Laparoscopic management of left thoracoabdominal stab wounds: a prospective study.

BACKGROUND: Left thoracoabdominal stab wounds (LTSWs) leading to diaphragmatic injuries can cause serious morbidity and mortality. The diagnosis and treatment of LTSWs are controversial. This study investigated the reliability of laparoscopy for the diagnosis and treatment of diaphragmatic lacerations in hemodynamically stable patients with an LTSW, hypothesizing that laparoscopy is sufficient for diagnosing and treating diaphragmatic injury after an LTSW. METHODS: This study included 36 cases of LTSWs with no hemodynamic instability or abdominal tenderness seen between June 2002 and June 2007. After systemic examination and resuscitation of the patients, chest x-ray and focused assessment with sonography for trauma were carried out and then laparoscopic exploration was performed in all cases. RESULTS: Of the 36 cases, 36.1% (n=13) had injuries to the diaphragm and 53.8% (7/13) had associated intraabdominal injuries. Nine (69.2%) of the patients with diaphragmatic injuries, but no hollow organ injuries, were repaired through laparoscopy. The hemopneumothorax was found in 33.3% (n=12) of the patients. No relationship was seen between diaphragmatic injuries and the location of the LTSW and existence of hemopneumothorax. CONCLUSIONS: Laparotomy was required in only 11.1% (4/36) of the cases with LTSWs and 30.8% (4/13) of the cases with diaphragmatic injury. Diagnostic and therapeutic laparoscopy was a sufficient and necessary surgical procedure in cases with a hemodynamically stable LTSW, when emergency surgery (laparotomy or thoracotomy) was not necessary.

Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study.

AIM: The results of controlled-intermittent anal dilatation (CIAD) or lateral internal sphincterotomy (LIS) in the treatment of chronic anal fissures are presented. MATERIAL AND METHODS: Forty patients who were randomized to two groups underwent CIAD or a LIS. The pre- and post-operative mean anal canal resting pressures (MACRPs) and symptoms were recorded and the results were compared. RESULTS: Two months post-operatively, 18 patients in the CIAD group and 17 patients in the LIS group had healed completely, and had no anal incontinence or other complications. The post-operative improvement in pain, bleeding, and constipation did not differ significantly between the two groups. In the CIAD and LIS groups, the pre-operative MACRPs were 89.7+/-16.5 and 87.6+/-12.3 mmHg, respectively; 2 months post-operatively, the MACRPs had significantly decreased to 76.9+/-13.7 and 78.1+/-11.3 mmHg in the CIAD and LIS groups, respectively. No statistical difference existed in the pre- or post-treatment MACRPs between the groups. CONCLUSION: CIAD applied with a standardized technique reduced anal canal resting pressure and provided symptomatic healing that was equivalent to a LIS. Since there were no findings of incontinence, or situations which resulted in sphincter damage, we conclude that CIAD is suitable for patients with chronic anal fissures because it is less invasive than LIS, with equivalent efficacy and safety. In addition, the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence.

Laparostomy in patients with severe secondary peritonitis.

BACKGROUND: The aim of this study was to evaluate the effectiveness of laparostomy with the Bogota bag for the management of patients with severe secondary peritonitis and the risk factors for survival. METHODS: Thirty-seven patients (22 males, 15 females; mean age 63.5; range 44 to 83 years) with secondary peritonitis were treated by laparostomy and temporary closure with Bogota bag. APACHE II scores and Mannheim Peritonitis Index (MPI) were used to calculate the disease severity. The outcomes and effectiveness of APACHE II and MPI values were analyzed retrospectively. RESULTS: The mortality rate was 43.2%. Significant differences were noted between survivors and non-survivors according to initial APACHE II and MPI scores and the number of operations. The non-survivors had higher APACHE II (r=0.81, p=0.001) and MPI (r=0.39, p=0.02) scores. The patients who survived were re-operated 1.6 times and those who died were re-operated 4.7 times. In five patients, laparostomy was closed primarily, while in the others, the wound was left open to heal secondarily. CONCLUSION: Patients with higher APACHE II and MPI scores and number of operations had higher rates of mortality due to their major risk factors. Temporary abdominal closure using the Bogota bag in patients with secondary peritonitis is an inexpensive-simple method, permitting evaluation of underlying viscera and recognition of infection.