Pacifying the open abdomen with concomitant intestinal fistula: a novel approach.

The management of the open abdomen, particularly when complicated by the presence of intestinal fistula, remains a significant challenge of modern trauma care. Although several approaches have been proposed, these varied and complex cases defy the application of a universal approach to local therapy. Ultimately, abdominal closure is desired but is not always possible. Accordingly, surgeons must be well versed in the application of a number of useful approaches that may serve to facilitate control of fistula drainage while permitting management of the surrounding open wound. We contribute a management approach that is simplistic in design, provides for effective fistula control, and permits the subsequent unhindered granulation of the surrounding wound in abdomens not amenable to delayed closure techniques.

Management of a nontraumatic extracranial internal carotid aneurysm with external carotid transposition.

Primary aneurysms of the extracranial internal carotid artery are exceptionally rare, with only a very few reports in the medical literature that are not related to known connective tissue disease or antecedent trauma. The natural history of these entities has not been precisely defined. Nevertheless, the embolic risk that an aneurysm at this location represents mandates prompt intervention when identified. We present the case of a 42-year-old female who was found to have a 3-cm aneurysm of the right extracranial internal carotid artery after seeing a physician for refractory headaches. In an austere environment with limited resources, this patient was successfully managed with the use of external carotid transposition to the distal internal carotid artery, cephalad to the aneurysm.

Does lower limb revascularization result in an improvement in sensory perception thresholds?

Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We wished to determine whether revascularization of chronically ischemic limbs results in any clinical changes in peripheral sensory thresholds. We prospectively measured quantitative vibration perception thresholds (VPT) using a Horwell neurothesiometer (in volts) in patients undergoing infrainguinal bypass, preoperatively and up to 6 month postoperatively. The bypassed limbs' preoperative VPT values were higher (lesser sensory perception) than the contralateral control limbs' preoperative values (mean score differences: 6 +/- 2 and 4 +/- 10 at toe and foot levels respectively; p ? 0.004). Preoperative VPT values were not different from the 6-month postoperative values for the revascularized legs at toe and foot levels for all 55 patients (mean score change of ?0.84 and ?1.32, p > 0.5). The contralateral limbs' VPT values did not change significantly over the 6-month period (mean change scores of 2.9, p > 0.15, and 2, p > 0.30, for toe and foot, respectively). A comparison of preoperative values between limbs that were eventually amputated and saved revealed no statistically significant differences. This study suggests that revascularization does not result in a clinically detectable improvement in sensory neuropathy. It may, however, prevent further degradation. The degree of preoperative neuropathy does not affect outcome in terms of limb salvage.