mesh reaction requiring a short course of intravenous antibiotics, and trocar site pain (two patients). There were no recurrences during a mean follow-up of 41 months (range 3-74 months). We conclude that laparoscopic incisional herniorrhaphy offers a safe and effective repair for large primary and recurrent ventral hernia with low morbidity.

Spigelian hernias: repair and outcome for 81 patients.

Spigelian hernia is a rare partial abdominal wall defect. The frequent lack of physical findings along with vague associated abdominal complaints makes the diagnosis elusive. A retrospective review of Mayo Clinic patients was performed to find all patients who had undergone surgical repair of a Spigelian hernia from 1976 to 1997. Patients were scrutinized for presentation, work-up, therapy, and outcome. The goal of this study was to obtain long-term outcome. The study was set in a tertiary referral center. There were 76 patients in whom 81 Spigelian hernias were repaired. Symptoms most commonly included an intermittent mass (n = 29), pain (n = 20), pain with a mass (n = 22), and bowel obstruction (n = 5). Five patients were asymptomatic. Preoperative imaging was performed in 21 patients and correctly diagnosed the hernia in 15. Spigelian hernias were repaired by primary suture closure (n = 75), mesh (n = 5), and laparoscopic (n = 1) techniques. Eight patients (10%) required emergent operations. Thirteen hernias (17%) were found to be incarcerated at the time of the operation. Overall mean follow-up for the 76 patients was 8 years, with three hernia recurrences identified. Spigelian hernia is rare and requires a high index of suspicion given the lack of consistent symptoms and signs. An astute physician may couple a proper history and physical examination with preoperative imaging to secure the diagnosis. Mesh and laparoscopic repairs are viable alternatives to the durable results of standard primary closure. Given the high rate of incarceration/strangulation, the diagnosis of Spigelian hernia is an indication for surgical repair.

A Heart Defect Found Upon Self-Examination in an Asymptomatic Patient

A 32-year-old echocardiographic technician was honing her skills by self-examination when she noted that her right ventricle was dilated. A cardiologist confirmed her finding and noted a left-to-right shunt across a 1-cm defect in the fossa ovalis region of the atrial septum. The patient was entirely asymptomatic and regularly engaged in an aerobic exercise program. Physical examination revealed mild pectus excavatum. The right ventricle was not palpable. The a wave in the jugular venous pulse was larger than the v wave. The second heart sound was of normal intensity, was persistently split, and moved physiologically with respiration. The only definite auscultatory abnormality was a third heart sound followed by a short diastolic rumble heard at the lower left sternal border. A chest roentgenogram showed mild enlargement of the cardiac silhouette and minimal prominence of the pulmonary trunk and vasculature. A normal electrocardiogram was recorded. The normal electrocardiogram, the inequality of the a and v waves in the jugular pulse, the respiratory movement of the second heart sound, the absence of a systolic ejection murmur, and the size of the defect measured echocardiographically all suggested that the defect was restrictive and the left-to-right shunt smaller than usual. On the other hand, the third heart sound and short diastolic rumble, the minor abnormalities on chest roentgenogram, and the dilated right ventricle on echocardiography indicated that the shunt was hemodynamically important, and operative closure was recommended. After collecting second opinions for over a year, the patient agreed, and the defect was closed by primary suture. This is the second of our patients whose fossa ovalis–type atrial septal defect was discovered in such a serendipitous fashion. The first was a 22-year-old echocardiographic repairman seen 28 years ago. When he finished repairing the echocardiograph, he was asked to volunteer for an echocardiogram to be sure the machine was working properly, and the defect was found. He also underwent primary suture closure despite being asymptomatic. Until the echocardiograph came into daily use in cardiologic practice, atrial septal defects were diagnosed on the basis of symptoms, sometimes subtle but unmistakable physical findings, distinctly abnormal chest roentgenograms, and abnormal electrocardiograms that typically showed incomplete right bundle-branch block, often with right axis deviation. Because symptoms developed in 70% of such patients by age 40 and in virtually all of them by age 60 (1), and because operative closure carried a low risk and improved prognosis when performed early (2–5), closure of fossa ovalis–type atrial septal defects was uniformly recommended in the absence of severe pulmonary arterial disease. Does this conventional wisdom apply to patients, such as ours, whose defects are smaller and probably would not have been discovered except for serendipitous echocardiography? Opinion is divided (6). The patient herself has had second thoughts post-operatively because of several bouts of postpericardiotomy syndrome, a common problem after operative closure of atrial septal defects. She has now been well for more than 3 years, and those doubts are receding. Our own view is that a left-to-right shunt large enough to cause right ventricular enlargement should be closed, even in the absence of symptoms. As catheter-delivered devices to close holes in the atrial septum are perfected (7), perhaps even smaller defects will be closed routinely, regardless of symptoms.

Postintubation Tracheal Rupture

Tracheal rupture following endotracheal intubation is an extremely rare emergency that needs expedient diagnosis and treatment. The clinical and radiological features of postintubation tracheal rupture in a 45-year-old woman who underwent vertebral stabilization are described. Primary suture closure was performed successfully via a cervical approach.

Use of Fascia Lata in Revision of Filtration Surgery

To report on a successful use of fascia lata patch graft in revision of trabeculectomy for management of severe chronic discomfort associated with an exuberant conjunctival filtering bleb over a very nasal filtering site. After dissecting a conjunctival flap over the area of the trabeculectomy at the nasal quadrant, fascia lata patch graft was sutured in place over the filtering site when primary suture closure was found ineffective. A new trabeculectomy was performed temporal and superior to the old site, and the conjunctival wound closed watertight. The fascia lata patch graft was effective in closing the filtration over the old trabeculectomy site at the nasal quadrant, and a new filtering bleb developed superiorly over the new trabeculectomy site, resulting in sustained IOP control. Fascia lata patch graft was effective in revision of trabeculectomy.

Packing and Planned Reexploration for Hepatic and Retroperitoneal Hemorrhage: Critical Refinements of a Useful Technique

We evaluated 35 consecutive patients treated with temporary intraabdominal packing for control of bleeding to determine factors that could improve hemorrhage control, morbidity from infection, and mortality. Twelve patients could not be resuscitated from hemorrhagic shock and died in the operating or recovery room. Bleeding was controlled in the remaining 23 patients; however, five (22%) died of complications other than hemorrhage. Intra-abdominal abscesses occurred in seven of the 21 patients who survived longer than 5 days and were more frequent in patients who had gastrointestinal perforation (50% versus 27%) and selective hepatic artery ligation (80% versus 19%). Four patients with either retrohepatic vena cava injury, hepatic vein injury, or both, were packed without attempted repair; three underwent delayed repair and survived. Coagulopathy occurred in 55% of patients who received greater than 15 units of blood before packing but in only 17% who received less than 15 units. The abdomens of ten patients were closed with a prosthetic mesh which did not prevent hemorrhage control, and only one patient developed a wound infection compared to 42% of patients with primary suture closure. We therefore conclude: 1) packing is more effective if instituted early (when less than 15 units of blood have been transfused) and is not contraindicated before either repair of retrohepatic vena cava injury, hepatic vein injury, or both; 2) selective hepatic artery ligation should be avoided if packing alone stops bleeding; 3) abdominal closure with a synthetic mesh decreases the incidence of wound infection; and 4) patients should be returned to the operating room for repacking if 24-hour postoperative blood requirements exceed 10 units.

Esophageal perforation: A therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Tee (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Rectal tears in the horse: an analysis of 35 cases.

The records of 35 horses with Grade 3 or 4 rectal tears, presented to the Veterinary Medical Center at Texas A & M University over a five year period, were reviewed. Grade 3 tears were sub-classified according to whether the remaining tissue was serosa (Grade 3a) or mesorectum (Grade 3b). Five horses were destroyed on presentation and 30 were treated by primary suture closure (8 horses), faecal diversion alone (9 horses) or in combination with suture closure (11 horses) and packing of the tear with medicated gauze sponges (two horses). Faecal diversion was achieved with a temporary indwelling rectal liner (TIRL) in 19 horses and colostomy in one. Survival was related to classification of the tear, efficacy of first aid measures administered at time of injury and method of treatment. Seventy-four per cent of horses with Grade 3a tears and 44 per cent of those with Grade 3b tears survived. Grade 4 tears had a grave prognosis. Horses given adequate first aid before admission had a better survival rate. With proper patient selection, primary closure of the tear with sutures yielded excellent results. In horses which were not candidates for suture closure alone, a combination of faecal diversion and suturing gave better results than faecal diversion only. In addition, selected horses were treated successfully by packing the rectal tear with gauze sponges. The results demonstrate the value of a TIRL to divert faeces and appropriate first aid measures in treating rectal tears.

Comparative Transoral Dural Closure Techniques: A Canine Model

A watertight dural closure is difficult to achieve after transoral-transclival operation for ventral intradural lesions at the craniocervical junction. These procedures have a high morbidity and mortality from cerebrospinal fluid (CSF) fistula, meningitis, and abscess. We used a canine model to test three different techniques of dural closure after transoral intradural operation: primary suture closure, laser patch weld, and fibrin glue patch closures. The primary suture closure technique was inadequate. All eight leaked CSF at the time of operation, and five had radiographic leaks and were incompetent at autopsy. All seven of the laser closures leaked CSF at operation, yet only one was incompetent at autopsy. The fibrin glue technique was superior and provided a solid seal at operation, even with repeated Valsalva maneuvers to 40 mm Hg. The immediate and persistent seal at operation is clinically significant because it may prevent CSF leak, meningitis, and abscess formation in human patients after transoral surgery. Fibrin glue is excellent for repairing complex dural defects and merits evaluation in clinical trials.

Surgical repair of tetralogy of Fallot: Long-term follow-up with particular emphasis on late death and reoperation

Early and late results in 309 patients undergoing repair of tetralogy of Fallot between 1960 and 1982 were analyzed with respect to independent determinants of operative mortality, late reoperation, and late death. Follow-up extended to 22 years and totaled 2,743 patient-years. The operative mortality rate was 4.9% +/- 1.3%. Multivariate logistic regression analysis revealed that only young age, long cardiopulmonary bypass time, and (probably) extent of right ventricular outflow tract patch were independent significant determinants of operative mortality. Patients who required a transannular right ventricular outflow tract patch and those who underwent repair without any outflow tract patch were at higher risk than those who received a separate right ventricular and/or pulmonary artery patch. The long-term results were highly satisfactory: Only 15% +/- 3% of patients required reoperation 13 years postoperatively, and 85% +/- 4% of discharged patients were alive 16 years later. Time-dependent linear stepwise multivariate discriminant analysis showed that extent of right ventricular outflow tract patch (transannular greater than none greater than right ventricular and/or [separate] pulmonary arterial), longer ischemic arrest time, previous palliative shunt, and primary suture closure of the ventricular septal defect were the only covariates that independently portended a higher likelihood of reoperation. Similarly, only older age, absence of hypoxic spells, and reoperation were significantly and independently related to the probability of late death. The results of these analyses demonstrate that intracardiac repair of tetralogy is a durable procedure for upwards of 20 years; however, high-risk subsets of patients can be identified in terms of operative mortality, reoperation, and late death. Thus, there is still a need for improvement, particularly future research devoted to better understanding of the electrophysiological mechanisms responsible for arrhythmias, electrosurgical and medical arrhythmia therapy, and right and left ventricular mechanics after repair of tetralogy of Fallot.

Perforation and rupture of the esophagus.

A series of 57 esophageal perforations from the period 1963-1982 is reported. They comprised 42 iatrogenic, instrumental perforations and 15 non-iatrogenic, mainly spontaneous and postemetic ruptures. The clinical manifestations were mostly pain, fever, subcutaneous and mediastinal emphysema, pleural effusion and pneumothorax. Esophageal leak was demonstrated in 73% of contrast studies. The overall mortality rate was 25%. It was 21% in cases with primary suture closure and 50% when treatment consisted of drainage. The mortality rate was 19% when treatment was begun within 24 hours and 35% when there was longer delay. Other factors influencing the mortality rate seemed to be type and location of the perforation and age of the patient. Early surgical intervention is advocated for perforation or rupture of the intrathoracic esophagus. Data in the literature and our own findings indicate that also in cervical esophageal perforations early surgical repair is justifiable.

Residual shunting in the early postoperative period after closure of atrial septal defect: Echocardiographic comparison of patch materials

Residual shunting after surgical closure of septal defects is a common postoperative complication. In this study, contrast echocardiography was used to assess the effect of different surgical patch materials on early postoperative residual shunting. The study consisted of 44 patients (aged 3 days to 64 years) with simple or complex atrial septal defects. Total pulmonary-to-systemic flow ratios ranged form 1.8:1 to 4.0:1. Three methods were used to close the atrial septal defects: primary suture closure (n = 7), patching with thin, knit Teflon fabric (n = 13), and patching with thicker, low porosity, knit Teflon fabric (n = 24). Contrast echocardiographic injections were performed through central venous and left atrial lines positioned at operation for monitoring purposes. Ten of the 44 patients had residual shunts. In five of them, daily contrast studies showed progressive diminution in shunting with eventual resolution, but in the other five patients, shunting persisted beyond the first 5 postoperative days. Three of the latter five required reoperation for actual residual anatomic defects. No patient whose atrial septal defect was closed by either direct suture or thick, low porosity Teflon fabric had shunting detected at any time postoperatively. Our data confirmed temporary leakage across newly implanted intracardiac patches. However, shunts that persist beyond the first postoperative week indicate true anatomic residua and not porous patch material. If a patient's recovery is complicated, use of contrast echocardiography can determine whether a residual shunt is a causative factor. In patients with complex lesions in whom continued shunting during the early postoperative period may cause serious hemodynamic consequences, heavier, low porosity patch material can be useful.

The injured colon: relationships of management to complications.

One hundred thirty-seven patients who sustained intraperitoneal colon wounds were admitted to the University of Louisville Hospital during the three-year period ending December 31, 1979. One hundred twenty penetrating wounds and 17 blunt injuries were treated. An intraoperative classification system was employed, in which Grade 1 injuries were characterized by minimal contamination, the absence of associated organ injuries, minimal shock, and no significant delay between injury and definitive operation. All of these were managed by single-layer closure. More severe wounds were treated by colostomy or exteriorization. The overwhelming majority of the patients (116) sustained Grade 2 injuries. Twenty-two patients (16%) died. Nine deaths (6% of the patients) were directly attributable to the colon wounds. Twenty-five Grade 1 injuries were treated by primary suture closure with a single complication (3% of the patients). Nine wounds were exteriorized for later reinsertion into the peritoneal cavity, but only two patients were spared colostomy by this method. Right colon injuries were, clearly, more severe than left or sigmoid colon wounds. Intraoperative classification allowed selection of a group of patients in whom suture repair was safe. Colostomy was associated with the lowest complication rate for Grade 2 and 3 wounds.