Use of biodegradable (PGA) fabric for repair of solid organ injury: a combined institution experience

Autologous omentum transposition for regeneration of a renal injury model in rats

BACKGROUND

After renal trauma, surgical treatment is vital, but sometimes there may be loss of function due to fibrosis. This study aimed to evaluate the effect of autologous omentum flaps on injured renal tissues in a rat model.

METHODS

A total of 30 Wistar albino rats were included and randomly divided equally into a control group and four intervention groups. Iatrogenic renal injuries were repaired using a surgical technique (primary repair 1 group and primary repair 2 group) or transposition of the autologous omentum (omentum repair 1 group and omentum repair 2 group). Blood samples were taken preoperatively and on the 1st and 7th postoperative days in all groups and on the 18th postoperative day in the control and two intervention groups. All rats were sacrificed on the 7th or 18th day postoperatively, and their right kidneys were taken for histopathological evaluation.

RESULTS

The mean urea level significantly decreased from day 1 to day 7 and from day 1 to day 18 in the omentum repair 2 group (P = 0.005 and P = 0.004, respectively). There were no other significant changes in urea or creatinine levels within the intervention groups (P > 0.05). There was no significant correlation between the urea and creatinine levels and the histological scores (P > 0.05). The primary repair 1 and 2 groups had significantly higher median granulation and inflammation scores in the kidney specimen than the control and omentum repair groups (P < 0.05). The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group (P < 0.05). The completion score for the healing process in the kidney specimen was significantly higher in the omentum repair groups than in the primary repair groups (P < 0.05). The omentum repair 2 group had significantly lower median granulation and inflammation scores in the surrounding tissues than the primary repair 2 group (P < 0.05). Granulation degree in the kidney specimen was strongly and positively correlated with the inflammation degree (r = 0.824, P < 0.001) and foreign body reaction in the kidney specimen (r = 0.872, P < 0.001) and a strong and negative correlation with the healing process completion score in the kidney (r = - 0.627, P = 0.001). Inflammation degree in the kidney specimen was strongly and positively correlated with the foreign body reaction in the kidney specimen (r = 0.731, P = 0.001) and strongly and negatively correlated with the healing process completion score in the kidney specimen (r = - 0.608, P = 0.002).

CONCLUSION

Autologous omentum tissue for kidney injury repair attenuated inflammation and granulation. Additionally, the use of omental tissue to facilitate healing of kidney injury may theoretically lead to a more effective healing process and reduced fibrosis and tissue and function loss.

Iatrogenic liver trauma managed with mesh-wrapping and ligation of portal vein branch: A case report

INTRODUCTION

Liver trauma is a critical condition that requires swift multidisciplinary approach. In complex hepatic injuries perihepatic packing is an established life-saving procedure. The aim of this study is to evaluate and highlight the value of absorbable mesh wrapping of the injured liver, combined with ipsilateral ligation of portal vein branch.

CASE PRESENTATION

An 82-year-old patient underwent an open cholocystectomy, for gallbladder empyema. The second postoperative day he was re-operated on due to active hemorrhage. The bleeding was controlled by suturing the bed of the gallbladder fossa. During this maneuver a portal vein branch was torn resulting in a rapidly expanding subcapsular liver hematoma which led to the formation of two deep lacerations on the liver parenchyma. This life-threatening condition was treated by wrapping an absorbable mesh around the right liver lobe and subsequently ligating the right portal vein branch extrahepaticaly.

CONCLUSION

Mesh wrapping of the fragmented liver with absorbable mesh constitutes a safe and effective method, in treating grade IV and V liver injuries, especially when combined with ipsilateral ligation of the bleeding vessel.

Beyond splenectomy — options for the management of splenic trauma

The spleen remains a vulnerable organ to blunt or penetrating abdominal trauma and recognition of its important immunological role has meant that alternatives to mandatory splenectomy for splenic injury are now available. This article examines the alternatives to splenectomy and then discusses the post-splenectomy management of patients.

Utilidad de las mallas reabsorbibles en los traumatismos esplénicos

INTRODUCTION

The spleen is not an essential organ for survival but given its important role in immunologic functions its preservation is justified.

OBJECTIVE

To analyze our experience with absorbable meshes applied to treat splenic injuries.

PATIENTS AND METHOD

We performed an ambispective study. From July 1999 to February 2004, 30 patients were treated for traumatic splenic injuries. Ultrasonography and/or spiral computed tomography scanning was carried out for the initial screening evaluation and grading of splenic injuries. The New Injury Severity Score (NISS) was calculated to quantify the severity of trauma. Operative splenic preservation was performed according to established selection criteria. Splenorrhaphy with prosthetic material was accomplished by means of a bag of polyglycolic acid mesh measuring 18 cm yen 23 cm (Dexon mesh) that was hand tailored and wrapped around the entire surface of the spleen.

RESULTS

Thirty patients with splenic traumatic injuries were treated. The mean age was 36.2 +/- 16.6 years. Twenty-three patients (76.6%) required splenectomy, nonoperative management was achieved in 1 patient (3.3%), and splenorrhaphy with prosthetic material was carried out in 6 patients (20%). Grade III injuries were present in 13 patients (43.3%), grade IV in 13 patients (43.3%), and grade V in 4 patients (13.3%). The mean NISS was 18.9 +/- 9.1. No significant differences were detected between the two groups (splenectomy or mesh splenorrhaphy) in NISS (p=.53) or grade of splenic injuries (p=.69). Morbidity was related to the presence of multiple injuries (p=.002) and was greater in the group with mesh splenorrhaphy (p=.002); however, there were no septic complications in this group. A positive correlation was observed between the length of hospital stay and NISS (p=.01). The length of hospital stay was also significantly associated with the presence of multiple injuries (p=.005) and with morbidity (p=.0002), but was not associated with the type of surgery carried out (p=.17). No complications were observed during follow-up (median of 28 months) in patients who underwent splenic salvage procedures.

CONCLUSIONS

Mesh splenorrhaphy is a suitable therapeutic option for patients with severe trauma, grade IV splenic injuries, or delayed rupture of the spleen. Both morbidity and length of hospital stay were associated with the presence of multiple injuries rather than with the type of surgery carried out. The safety, effectiveness and absence of septic complications related to the use of prosthetic material in splenic trauma salvage surgery were notable.

Mesh wrap in severe pediatric liver trauma

PURPOSE

This study reviews the authors' experience in treating severe pediatric liver injuries with absorbable mesh wrapping. The authors found this relatively new therapeutic method very useful in selected cases, although its use is not very common in children. The authors analyze the indication describe some technical aspects, and discuss the advantages and the pitfalls of the method.

METHODS

In a 10-year period between 1990 and 2000, 181 children were admitted to Hillel-Yaffe Medical Center with blunt hepatic trauma. A total of 132 children were treated conservatively, and 49 (27%) were operated on. The operated group included 35 cases of isolated liver injuries and 14 cases of additional intraabdominal injuries. Thirty-four children were operated on between 1990 and 1995 (36% of 96 children), whereas between 1995 and 2000, 15 children were operated on (17% of 85 children), including 4 children aged 18 months to 15 years with massive liver bleeding who were treated with mesh wrap technique. The retrospective analysis of these 4 cases indicates a progressive policy in the recognition of cases suitable for mesh wrapping and gallbladder conservation.

RESULTS

The perihepatic mesh wrap technique controlled the bleeding in all children. In 3 of them the right lobe was wrapped, and, in 1 case, total liver wrapping was performed. Hepatic enzymes and bilirubin levels were elevated in the first 3 to 7 days and declined gradually to normal levels. The perihepatic mesh was not an obstacle to a transcutaneous drainage of an intrahepatic biloma. All 4 children returned to normal physical activities.

CONCLUSIONS

Liver mesh wrap is a simple, effective, and rapid way to obtain hemostasis and to conserve parenchyma in severe traumatized liver. The decision to wrap the liver should be done early to prevent acidosis and hypothermia. Cholecystectomy is not an integral part of the procedure in children. The morbidity is low, and most of the complications can be treated nonsurgically.

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

OBJECTIVE

To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject.

METHODS

A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale.

RESULTS

There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized.

CONCLUSIONS

Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.

Dexon Mesh Splenorrhaphy for Intraoperative Splenic Injuries

The preferred management option for intraoperative splenic injuries is organ repair and preservation rather than splenectomy given the important immunologic function of the spleen. Wrapping the injured spleen with a Dexon mesh has been shown to be an effective alternative to splenectomy for significant splenic bleeding. However, this technique uses a foreign body that carries a theoretical infectious risk particularly in cases in which the alimentary tract has been opened. This study was undertaken to evaluate whether Dexon mesh splenorrhaphy when used for intraoperative splenic injuries was associated with significant infectious complications. The clinical courses of 23 patients who had Dexon mesh splenorrhaphy performed at a university teaching hospital for intraoperative splenic injury from 1991 to 1999 were reviewed. Eleven patients (48%) had their gastrointestinal tract opened during the surgery. No patients developed an intra-abdominal abscess or required reoperation for bleeding. The most common postoperative complications were left lower lobe atelectasis (18 patients, 78%), postoperative fever (13 patients, 56%), and left pleural effusion (12 patients, 52%). Dexon mesh splenorrhaphy effectively controls splenic bleeding due to intraoperative injury without significant infectious complications.

Can we evaluate the pressure of perihepatic packing? Results of a study on dogs

The pressure of perihepatic packing can cause organ perfusion disturbances. The problem is to determine the pressure applied during the operative procedure. The objective of this animal study was to assess the perihepatic packing pressure and its effect on the pressure in the inferior vena cava (IVC). In order to assess the pressure in the IVC a catheter was introduced through the femoral vein. A rearranged tourniquet for blood pressure measurement was placed on the dog liver and with various perihepatic pressures the resulting pressures in the IVC were assessed. It was established, that by applying pressure of 30 mm Hg to the liver, the pressure in the IVC did not exceed 10 cm of water. Two clinical cases are reported where the method was shown to be crucial for the management. The first one is related to haemodynamic instability after successful perihepatic packing for grade V injury. In the second case, an otherwise stable patient had significantly elevated pressure in the IVC, which crucially influenced the treatment. The introduction of a catheter into the IVC to monitor the pressure in patients with liver injuries is useful.