Penetrating injury to the buttock: an update.

Clinical research on penetrating injury to the buttock is sparse and largely limited to case reports and clinical series. The purpose of this paper is to provide a detailed overview of literature of the topic and to propose a basic algorithm for management of penetrating gluteal injuries (PGI). MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. Thirty-seven papers were selected and retrieved for overview from 1,021 records. PGI accounts for 2-3 % of all penetrating injuries, with a mortality rate up to 4 %. Most haemodynamically stable patients will benefit from traditional wound care and selective non-operative management. When gluteal fascia injury is confirmed or suspected, a contrast-enhanced CT-scan provides the most accurate injury diagnosis. CT-scan-based angiography and endovascular interventions radically supplement assessment and management of patients with penetrating injury to the major buttock and adjacent extra-buttock arteries. Immediate life-saving damage-control surgery is indicated for patients with hypovolemic shock and signs of internal bleeding. A universal basic management algorithm is proposed. This overview shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7.

Long-term results of single intradermal 1 % methylene blue injection for intractable idiopathic pruritus ani: a prospective study.

BACKGROUND: The aim of this study was to assess the effectiveness and side effects of methylene blue injection into the perianal skin of patients with chronic refractory idiopathic pruritus ani (IPA). METHODS: Patients with IPA who failed to respond to standard perianal skin care advice and treatment of associated pathologies were included. One per cent methylene blue solution was injected intradermally into the itching perianal area up to the level of the dentate line, with a 10-ml syringe with a 22-gauge needle, using a total of 15 ml. A patient symptom score from 1 to 5 was used (1 = worst). The study was designed as a single-centre, prospective, non-randomized trial. RESULTS: Between September 2004 and November 2008, 10 patients with IPA were included in the study. Symptoms resolved within 4 weeks in all cases. Numbness of the perianal area and tattooing disappeared within the period of 3-4 weeks. There was no skin necrosis or anaphylaxis. The median follow-up was 47 months, range 29-60 months. Anal itching recurred in 8 patients. Four of those 8 patients noted that anal itching was less severe when it recurred, and it was unchanged in the other 4 patients. Six out of 10 patients felt much better or reported the resolution of pruritus ani. CONCLUSIONS: An intradermal application of 1 % methylene blue solution is associated with a positive effect on IPA with mild side effects related to sensory cutaneous innervation in all patients within the first 4 weeks following the procedure and a 20 % success rate within 60 months.

Comparison of laparoscopic versus open repair for perforated duodenal ulcers.

BACKGROUND: There is great controversy regarding the choice of procedure for perforated duodenal ulcer patients. The purpose of this study was to compare the early outcome results of laparoscopic and open repair and to propose which risk factors influence the outcome. METHODS: Between October 1996 and May 2004, 60 patients underwent laparoscopic and 162 patients underwent open repair of perforated peptic ulcers in a tertiary care academic center. The results were retrospectively analyzed. The primary outcome measures included operative time, duration of hospital stay, morbidity, and mortality. RESULTS: The operative time was significantly longer in the laparoscopy group compared to the open repair group (76.2 +/- 35.3 vs 57.3 +/- 26.1 min, respectively). The hospital stay in surviving patients appeared to be significantly shorter after laparoscopy than after open repair (7.8 +/- 5.3 vs 10.3 +/- 10.6 days, respectively). Eight patients (13%) in the laparoscopic group and 41 patients (25%) in the open repair group had morbidity in the postoperative period. Suture leakage was confirmed in four patients (7%) following laparoscopic repair and in three patients (2%) in the open repair group. There were 20 deaths (9%), all in the open repair group. CONCLUSIONS: Independent Boey risk factors, patient age, and large perforation size have a negative impact on patient recovery. Both laparoscopic and open repair are equally safe and effective in perforated duodenal ulcer patients with a Boey score of 0 or 1.

Systematic review comparing laparoscopic and open repair for perforated peptic ulcer.

BACKGROUND: The advantages of laparoscopic over open repair for perforated peptic ulcer are not as obvious as they may seem. This paper summarizes the published trials comparing the two approaches. METHODS: Two randomized prospective, five non-randomized prospective and eight retrospective studies were included in the analysis. Relevant trials were identified from the Medline/Pubmed database and the reference lists of the retrieved papers were then analysed. The outcome measures used were operating time, postoperative analgesic requirements, length of hospital stay, return to normal diet and usual activities, and complication and mortality rates. Published data were tested for heterogeneity by means of a chi2 test. Meta-analysis methods were used to measure the pooled estimate of the effect size. In total, 1113 patients are represented from 15 selected studies, of whom 535 were treated by laparoscopic repair and 578 by open repair; 102 patients (19.1 per cent) underwent conversion to open repair. RESULTS: Statistically significant findings in favour of laparoscopic repair were less analgesic use, shorter hospital stay, less wound infection and lower mortality rate. Shorter operating time and less suture-site leakage were advantages of open repair. Three variables (hospital stay, operating time and analgesic use) were significantly heterogeneous in the papers analysed. CONCLUSION: Laparoscopic repair seems better than open repair for low-risk patients. However, limited knowledge about its benefits and risks compared with open repair suggests that the latter, more familiar, approach may be more appropriate in high-risk patients. Further studies are needed.

Clinicopathological significance of fibrotic capsule formation around liver metastasis from colorectal cancer.

PURPOSE: The fibrous capsule around hepatocellular carcinoma is well known to be an indicator of a good prognosis. However, the fibrotic stromal response in the liver to a metastatic tumor remains unclear. PATIENTS AND METHODS: In order to clarify the prevalence of fibrotic capsular formation around liver metastases as well as the prognostic and biological significance of the fibrotic capsule, 69 colorectal cancer patients, who underwent radical hepatectomy due to liver metastases, were investigated using immunohistochemical methods. RESULTS: Encapsulated metastases as defined by a thick fibrotic band surrounding the entire surface of a metastasis were detected in 20% of the cases. The rate of initial recurrence in the remnant liver, which is a strong indicator for poor prognosis of colorectal liver metastasis, was significantly lower in the encapsulated metastasis group as compared with the non-encapsulated metastasis group. Proliferating fibroblastic cells in the capsule were myofibroblasts positively stained for alpha-smooth muscle actin (alpha-SMA) and they deposited dense extracellular matrices rich in collagen Type 1 in the layer of the inner half and secreted MMP-1, MMP-2, and TIMP-1 in the layer of the outer half of the capsule. Activation of alpha-SMA positive hepatic stellate cells (HSC) was also observed in the liver parenchyma adjacent to metastases. CONCLUSIONS: The results indicate that fibrotic capsular formation is associated with a lower rate of initial local recurrence in the remnant liver, and that the capsule may serve as a mechanical and chemical barrier to local invasion by metastatic tumor cells. Proliferating stromal cells in the capsule are myofibroblasts, probably derived from HSC activated by colorectal liver metastasis in the liver parenchyma.