Does prophylactic subcutaneous heparin increase the risk of wound infection after colorectal surgery?

Chemical prophylaxis using unfractionated heparin (UH) and low-molecular weight heparin is used in surgical patients to prevent venous thromboembolism. There is some evidence that prophylactic doses of heparin may increase the rate of surgical site infection (SSI) after elective orthopedic procedures. Little is known regarding the effect of heparin on SSI after colorectal procedures. We performed this study to study the effect of prophylactic unfractionated heparin on the rate of SSI after colorectal procedures. We did a retrospective analysis of 155 consecutive cases of patients of a single colorectal surgeon who underwent colorectal resection. Subcutaneous unfractionated heparin was given to 52 patients (29%). The rate of SSI in the group that received UH was 33 per cent versus 28 per cent in the group that did not receive UH (P = 0.31). There was also no significant effect of prophylactic heparin on SSI noted among any patient subgroup. The use of prophylactic unfractionated heparin after colorectal procedures does not seem to increase the rate of surgical site infection.

Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation.

PURPOSE: Wound infections after ileostomy closure are common with primary closure of the skin. Although this risk can be reduced by secondary closure, cosmetic outcomes are less than desirable. In an effort to balance these issues, we have used circumferential subcuticular wound approximation to decrease wound size. This study compares outcomes of primary closure vs. circumferential subcuticular wound approximation after ileostomy closure. METHODS: Forty-nine consecutive patients undergoing ileostomy closure over an 18-month period were reviewed. During the first half of this study, all ileostomy sites underwent primary closure, while during the second half all ileostomy sites underwent circumferential subcuticular wound approximation. Short-term outcomes were tabulated including wound infection. Long-term outcomes were assessed using a novel six-point patient satisfaction scale. RESULTS: Primary closure was performed in 25 patients and circumferential subcuticular wound approximation performed in 24 patients. No wound infections occurred in the circumferential subcuticular wound approximation group, compared to 40 percent wound infection rate observed in the primary closure group (P = 0.002). The mean patient satisfaction score was higher in the circumferential subcuticular wound approximation group (18.4) vs. the primary closure group (15.9; P > 0.05). CONCLUSIONS: Circumferential subcuticular wound approximation was associated with a significantly lower incidence of wound infection after ileostomy closure compared to primary closure. A trend was present toward better cosmetic results for circumferential subcuticular wound approximation than primary closure.

Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient: Fasciotomy is not the best answer.

BACKGROUND: Compartment syndrome of the leg secondary to spontaneous bleeding has been described in coagulopathic patients. Correction of the coagulopathy and emergency fasciotomy is the recommended treatment. We present a cirrhotic patient with a short life expectancy who developed compartment syndrome of the leg secondary to spontaneous bleeding. This patient underwent fasciotomy of the leg and subsequently developed persistent postoperative bleeding and required repeated transfusions of blood and blood products. The patient eventually expired in the hospital 1 month after surgery. RESULTS: Compartment syndrome of the leg occurring in patients with coagulopathy secondary to cirrhosis is very difficult to manage. Coagulopathy in these patients is hard to correct and constant bleeding from fasciotomy site is a major complication mandating frequent transfusions of blood and blood products. The complications of fasciotomy in these patients may outweigh the complications of untreated fasciotomy, particularly in patients with a short life expectancy. CONCLUSIONS: Fasciotomy is not always the best treatment for compartment syndrome of the leg. In certain patients, particularly in the coagulopathic, end-stage cirrhotic patient with a short life expectancy who is not a candidate for liver transplantation, fasciotomy is not indicated. Fasciotomy should be used selectively, if at all, in patient population with end-stage and terminal diseases.

Percutaneous tracheostomy in neurosurgical patients with intracranial pressure monitoring is safe.

BACKGROUND: Percutaneous tracheostomy (PT) is performed routinely on neurosurgical patients in many critical care units. Some of these patients suffer from severe brain injury and require intracranial pressure (ICP) monitoring. It remains uncertain whether this procedure causes an increase in ICP or jeopardizes the cerebral perfusion pressure (CPP) in these patients. We studied the effects of PT on ICP and CPP in this group of patients. METHODS: Our study group consisted of 52 neurosurgical patients in the surgical intensive care unit of an urban, Level I Trauma Center who had ICP monitoring and underwent PT between 2001 and 2005. Data were collected from 24 hours before to 24 hours after PT. ICP, CPP, and Glasgow Coma Score (GCS) scale were measured hourly during the study period. RESULTS: There was no statistically significant change in the mean ICP over the 48-hour study period or after the procedure. There was a temporary increase in ICP during the procedure (1.60 mm Hg) which was statistically not significant. There was statistically significant increase in the mean CPP after the procedure, although this increase was clinically not significant. The risk of having a critically high ICP (>20 mm Hg) or low CPP (<60 mm Hg) values did not increase after the procedure. There was no significant change in GCS after the procedure. CONCLUSION: PT in neurosurgical patients with ICP monitor does not cause clinically significant or hazardous changes in ICP, CPP, and GCS. We therefore consider PT to be safe in neurosurgical patients.

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Percutaneous endoscopic-guided gastrostomy (PEG) is done routinely on patients who suffer from inability to feed by mouth. PEG is generally considered a safe procedure with a low complication rate. A commonly underreported complication of PEG is malposition. This manuscript is a guideline to diagnosis and management of PEG malposition. We describe the different types of malposition, their diagnosis and management.

Early pneumoperitoneum after percutaneous endoscopic gastrostomy in intensive care patients: sign of possible bowel injury.

BACKGROUND: Although percutaneous endoscopic gastrostomy may be complicated by iatrogenic bowel injury, most clinicians consider a small pneumoperitoneum on radiographs obtained after the procedure a benign finding of little clinical consequence. The possibility of a relationship between findings of early pneumoperitoneum after percutaneous endoscopic gastrostomy and subsequent iatrogenic bowel injury was examined. METHODS: Charts of 85 patients in a surgical intensive care unit who had undergone percutaneous endoscopic gastrostomy between 2000 and 2005 were retrospectively reviewed. All patients had a follow-up upright chest radiograph obtained after percutaneous endoscopic gastrostomy. The charts of 4 patients with radiographs that showed early pneumoperitoneum were reviewed. RESULTS: Findings were clinically significant in 1 of the 4 patients. That patient had a perforated transverse colon that required surgical repair. The other 3 patients had no complications. CONCLUSION: Pneumoperitoneum after percutaneous endoscopic gastrostomy may be a sign of possible bowel injury and requires further evaluation. It should not be dismissed as benign. Obtaining a chest radiograph after a patient has undergone percutaneous endoscopic gastrostomy is essential.

Cecal vascular malformation mimicking appendicitis in a child.

A 5-year-old girl presented with abdominal pain suggestive of appendicitis. Intraoperatively, a solid cecal mass was identified along with mesenteric adenopathy. A right hemicolectomy was performed. Pathologic examination revealed a vascular malformation with evidence of recent hemorrhage.