Analysis of 162 Colon Injuries in Patients with Penetrating Abdominal Trauma: Concomitant Stomach Injury Results in a Higher Rate of Infection

0.05% Chlorhexidine Gluconate Irrigation in Trauma/Emergency General Surgical Laparotomy Wounds Closure: A Pilot Study

INTRODUCTION

Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSIs) compared to the elective setting. Packaged Food and Drug Administration-approved 0.05% chlorhexidine gluconate (CHG) irrigation solution reduces SSI rates in nonemergency settings. We hypothesize that the use of 0.05% CHG irrigation solution prior to closure of emergent EL incisions will be associated with lower rates of superficial SSI and allows for increased rates of primary skin closure.

METHODS

A retrospective observational study of all emergent EL whose subcutaneous tissue were irrigated with 0.05% CHG solution to achieve primary wound closure from March 2021 to June 2022 were performed. Patients with active soft-tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test and chi-square test, were used to compare groups as appropriate. A P value <0.05 was statistically significant.

RESULTS

Sixty-six patients with a median age of 51 y (18-92 y) underwent emergent EL. Primary wound closure is achieved in 98.5% of patients (65/66). Bedside removal of some staples and conversion to wet-to-dry packing changes was required in 27.3% of patients (18/66). We found that most of these were due to fat necrosis. We report no cases of fascial dehiscence.

CONCLUSIONS

In patients undergoing EL, intraoperative irrigation of the subcutaneous tissue with 0.05% CHG solution is a viable option for primary skin closure. Further studies are needed to prospectively evaluate our findings.

Contrast study after gastric repair: a review of incidence, outcomes and risk factors at an adult level 1 trauma center

PURPOSE

The role of contrast study after traumatic gastric repair, continues to be controversial. To that end, we aim to review the incidence, outcomes, and risk factors of patients undergoing contrast study after traumatic gastric repair.

METHODS

This was a retrospective review of all trauma patients admitted to a level 1 trauma center that sustained gastric injuries with subsequent repair between 2011 and 2018. Demographics, surgical interventions, complications, and clinical outcomes were evaluated. Statistical analysis included Chi-square/Fisher exact univariate analysis and multivariate logistic regression analysis with a 5% significance level.

RESULTS

A total of 233 patients received a gastric repair, of whom 49 (21%) had a contrast study performed. Out of 49 patients with a contrast study, one was found to have a gastric leak. Mean time to contrast study was 6.3 ± 2.7 days. There was no statistically significant difference in post-operative complications between non-contrast and contrast study groups. Multivariate logistic regression analysis demonstrated a lack of statistical significance in clinical risk factors that would lead to obtaining a contrast study.

CONCLUSION

Gastric leak after repair is rare and there is no statistically significant difference in clinical outcomes when comparing patients who underwent contrast study to those who did not. Routine contrast study after traumatic gastric repair may not be necessary and further evidence is warranted to determine the risk factors for a selective contrast study.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

BACKGROUND

Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties.

METHODS

Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals.

RESULTS

Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively.

CONCLUSIONS

Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

Primary Skin Closure after Repair of Hollow Viscus Injuries

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender ( P = 0.03) and base deficit were associated ( P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs ( P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.

Colon Trauma: Evidence-Based Practices

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

Traumatic colon injury in damage control laparotomy-A multicenter trial: Is it safe to do a delayed anastomosis?

BACKGROUND

Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes.

METHODS

A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma.

RESULTS

Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06).

CONCLUSIONS

DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught

BACKGROUND

Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI.

PATIENTS AND METHODS

Patients age ≥18 who underwent trauma laparotomy (TL) or damage control laparotomy (DCL) from 2008-2013 and had class III/IV wounds were included. Demographic, injury, treatment, and outcome variables were compared based on skin closure methods: Primary closure, intermittently stapled with wicks, or open management. Subgroup analyses for TL, DCL, and high-risk patients with stomach, colon, or rectal injuries were performed. Bivariable and multivariable logistic regression (MLR) analyses were performed to identify risk factors for superficial/deep SSI and surgical incision complications.

RESULTS

A total of 348 patients were included. The median age was 47 years; 14% were female; 21% had blunt injuries. Overall SSI was highest for open incisions (p < 0.05), but there was no difference in superficial/deep SSI. Primary closures healed a median of 20 days, compared with 68 and 71 days for the intermittently stapled and open groups, respectively (p < 0.001). Primary closure in TL and high-risk patients also had the lowest SSI rates (all p < 0.05), but there were no differences in superficial/deep SSI in any subgroup. In TL patients, diabetes mellitus and colon injuries were independently associated with the development of superficial/deep SSI and surgical incision complications; however, skin closure method was not.

CONCLUSION

In class III and IV wounds, primary closure was associated with the lowest SSI, shortest length of stay and healing time. Method of skin closure, however, did not have an independent effect on the development of superficial/deep SSI or surgical incision complications. These suggest that primary skin closure in contaminated and dirty abdominal wounds may be performed more safely than commonly perceived.

Factors Associated With Risk of Surgical Wound Infections

Surgical wound infections are the most common hospital-acquired infections among patients who undergo inpatient surgery. Risk of infection is a function of both patient susceptibility and exposure. The authors studied all discharges in Pennsylvania from October 1, 2004, through September 30, 2005, in which a circulatory (n= 65 940), neurological (n= 6706), or orthopedic (n = 107 825) procedure was performed using data from the Pennsylvania Health Care Cost Containment Council. They estimated the impact of patient-specific factors on risk of infection and compared the ability of these factors to predict infections relative to hospital effects. Results suggested that for all 3 types of procedures, patient-specific factors were a significant determinant of risk of surgical wound infection. However, prediction of infection was improved by 23% to 33% when hospital fixed effects were included. Although patient-specific factors had a statistically significant association with risk of infections, much of the risk of surgical wound infections is determined by hospital factors.

Synergistic Effect of Combined Hollow Viscus Injuries on Intra-Abdominal Abscess Formation

The strong association between penetrating colon injuries and intra-abdominal abscess (IAA) formation is well established and attributed to high colon bacterial counts. Since trauma patients are rarely fasting at injury, stomach and small bowel colony counts are also elevated. We hypothesized that there is a synergistic effect of increased IAA formation with concomitant stomach and/or colon injuries when compared to small bowel injuries alone. Consecutive patients at a level one trauma center with penetrating small bowel (SB), stomach (S), and/or colon (C) injuries from 1996 to 2012 were reviewed. Logistic regression determined associations with IAA, adjusting for age, gender, Injury Severity Score (ISS), admission Glasgow Coma Score, transfusions, and concurrent pancreas or liver injury. A total of 1518 patients (91% male, ISS = 15.9 ± 8.4) were identified: 496 (33%) SB, 231 (15%) S, 288 (19%) C, 40 (3%) S + SB, 69 (5%) S + C, 338 (22%) C + SB, and 56 (4%) S + C + SB. 148 (10%) patients developed IAA: 4 per cent SB, 9 per cent S, 10 per cent C, 5 per cent S + SB, 22 per cent S + C, 13 per cent C + SB, and 25 per cent S + C + SB. Multiple logistic regression demonstrated that ISS, 24 hour blood transfusions, and concomitant pancreatic or liver injuries were associated with IAA. Compared with reference SB, S or S + SB injuries were no more likely to develop IAA. However, S + C, SB + C, and S + C + SB injuries were significantly more likely to have IAA. In conclusion, combined stomach + colon, small bowel + colon, and stomach, colon, + small bowel injuries have a synergistic effect leading to increased IAA formation after penetrating injuries. Heightened clinical suspicion for IAA formation is necessary in these combined hollow viscus injury patients.

MDCT of complications and common postoperative findings following penetrating torso trauma

Victims of penetrating torso trauma often present with findings that necessitate emergent exploratory laparotomy, precluding scanning with multidetector computed tomography (MDCT) until the postoperative period. This article reviews the wide range of complications as well as expected findings that may be encountered at MDCT performed postoperatively. Little has been written to guide the radiologist in interpreting these often complex and potentially confusing studies.

Colon diversion versus primary colonic repair in gunshot abdomen with penetrating colon injury in Libyan revolution conflict 2011 (a single center experience)

PURPOSE

The objective of this study is comparing colon diversion versus primary repair in penetrating colon gunshot injuries.

METHODS

A retrospective study of 63 cases of gunshot abdomen with penetrating colon injury were admitted to Al-jalla Hospital in 2011 in Benghazi, Libya. After surgical intervention, these patients were observed for any postoperative complications.

RESULTS

During the study period, 63 eligible patients included, 62 (98.4%) were males and 1 (1.6%) was female. And the mean age was 29.24 years. Eighteen patients had an injury on the right side of the colon, while 16, 6, 11, 6, 2, 3, and 1 patients had an injury on the transverse, left, sigmoid, rectum, right transverse, left transverse, and total colonic injury, respectively. In the first group, 23 patients (36.5%) was treated with colon diversion, (2 with Hartmann's operation, 21 with loop colostomy). In the second group, 40 patients (63.4 %) was treated with primary repair. Eighteen (28.5%) with right hemicolectomy, 5 (7.9%) with transverse colon resection and anastomosis, and 17 (26.9%) with simple repair. We evaluate the rate of postoperative complication and compare the postoperative morbidity between both groups.

CONCLUSION

In our study, there was no significant statistical difference between types of operations and rate of complications (P = 0.18). We could not see any advantage of the diversion over the primary repair. To reduce risk of the psychological trauma, complications of colostomy, unnecessary repeated hospitalization, decrease of economic cost, and complications of stoma revision operation, we should consider that the primary repair of penetrating colon injuries is an acceptable alternative method of treatment over the colostomy.

Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement

BACKGROUND

Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates.

METHODS

Patients who underwent trauma laparotomy (2004-2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence.

RESULTS

Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0-40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013).

CONCLUSION

Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients.

LEVEL OF EVIDENCE

Therapeutic study, level III.

The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies

OBJECTIVES

Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections (SSI) after trauma laparotomy.

BACKGROUND

Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery, the effects of intraoperative hypothermia on SSI remain unstudied in trauma.

METHODS

A review of all patients (July 2003-June 2008) who survived 4 days or more after urgent trauma laparotomy at a level I trauma center revealed 524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of intraoperative hypothermia, were evaluated. The primary outcome measure was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the entire range of lowest intraoperative temperature measurements established the temperature nadir that best predicted SSI development. Single and multiple variable logistic regression determined SSI predictors.

RESULTS

The mean intraoperative temperature nadir of the study population (n = 524) was 35.2°C ± 1.1°C and 30.5% had at least 1 temperature measurement less than 35°C. Patients who developed SSI (36.1%) had a lower mean intraoperative temperature nadir (P = 0.009) and had a greater number of intraoperative temperature measurements <35°C (P < 0.001) than those who did not. Cut-point analysis revealed an intraoperative temperature of 35°C as the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than 35°C independently increased the site infection risk 221% per degree below 35°C (OR: 2.21; 95% CI: 1.24-3.92, P = 0.007).

CONCLUSIONS

Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia less than 35°C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained in patients undergoing operative trauma procedures.

Prevention of infections associated with combat-related thoracic and abdominal cavity injuries

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Microbiological profile and antimicrobial susceptibility in surgical site infections following hollow viscus injury

INTRODUCTION

The purpose of this study was to assess the microbiological profile, antimicrobial susceptibility, and adequacy of the empiric antibiotic therapy in surgical site infections (SSI) following traumatic hollow viscus injury (HVI).

METHODS

This is a retrospective study of patients admitted with an HVI from March 2003 to July 2009. SSI was defined as a wound infection or intra-abdominal collection confirmed by positive cultures and requiring percutaneous or surgical drainage.

RESULTS

A total of 91 of 667 (13.6%) patients with an HVI developed an SSI confirmed by positive culture. Mean age was 33.0 +/- 14.1 years, mean Injury Severity Score (ISS) was 17.7 +/- 9.6, 91.2% were male, and 80.2% had sustained penetrating injuries. The SSI consisted of 65 intra-abdominal collections and 26 wound infections requiring intervention. The most commonly isolated species in the presence of a colonic injury was Escherichia coli (64.7%), Enterococcus spp. (41.2%), and Bacteroides (29.4%), and in the absence of a colonic perforation, Enterococcus spp. and Enterobacter cloacae (both 38.9%). Susceptibility rates of E. coli and E. cloacae, respectively, were 38% and 8% for ampicillin/sulbactam, 82% and 4% for cefazolin, 96% and 92% for cefoxitin, with both 92% to piperacillin/tazobactam, and 100% to ertapenem. The initial empirical antibiotic therapy adequately targeted the pathogens in 51.6% of patients who developed an SSI.

CONCLUSION

The distribution of the microorganisms isolated from SSIs differed significantly according to whether or not a colonic injury was present. Empiric antibiotic treatment was inadequate in upwards of 50% of patients who developed an SSI. Further investigation is warranted to determine the optimal empiric antibiotic regimen for reducing the rate of postoperative SSI.

Impact of Hollow Viscus Injuries on Outcome of Abdominal Gunshot Wounds

Abdominal gunshot wounds (GSW) are a source of morbidity and mortality. Limited data are available on the effect of hollow viscus injuries (HVI) secondary to gunshot wounds. GSW sustained in the Louisville area from 2004 to 2007 were reviewed. Attention was given to the impact of HVI from abdominal GSW. Statistical significance was determined. One-hundred ten patients sustained GSW with peritoneal violation. Eighty-six had HVI. Eighteen died after laparotomy with 15 having an HVI. Patients undergoing damage control (DC) have a significant increase in mortality compared with those not requiring DC. Exsanguination was the major cause of mortality (67%). Mortality directly related to HVI was found in 11 per cent. Twenty patients underwent DC with 11 deaths. Isolated HVI did not show a significantly increased mortality compared with other injury patterns involving solid organ or major vascular structures. Various methods of repair showed no significant survival advantage. Recognition and repair of HVI in abdominal GSW is crucial to patient salvage. Definitive repair of HVI at the initial operation should be considered. Primary repair of HVI is preferred although no survival disadvantage is seen in other forms of repair in marginally stable patients. Definitive repair at the initial operation decreases complications.

The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality

It is presumed that as the number of gunshot wounds (GSWs) increases, so do the Injury Severity Score (ISS) and mortality risk. We hypothesized that the number of bullet wounds relates to ISS and death; however, a single GSW to the head is ominous. We reviewed the charts of all GSW patients admitted to a trauma center from 2004 to 2006 (n = 531). We analyzed patient demographics, ISS, and mortality. There was no correlation with the number of GSWs with either ISS or mortality. There was only a 0.3 per cent increased risk of death for each additional GSW ( r2 = 0.12). Patients with a single GSW versus multiple GSWs had no difference in mortality (9.1 vs 8.4%, P = 0.8). A single GSW to the head carried a 50 per cent mortality risk. For those who sustained both head and body GSWs, each additional GSW did not increase mortality ( r2 = 0.007). Our study shows that the number of GSWs has no affect on mortality or ISS. Internal triage and management of gunshot victims should not be affected by the categorization of patients as having a single versus multiple GSWs.

Gastric Injury Increases Infections in Trauma Patients

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.

Can gastric irrigation prevent infection during NOTES mesh placement?

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) ventral hernia repair could avoid abdominal wall incisions. The infectious risk for mesh placement is of concern. We compared NOTES with laparoscopic mesh placement.

METHODS

Thirty-seven swine were randomized to abdominal wall polypropylene mesh placement via NOTES or laparoscopy or NOTES control. All animals received antibiotics and gastric irrigation; the laparoscopy group also received preoperative acid suppression. In the NOTES mesh group, the 2-cm(2) polypropylene mesh was placed using a transgastric transportation device and clipped to the anterior abdominal wall. The control animals underwent endoscopy (no gastrotomy) followed by laparoscopic mesh placement or NOTES only without mesh placement. Necropsy was performed at 14 days.

RESULTS

One NOTES mesh placement was incomplete (endoscope failure). All mesh animals survived to 14 days. At necropsy, significantly more mesh infections were noted in the NOTES mesh versus laparoscopy group (4:11 vs 0:14; p = 0.03). Gastric irrigation reduced the bacterial load significantly in all groups (p < 0.001). Infection was independent of gastric bacterial load. No difference between acid suppressed and non-suppressed animals was seen.

CONCLUSION

The mesh placement via NOTES is technically feasible but has a high infection rate despite irrigation. Sterile conduits are needed to enable NOTES-type hernia repair with mesh.

Factors affecting prognosis in patients with gastric trauma

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P < 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs. 87 of 492 or 18%; P < 0.001), required more blood (16+/-16 U vs. 6+/-11 U; P < 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs. 75 of 492 or 15%; P = 0.001), and had an increased length of stay (20+/-30 days vs. 13+/-18 days; P = 0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.

Das Abdominaltrauma

Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.