Rapid Bedside Ultrasound Evaluation of a Ruptured Abdominal Aortic Aneurysm With a Prior Repair

ABSTRACT Ruptured aortic aneurysms carry a high risk of morbidity and mortality, particularly if not rapidly identified. We present an 87-year-old male, with a history of hypertension and prior endovascular aortic repair, who presented to the Emergency Department (ED) with several days of epigastric abdominal pain radiating to his back and flanks. The patient acutely deteriorated in the ED, and point-of-care ultrasound rapidly identified active extravasation from an abdominal aortic aneurysm with visualization of prior endograft. Point-of-care ultrasound in this patient expedited the diagnosis, resuscitation, and transfer to the operating room with definitive repair by vascular surgery. The patient recovered and was discharged in stable condition.

P109 MANAGEMENT OF THE OPEN ABDOMEN WITH COMBINED THERAPIES. HOW TO AVOID VENTRAL HERNIAS AND BE ABLE TO PERFORM THE REPAIR OF THE ABDOMINAL WALL IN A DEFINITIVE WAY

Aim To demonstrate that in patients with abdominal sepsis, delayed primary fascial closure and definitive abdominal wall repair can be achieved, in the same hospitalization, using combined therapies, which reduces the percentage of ventral hernias. Material and Methods Medical records, tomography images and outpatient controls of 9 patients were reviewed, which required open abdomen management for abdominal sepsis using negative pressure therapy combined with a dynamic fascial mesh traction, from February 2020 until May 2021. Results 9 patients (2 men and 7 women), all Grade 2C open abdomen according to Björck clasification, with a median age of 43 years (25-71). The median time therapy was 29±3 days. The primary fascial closure rate was 100% (n = 9), 77.8% (n = 7) underwent a definitive repair of the abdominal wall with absorbable synthetic mesh in the same hospitalization, while 22.2% (n = 2) did not, due to being cancer patients. The mortality rate was 11.1% (n = 1) due to pneumonia and the fistula rate was 11.1% (n = 1). None developed an incisional hernia at the one-year follow-up. Conclusions The combination of negative pressure therapy with dynamic fascial mesh traction, in the management of the open abdomen, allows us to achieve a 100% delayed primary fascial closure, avoiding ventral hernia. In the same hospitalization, while the patient leaves the critical stage, we can achieve a definitive repair of the abdominal wall using absorbable synthetic meshes returning the biomechanics to the abdominal wall, improving the quality of life of these patients.

P110 MANAGEMENT OF THE OPEN ABDOMEN WITH COMBINED THERAPIES. HOW TO AVOID THE VENTRAL HERNIA AND BE ABLE TO PERFORM THE REPAIR OF THE ABDOMINAL WALL IN A DEFINITIVE WAY

Aim To demonstrate that in patients with abdominal sepsis, delayed primary fascial closure and definitive abdominal wall repair can be achieved, in the same hospitalization, using combined therapies, which reduces the percentage of ventral hernias. Material and Methods Medical records, tomography images and outpatient controls of 9 patients were reviewed, which required open abdomen management for abdominal sepsis using negative pressure therapy combined with a dynamic fascial mesh traction, from February 2020 until May 2021. Results 9 patients (2 men and 7 women), all Grade 2C open abdomen according to Björck clasification, with a median age of 43 years (25-71). The median time therapy was 29±3 days. The primary fascial closure rate was 100% (n = 9), 77.8% (n = 7) underwent a definitive repair of the abdominal wall with absorbable synthetic mesh in the same hospitalization, while 22.2% (n = 2) did not, due to being cancer patients. The mortality rate was 11.1% (n = 1) due to pneumonia and the fistula rate was 11.1% (n = 1). None developed an incisional hernia at the one-year follow-up. Conclusions The combination of negative pressure therapy with dynamic fascial mesh traction, in the management of the open abdomen, allows us to achieve a 100% delayed primary fascial closure, avoiding ventral hernia. In the same hospitalization, while the patient leaves the critical stage, we can achieve a definitive repair of the abdominal wall using absorbable synthetic meshes returning the biomechanics to the abdominal wall, improving the quality of life of these patients.

Surgical repair of a large intrathoracic meningocele associated with neurofibromatosis type 1 after failed cystoperitoneal shunts: illustrative case

BACKGROUND Surgical treatment of intrathoracic meningoceles, commonly associated with neurofibromatosis type 1 (NF1), aims to reduce sac size for symptomatic relief. The procedures can be divided into cerebrospinal fluid diversion and definitive repair. The authors describe the management of an intrathoracic meningocele in a 56-year-old female with preexisting NF1. OBSERVATIONS The patient presented with progressive dyspnea. Magnetic resonance imaging revealed a left hemithoracic meningocele arising from the thecal sac at C7–T2. Two attempts at diversion by cystoperitoneal shunts resulted in recurrence. For definitive repair, T2–3 costotransversectomy was performed, and intradural closure of the meningocele opening was performed utilizing spinal dura and autologous fascia lata graft. Trapezius muscle regional flap was turned for reinforcement. Persistent leak warranted reoperation 7 days later. A transthoracic approach was undertaken using video-assisted thoracoscopic resection of the sac at aortic arch level, with reinforcement by latissimus dorsi flap and synthetic materials. Mechanical pleurodesis was performed. Intradural repair of the meningocele opening was revised. LESSONS Inherent dural abnormality makes repair difficult for meningoceles associated with NF1. A combined intradural and thoracoscopic approach with regional muscle flap and synthetic material reinforcement is a unique method for definitive treatment. Some essential points of perioperative management are highlighted.

Duroplasty in iatrogenic dorsal spinal cord herniation: illustrative case

BACKGROUND The case report detailed an unusual presentation of an iatrogenic dorsal cord herniation at the level of the thoracic cord after insertion of an epidural catheter 8 months before presentation to the neurosurgical clinic. OBSERVATIONS Only 13 cases of iatrogenic dorsal cord herniation, most of which occurred after spinal surgery, have been described in the literature. This was the first case of a spinal cord hernia described after the insertion of an epidural catheter. In this case study, the authors described a 38-year-old man who presented with progressive lower limb weakness, sensory deficits, perianal numbness, and urinary/fecal incontinence. He was diagnosed with a spinal cord hernia that reherniated after an initial sandwich duroplasty repair. Definitive repair was made after his re-presentation using an expansile duroplasty. LESSONS In patients with previous spinal instrumentation who present with neurological symptoms, spinal cord herniation should be considered a likely differential despite its rarity. In this case, a simple duroplasty was insufficient to provide full resolution of symptoms and was associated with recurrence. Perhaps a combination of graft and expansile duroplasty may be used for repair, especially when associated with a tethered cord and in the presence of significant adhesions.

Damage control in the intensive care unit: what should the intensive care physician know and do?

When trauma patients are admitted into the intensive care unit after undergoing damage control surgery, they generally present some degree of bleeding, hypoperfusion, and injuries that require definitive repair. Trauma patients admitted into the intensive care unit after undergoing damage control surgery can present injuries that require a definite repair, which can cause bleeding and hypoperfusion. The intensive care team must evaluate the severity and systemic repercussions in the patient. This will allow them to establish the need for resuscitation, anticipate potential complications, and adjust the treatment to minimize trauma-associated morbidity and mortality. This article aims to describe the alterations present in patients with severe trauma who undergo damage control surgery and considerations in their therapeutic approach. The intensivist must detect the different physiological alterations presented in trauma patients undergoing damage control surgery, mainly caused by massive hemorrhage. Monitor and support strategies are defined by the evaluation of bleeding and shock severity and resuscitation phase in ICU admission. The correction of hypothermia, acidosis, and coagulopathy is fundamental in the management of severe trauma patients.

Acquired tracheoesophageal fistula in a pregnant patient with COVID-19 pneumonia on prolonged invasive ventilation

A previously healthy pregnant woman was diagnosed with COVID-19 pneumonia and was subsequently intubated. Throughout the course of her illness, the patient was treated for recurrent bouts of pneumonia. A high-resolution chest and neck CT scan confirmed the presence of a tracheoesophageal fistula (TEF), which may have been caused by the presence of the overinflated endotracheal cuff, prolonged steroid use, hypoxic injury and possible direct injury of the tracheal mucosa from COVID-19 itself. A temporising procedure, involving tracheostomy with an extended-length tracheal tube, was performed. Unfortunately, the patient succumbed to infection prior to definitive repair. This case highlights the importance of keeping a high index of suspicion for tracheal injury in patients who experience prolonged periods of intubation. It also underlies the high morbidity and mortality rate associated with TEF, although being a rare disease.

Early Re- Laparoscopy in Suspected Bile Duct Injuries after Laparoscopic Cholecystectomy

Introduction: Management of patients with suspected bile leak or bile duct injury after laparoscopic cholecystectomy is challenging. Early laparoscopy in these groups of patients will benefit in terms of diagnostic as well therapeutic purpose. Objective: This study is done to assess utility of early re-laparoscopy in suspected bile duct injury in early postoperative period following laparoscopic cholecystectomy. Methodology: It is a descriptive study of all consecutive patients who underwent diagnostic as well therapeutic re-laparoscopy when required in suspected bile duct injury in early postoperative laparoscopic cholecystectomy that is within 72 hours of presentation. Study was conducted over a period from June 2019 to December 2020 at Kathmandu medical College, Sinamangal, Kathmandu, Nepal. Relaparoscopic operative findings and therapeutic intervention done were recorded. Result: The mean age at presentation was 34.6 years and male to female ratio was 1:1.8. During the study period, eleven patients underwent re-laparoscopy out of which one had no bile leak. Six out of ten were managed definitely in the same time of re-laparoscopy. However, four patients underwent definitive biliary reconstruction as they had already undergone arteriography in CT scan. Conclusions: Early re-laparoscopy may be beneficial prior to detail radiological investigations in suspected bile leak patients. Early re-laparoscopy can be an effective diagnostic as well therapeutic tool; and also it can help in planning for definitive repair in later date.