Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma.

BACKGROUND: A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately. METHODS: Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in a suburban teaching hospital. RESULTS: A total of 1,493 adult blunt head trauma patients between January 2001 and May 2005 were analyzed. Of these, 159 patients were warfarin-anticoagulated at the time of trauma. The mortality in anticoagulated patients was statistically significantly higher than in the control group (38/159, 23.9% vs. 66/1,334, 4.9%; p < 0.001; odds ratio 6.0). Mortality of patients over 70 years of age was significantly higher than in the younger population (p < 0.001). Both mortality and the occurrence of intracranial hemorrhage (ICH) after head trauma were significantly increased with higher INR (Cochran's linear trend p < 0.001), especially with INR over 4.0 (mortality 50%, risk of ICH 75%). Preinjury warfarin anticoagulation and age were found to be predictive of survival in a binary logistic regression model (92.5% correct prediction, p = 0.027). Addition of Injury Severity Score and initial Glasgow Coma Score to this model only modestly improved its predictive performance (95.4% correct prediction, p < 0.001). CONCLUSIONS: Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI. Warfarin anticoagulation carries a six-fold increase in TBI mortality. Age over 70 years and excessive anticoagulation are associated with higher mortality, as well.

Safely increasing the efficiency of thyroidectomy using a new bipolar electrosealing device (LigaSure) versus conventional clamp-and-tie technique.

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electrosealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n=155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n=70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n=85). The mean operative time was 130 +/- 37 minutes in the conventional group and 110 +/- 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 +/- 53 vs 33 +/- 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the LigaSure group (8.2 +/- 0.5 vs 8.4 +/- 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.

Acellular dermal matrix (AlloDerm): new material in the repair of stoma site hernias.

Parastomal hernias are a common complication after ileostomy or colostomy formation and can lead to complications, such as intestinal obstruction and strangulation. When a parastomal hernia presents, repair of the defect can pose a challenge to the surgeon to choose a repair that both reduces complications and recurrence rates. We present three cases of parastomal hernia repair using acellular dermal matrix (AlloDerm) as reinforcement to the primary hernia repair. We prospectively followed three patients who presented with parastomal hernia after ostomy formation in 2001-2002. The patients underwent repair of the parastomal hernia using primary fascial repair with reinforcement using AlloDerm as an on-lay patch. Two patients were followed for 6 months and 1 year, respectively, and remained hernia-free. One patient presented 8 months later with symptoms of intestinal obstruction that were relieved by nasogastric tube decompression and bowel rest. The patient subsequently returned 3 months later with intestinal obstruction and recurrent parastomal hernia that necessitated an operation for relocation of the stoma and repeat hernia repair. Repair of parastomal hernias using AlloDerm acellular dermal matrix as a substitute for a synthetic graft showed resilience to infection and, more importantly, tolerated exposure in an open wound without having to be removed. Larger studies with longer follow-up are needed to see if this material reduces the incidence of hernia recurrence.