Trends in clinical outcomes are seen including reduced length of stay, time to emergency department assessment and surgery, supplemented by non-clinical outcomes including reduced after hours operating and the potential for increased training opportunities. The published data presents certain weaknesses and further information is required to appreciate the applicability of certain aspects of the ASU model to smaller centres.
Backgrounds: Laparostomy is a common means of managing surgical catastrophes, but often results in large ventral hernias which prove difficult to repair. It is also associated with high rates of enteric fistula formation. Dynamic methods of managing the open abdomen have been shown to result in higher rates of fascial closure and fewer complications. Recent publications have suggested the addition of chemical components relaxation with botulinum toxin has an added advantage over prior methods. Methods: We report on a series of emergent cases managed by the combination of Botulinum toxin A (BTA) mediated chemical relaxation with a modified method of meshmediated fascial traction (MMFT) and negative pressure wound therapy (NPWT). Results: Thirteen cases (nine laparostomies and four fascial dehiscence) were successfully closed in a median of 12 days, using a median of 4 'tightenings', with no clinical herniation detected at follow up so far (median 183 days, IQR 123-292). There were no procedurerelated complications, but one death from the underling pathology. Conclusions: We report further cases of vacuum assisted mesh-mediated fascial traction (VA-MMFT) utilizing BTA in successfully managing laparostomy and abdominal wound dehiscence and continues the known high rate of successful fascial closure seen when applied in treating the open abdomen.
Purpose: Ileostomy volvulus is a rare cause of small bowel obstruction. We present an unusual case of ileostomy volvulus without the presence of adhesions. Additionally, a systematic literature review was performed to collate the current literature on the causes, diagnosis, treatment, and preventative measures of ileostomy-related small bowel obstruction. Methods: PubMed (Medline), Embase, Google Scholar, Scopus, and Cochrane CENTRAL were searched from their inception up to August 2022. This study adhered to the PRISMA guidelines and was registered on PROSPERO. The primary outcomes included patients' demographics, imaging modality, indication for initial surgery, type and configuration of stoma, surgical treatment, and recurrence of volvulus. The quality of included studies was assessed using the Murad tool. Written informed consent was obtained from the patient. Results: Seven studies were included, comprising 967 patients. Stoma outlet obstruction (SOO) was reported in all 159 patients, and 12 had ileostomy volvulus as the cause. A majority of patients had loop ostomies for ileostomy volvulus. No complications or mortality were reported in the included studies, and half of the included studies were deemed to be of good quality. Conclusion: This case demonstrates the need for high clinical suspicion of SOO in patients with loop ileostomy, and rapid management should be undertaken. Whilst loop ileostomies, increased rectus abdominal muscle thickness, and lower preoperative total glucocorticoid dosage are associated with SOO, large-scale retrospective studies are needed to validate our findings.
Survival after retroperitoneal necrotizing fasciitis in a 48-year-old immunocompetent man: the importance of a multidisciplinary approach Retroperitoneal necrotizing fasciitis (RNF) is a rare and potentially life-threatening condition. Main clinical features consist of severe abdominal pain, 1 fever, tachycardia and shock. 2,3 Risk factors include immunosuppression and recent surgery. 2,3 It is often accompanied by a systemic inflammatory response syndrome and frequently requires intensive care support. [4][5][6][7] Necrotizing fasciitis (NF) is most commonly seen in the extremities and perineum, rarely involving the retroperitoneal space. Causes of retroperitoneal infection include perforated diverticulitis, appendicitis, colon cancer, perianal abscess, pyelonephritis and pancreatitis. 1 RNF is caused by rapid proliferation of microorganisms and is often polymicrobial. 3,8 Significant morbidity and mortality are associated not only with the disease process itself, but also with the extensive surgical debridements required. 9 The median mortality of NF is debated; however, it is essentially fatal without intervention and approximately 20-50% with aggressive intervention. 2-8 This is likely significantly higher with retroperitoneal involvement, potentially due to delayed diagnosis from presentation. Mortality
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