Surgical wound morbidity in an austere surgical environment.

Surgical wound morbidity was analyzed for a U.S. military field hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine whether procedures performed in the field hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical infection rates of 1.5% for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists (ASA) Physical Status Classification class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound infections, 11 wound hematomas, 8 superficial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the field hospital environment was found to be equivalent to that described for the fixed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.

Heterotopic pancreatic tissue obstructing the gallbladder neck: a case report.

CONTEXT: Heterotopic pancreatic tissue is defined as pancreatic tissue outside the boundaries of the pancreas that has neither anatomic nor vascular continuity with the pancreas. Heterotopic pancreatic tissue in the gallbladder is uncommon and has rarely been reported to cause symptoms. We report a case of heterotopic pancreatic tissue obstructing the gallbladder neck resulting in cholecystitis. CASE REPORT: A 26-year-old female presented with right upper quadrant abdominal pain and fever. On physical examination the right upper quadrant was tender to palpation with a positive Murphy's sign. Laboratory tests were significant for elevated aspartate aminotransferase and alanine aminotransferase. Transabdominal sonography showed gallbladder wall thickening, a positive sonographic Murphy's sign, and an apparent large non-mobile stone at the gallbladder neck. Pathologic examination revealed cholecystitis but instead of a large stone there was a tan-yellow necrotic mass at the gallbladder neck. Microscopically, the mass consisted of heterotopic pancreatic tissue containing exocrine pancreatic acini, ducts, and islets of Langerhans. The final diagnosis was acute cholecystitis secondary to obstruction by heterotopic pancreatic tissue. CONCLUSION: Although heterotopic pancreatic tissue is usually an incidental finding on pathologic exam, one should not exclude it in the differential diagnosis of symptomatic gallbladder disease of indefinite etiology.

Reduction of conscious sedation requirements by olfactory stimulation: a prospective randomized single-blinded trial.

OBJECTIVES: This study investigated the possibility that olfactory stimulation would decrease sedation needed for colonoscopy and therefore decrease the recovery time needed after conscious sedation. MATERIALS AND METHODS: Patients were randomized to receive a cherry-flavoredscent in oxygen flowing at a 4 L per minute rate via nasal cannula or oxygen alone. The scent was provided in a cherry-flavored oil. A Bispectral Index (BIS) monitor (Aspect Medical Systems, Newton, MA) was placed and scores were recorded every 5 minutes during the procedure to control for different sedation patterns between different endoscopists. The recovery area nurse was unaware of whether a given patient was in the aroma or plain oxygen group, and based each patient's discharge on preexisting standardized criteria. RESULTS: Two hundred and eighty-four (284) patients completed the study. Both the procedure times and the recovery times were not statistically significant between the two groups. The doses of sedatives used, BIS scores at 5 minute intervals, and rate of change in BIS scores were also not statistically significant between the two groups. CONCLUSIONS: Overall, there is no difference between olfactory stimulation and inhaled oxygen with regard to amount of sedation used and recovery times for colonoscopy. An inhaled cherry- scent may not have as great a calming effect as other scents that have been studied.

Atypical presentation of a retrorectal ancient schwannoma: a case report and review of the literature.

Retrorectal tumors are rare and frequently present either incidentally or with vague symptoms. Schwannomas of the presacral region are one variant described as benign tumors of neurogenic origin. The "ancient degenerative variant" is uncommonly reported. We present the case of a 37-year-old man presenting with symptoms of left renal colic, impotence, and left trochanteric pain. Computed tomography and magnetic resonance imaging of the pelvis showed a presacral mass with cystic changes and calcifications consistent with a schwannoma. The patient underwent an exploratory laparotomy with resection of the tumor, which subsequent analysis showed to be a schwannoma with ancient degenerative changes.

Internal hernia after laparoscopic gastric bypass surgery: a case report and literature review.

Obesity is becoming more common in the United States, affecting > or = 30% of adults aged 20 years and older. Obesity (body mass index 30) is ranked second only to tobacco use as a preventable cause of death in the United States. Roux-en-Y gastric bypass (RYGBP) is being performed at a rapidly increasing rate, and laparoscopic Roux-en-Y gastric bypass (LRYGBP) surgery is frequently chosen rather than an open approach because of lower morbidity rates. One of the complications of LRYGBP includes small bowel obstruction (SBO) secondary to internal herniation. When RYGBP is performed through the open approach, SBO is most commonly caused by adhesions. The challenge with these patients is that the presenting signs, symptoms, and physical and radiological examinations may be vague, nonspecific, and/or nondiagnostic. Internal hernias that result as a complication of LRYGBP occur in 1 of 3 places. These locations include the transverse mesocolon, the jejunal mesenteric defect at the level of the jejunojejunostomy, and Petersen's space, which is the area between the mesentery of the Roux limb and the transverse mesocolon. We report the case of a 45-year-old woman who presented with SBO secondary to Petersen's hernia. The clinical presentation and radiologic studies are discussed.

Enteritis cystica profunda: is trauma the etiology? Interval development in the previously normal ileum: a case report and literature review.

Although well described in the colon, enteritis cystica profunda is an extremely rare lesion of the small intestine with only a few cases documented in English medical literature. It is a benign condition most often associated with Crohn's disease or Peutz-Jeghers syndrome in the adult. It has been described presenting as ileoileal intussusception in the pediatric population. We report a case of enteritis cystica profunda found incidentally on exploratory laparotomy with evidence of interval development over a 5-month period confirming trauma as the etiology.

Ischemic colitis of the ascending colon: a diagnostic and management conundrum.

Ischemic colitis is the most common form of intestinal ischemia. It most commonly involves the left side of the colon presenting with acute onset of abdominal pain followed by bloody diarrhea. Involvement of only the right or ascending colon is an infrequent occurrence. Because this problem is less recognized than its counterpart involving the left colon, the correct diagnosis and management may not be readily considered. We present a case of ischemic colitis presenting as a distal small bowel obstruction with emphasis on evaluation and management of this unusual clinical problem.

Laparoscopic appendectomy in patients with a body mass index of 25 or greater: results of a double blind, prospective, randomized trial.

BACKGROUND: The reported advantages of the laparoscopic approach to appendectomy are shortened hospital stay, less postoperative pain, and earlier return to usual activities (work). However, a prospective, randomized, double-blind trial comparing laparoscopic appendectomy with open appendectomy in active-duty males failed to disclose a benefit of laparoscopic appendectomy with regards to postoperative pain and return to work. The aim of our study was to compare open and laparoscopic appendectomy in overweight patients. METHODS: We conducted a prospective, randomized, double-blind study to determine whether laparoscopic appendectomy or the open procedure in overweight patients offers a significant reduction in lost workdays, postoperative pain, or operative time from. Open appendectomy in overweight patients (those with a body mass index > or =25) may be more difficult due to excessive subcutaneous adipose tissue. The open incision may be of considerable size, which may result in increased postoperative pain and a prolonged convalescence. RESULTS: There was a statistically significant increase in operative time for laparoscopic appendectomy of 11 minutes. As expected, the aggregate incision length for open appendectomy was twice that of the laparoscopic appendectomy. CONCLUSION: The data from this prospective, randomized, double-blind study failed to demonstrate any significant reduction in lost workdays, postoperative pain, or operative time with laparoscopic appendectomy.

Bursting strength evaluation in an experimental model of incisional hernia.

Incisional hernias occur in up to 11 per cent of patients undergoing abdominal surgery. Up to 50 per cent of these patients with hernias will require repeat operative procedures. Management of these hernias have focused primarily on tensile strength of the mesh material, have not addressed currently used materials, and have not compared the strength of these repairs with each other. Forty-nine adult Sprague-Dawley rats had an incisional hernia created by removing a portion of their abdominal wall that was then repaired primarily, using either a composite mesh, Dual mesh (Gore-Tex), or polypropylene mesh. Six weeks after the repair, the rats were euthanized. Hydrostatic distension of the abdominal cavity was performed to compare bursting strength of each repair. Wound tensile strength was assessed and compared. Tissue samples were also taken to compare repair types for incorporation of prosthetic materials. The gross weight of the animals subjected to hydrostatic distention was equivalent between groups, as was the volume required prior to failure of the repair. There was a trend toward improved tensile strength of the Prolene mesh repair, which had a lower average inflammatory and fibrosis score on histology. Overall, the type of mesh used for repair does not seem to impact significantly the strength of the repair when assessed 6 weeks postoperatively. Choice of prosthetic material to repair the hernia should be made based on economics and handling characteristics alone. Prolene mesh has satisfactory strength with the least amount of inflammation and fibrosis.

The economic impact of laparoscopic inguinal hernia repair: results of a double-blinded, prospective, randomized trial.

For this study, 66 patients with a preoperative diagnosis of unilateral primary inguinal hernia were randomized to undergo laparoscopic totally extra peritoneal (TEP), laparoscopic transabdominal (TAPP), or open inguinal hernia repair with polypropylene mesh (Lichtenstein type). Both the operative team caring for the patient postoperatively and the patient were blinded to the operative approach by placement of a large dressing covering the abdomen, which was not removed until postoperative day 3. The patients recorded their pain level on a visual analog pain scale daily. Medication usage also was recorded. All patients were seen at 7-day intervals until they returned to work. The patients were interviewed during their postoperative visits by an investigator blinded to the operative approach and questioned regarding their ability to return to work and their pain levels. The average number of lost work days in all the groups was 12, and there was no significant difference between the three groups (p = 0.074). The average operating time for the TAPP procedure was 59 min, less than the time required to complete either the TEP or the Lichtenstein approach, which had equivalent operative times (p = 0.027). The material cost was significantly lower for the Lichtenstein repair (1,200 dollars less) than for either of the laparoscopic approaches, a saving primarily related to consumable operating room supplies. The TEP repair costs were minimally higher than those for the TAPP repair (125 dollars more). No significant differences were noted in the postoperative pain scales, and the use of postoperative oral analgesics was equivalent. The higher operative costs noted for the laparoscopic hernia repairs were not offset by a shortened convalescence. Postoperative pain appears to be equivalent regardless of the operative approach chosen and is easily managed with oral analgesics.

Acute pain and narcotic use does not impair the ability to provide informed consent: evaluation of a competency assessment tool in the acute pain patient.

Patients evaluated in acute pain will often have narcotics withheld until after the patient has been evaluated by a surgeon and has given informed consent. Concern that the patient would have impaired judgment due to narcotic effects often prevents the administration of timely pain relief. The Hopkins Competency Assessment Tool (HCAT) is a validated instrument for both psychiatric and medical patients; it has not been validated to evaluate drug effects on judgment. Thirty consecutive patients agreed to participate in the trial over a 12-month period. The HCAT was administered prior to the planned major elective procedure and repeated on each postoperative day up to and including postoperative day 5. Narcotic use (as morphine equivalents), HCAT scores, demographic data, and surgical procedures were recorded. The average age of our patients was 53 years. Twenty-seven patients passed the initial HCAT, and one patient failed subsequent exams. No correlation was seen between HCAT score and narcotic dose. Narcotic administration sufficient for pain control does not impair the ability to provide informed consent. The only patient who failed the HCAT after an initial passing score was somnolent on the narcotic dose.

The economic impact of early enteral feeding in gastrointestinal surgery: a prospective survey of 51 consecutive patients.

Early postoperative oral feeding has been demonstrated to be safe and not increase postoperative morbidity. There are conflicting reports about its effect on postoperative length of stay. Some patients will fail attempts at early postoperative feeding and may be relegated to a longer postoperative course. Few studies to date have attempted to identify cost savings associated with early oral support, and those identified address nasoenteric support only. Fifty-one consecutive patients were randomized into either a traditional postoperative feeding group or an early postoperative feeding group after their gastrointestinal surgery. Length of hospital stay, hospital costs (excluding operating room costs), morbidity, and time to tolerance of a diet were compared. There was a tendency toward increased nasogastric tube use in the early feeding arm, but the morbidity rates were similar. Length of hospital stay and costs were similar in both arms. Early postoperative enteral support does not reduce hospital stay, nursing workload, or costs. It may come at a cost of higher nasogastric tube use, however, without an increase in postoperative morbidity.

The strictured anastomosis: successful treatment by corticosteroid injections--report of three cases and review of the literature.

Clinically significant anastomotic strictures usually only occur with very low colorectal anastomoses below the level of the peritoneal reflection. The reported rate averages 8 percent and has been attributed to tissue ischemia, localized sepsis, anastomotic leak, proximal fecal diversion, radiation injury, inflammatory bowel disease, and recurrent rectal cancer. Most patients will have symptoms of obstipation, frequent small bowel movements, and bloating. Symptomatic strictures are often approached by dilation (balloon or Hegar) or less often repeat resection. Many of these patients have anastomoses that are too low to consider repeat resection. Strictureplasty with linear stapling devices, stricture resection by use of the circular stapling device, and repeat dilations have all been described. Steroid injections into the stricture have been described in strictured esophagogastric anastomoses but have not been commonly used for strictured coloproctostomies. We describe three cases of coloanal stricture following resections that were complicated by postoperative pelvic abcesses, anastomatic leaks, and pelvic fibrosis. Two cases had undergone low coloanal anastomosis that was protected by a loop ileostomy and developed as significant stricture in the early postoperative period. The third case was managed without a protective loop ileostomy. These were initially managed by repeated dilation of the anastomosis. Each episode was followed by rapid recurrence of the stricture. All patients underwent subsequent dilation with injection of 40 mg of triamcinolone acetate (divided dose in four quadrants) into the stricture and subsequent complete resolution of the stricture. Those patients with loop ileostomies had them taken down and all have been followed for up to 12 months without clinical or endoscopic evidence of recurrent stricture.

The incidence of positive peritoneal cytology in colon cancer: a prospective randomized blinded trial.

Many investigators have attempted to explain the suspected increased incidence of port site metastasis in patients undergoing laparoscopic colorectal resections for cancer with animal models in which cancer is simulated by injection of a tumor slurry into the peritoneal cavity. This approach makes the basic assumption that all patients with colorectal malignancies have viable cancer cells freely circulating within the peritoneal cavity. Recent reports in open colorectal resections have conflicting results. Some suggest that the true incidence is negligible and related to advanced-stage cancers whereas others implicate a much higher incidence. We initiated a prospective blinded trial to establish the true incidence of malignant peritoneal cytology in colorectal cancer. One hundred eight consecutive colon resections underwent conventional peritoneal cytologic evaluation. The patients included those with inflammatory conditions of the colon as well as malignant disease. The cytopathologist was blinded as to the indications for surgery as well as the final pathology result. In only one case--stage IV rectal cancer with peritoneal carcinomatosis--was the cytologic specimen positive. Malignant cytology appears to be an infrequent occurrence and is restricted to advanced-stage cancer.