Delayed stomach necrosis in a patient with injured celiac artery branches after penetrating abdominal trauma.

Injuries of the celiac artery and its branches are rare, but potentially lethal. Ligation of these arteries is performed to control significant hemorrhage. However, few reports have described the adverse effects of ligating these arteries. A 69-year-old woman with a self-inflicted stab wound was brought to our hospital. Her blood pressure could not be measured, therefore aortic cross-clamping was performed, and epinephrine was administered for resuscitation, an emergency laparotomy was performed, and the roots of splenic artery and common hepatic artery were ligated. The left gastric artery which was anomalous and arose directly from the aorta, was also injured and had to be ligated. Norepinephrine was required after the surgery. Enhanced computed tomography performed on hospital day 4 revealed a disrupted celiac artery. The patient developed gastric necrosis on hospital day 23 and, hence, underwent total gastrectomy was performed. The possibility of delayed stomach necrosis should be considered during the postoperative management of patients who undergo ligation of all of the celiac artery branches and experience global hypoperfusion after the surgery.

Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management.

BACKGROUND: Many patients requiring conventional open abdominal management need a postoperative intermediate period with a large ventral hernia. This situation, in which the granulated abdominal contents are covered only with a skin graft, carry with it a high risk of enterocutaneous fistula, and the patients ultimately require late-stage abdominal wall reconstruction. Early abdominal wall reconstruction in noncandidates for standard fascial closure has received little attention. In this study we used bilateral anterior rectus abdominis sheath turnover flaps for early fascial closure which, to date, has not been evaluated as a technique for early fascial closure. METHODS: Eleven trauma and 18 nontrauma cases requiring open abdominal management over a 7-year period were reviewed. Bilateral anterior rectus abdominis sheath turnover flaps were created by longitudinal incisions along the lateral edge of the anterior rectus sheath, which were mobilized medially and approximated. The skin was closed primarily. RESULTS: Twelve nontrauma and eight trauma patients survived. No enteric fistula or abdominal abscess occurred. Anterior rectus sheath turnover flaps were used in nine of the 18 nontrauma and two of the 11 trauma patients, all of whom were unsuitable for standard fascial closure of prolonged visceral edema; the respective mean intervals from initial laparotomy to fascial closure were 9.4 and 18 days. Of the 11 patients with flaps, ten survived without fascial dehiscence or herniation (maximum follow-up: 65 months). CONCLUSIONS: Early fascial closure using the anterior rectus abdominis sheath turnover flap may reduce the need for skin grafting and subsequent abdominal wall reconstruction. This approach can be considered as an alternative technique in the early management of patients with open abdomen.

Immediate postoperative angiographic embolization after damage control surgery for liver injury: report of a case.

A multimodality strategy, including damage control and angioembolization techniques, has been reported to reduce the mortality associated with surgery for complex blunt hepatic injuries. However, the indications for angiographic evaluation and embolization in patients who require surgery for hepatic injury remain unclear. We report a case of blunt hepatic injury requiring emergency laparotomy, which we treated by damage control surgery because of an inaccessible major venous injury and the fact that coagulopathy was stopping hemostasis. The decision to perform immediate postoperative angiography was based on the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during surgery. Hepatic angiography revealed extravasation from a branch of the middle hepatic artery, which was embolized successfully. Although the definitive indications for immediate postoperative angioembolization for hepatic injury have not been established, the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during damage control surgery is an indication for immediate postoperative angioembolization.

Analysis of antimicrobial drug resistance of Staphylococcus aureus strains by WHONET 5: microbiology laboratory database software.

OBJECTIVES: To analyze our hospital laboratory microbiological data by using WHONET 5-Microbiology laboratory database software-, and to acquire information about antimicrobial resistance of Staphylococcus aureus strains among every ward. MATERIALS AND METHODS: The database of Staphylococcus aureus strains had been brought to our hospital microbiology laboratory from every ward in our hospital from September 2001 till December 2002. Analysis was performed under the condition as one isolate per one patient. Starting of "resistance profile" analysis in WHONET 5 and analyzing the microbiological laboratory testing reports for every ward. We chose Oxacillin, Levofloxacin, Erythromycin and Gentamicin as the antimicrobials that need to be investigated for resistance. We evaluated the monthly transition of resistance ratios with regard to the specific wards that have the moving lines of inpatients in order to verify the hypothesis that resistant strains may be carried from ward to ward along the moving lines of inpatients. RESULTS: The data of 2,113 Staphylococcus aureus strains were accumulated and analyzed. Overall Oxacillin resistance ratio in our hospital was 65.7%. The ward of the smallest Oxacillin resistance ratio was Pediatrics/Ophthalmology ward. The ratios of Oxacillin resistant were varied as from 67.9% to 96.7% regardless the categories of wards such as internal medicine or surgery. Multi-resistant MRSA strains were overwhelmingly dominant in the wards of surgery. The ratios of the Gentamicin sensitive strains that were resistant to Oxacillin were high over the every ward. The moving lines of inpatients existed between ICU/CCU ward and three rear wards. Two rear wards whose Oxacillin resistance changes were reflected to those of ICU/CCU, but one rear ward was not. CONCLUSION: Variation of resistant degree among wards were very obvious and large. We could survey the wards where patient-to-patient transmission of resistant organisms might occur along the moving lines of inpatients. WHONET 5 will be recognized as an analysis and surveillance tool for every infection control team to survey the suspicious wards.