1/58. Late traumatic intraocular lens extrusion after penetrating keratoplasty.BACKGROUND: Penetrating keratoplasty places a patient at risk for wound rupture from blunt trauma because the graft-host interface remains weakened for years after the surgery. Violent environments, contact sports, and strenuous activity put patients with compromised corneal structural integrity at high risk of traumatic injury. CASE REPORT: This case report presents a 42-year-old penetrating keratoplasty patient with a history of homelessness, polysubstance abuse, and domestic violence. This patient experienced a ruptured globe at the graft-host junction secondary to a direct blow by a fist, which extruded the intraocular lens from the eye. After emergency wound closure, the graft continued to degrade until bullous keratopathy developed. With little visual recovery potential for this graft, a Gunderson conjunctival flap procedure was implemented to decrease chronic ocular pain. CONCLUSIONS: After penetrating keratoplasty, patients should be periodically reminded of the susceptibility of the graft wound to injury from high-risk activity and violence. Constant use of protective eyewear should be recommended to corneal transplant recipients.- - - - - - - - - - ranking = 1keywords = closure (Clic here for more details about this article) |
2/58. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery.Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.- - - - - - - - - - ranking = 3keywords = closure (Clic here for more details about this article) |
3/58. vacuum-assisted wound closure: a new approach to spinal wounds with exposed hardware.STUDY DESIGN: The use of vacuum-assisted therapy to close upper thoracic and thoracolumbar spinal wounds was studied retrospectively. Two patients whose wounds failed conservative management were successfully treated by negative pressure therapy. OBJECTIVES: The authors evaluated the efficacy of applying vacuum therapy on patients with exposed spinal hardware and summarized current knowledge about this treatment. SUMMARY OF BACKGROUND DATA: vacuum therapy was applied three times on two patients. methods: Success was defined as a stable, closed wound that required no future surgery and had no signs of chronic infection. RESULTS: Both patients' wounds were closed successfully and have received follow-up treatment for up to 10 months with no sign of recurrence. CONCLUSIONS: The cases illustrate the usefulness of vacuum-assisted therapy as an adjunct in closing complex back wounds with exposed spinal hardware. In the authors' experience, it helps establish a soft tissue envelope for wound healing and simplifies the need for future surgery.- - - - - - - - - - ranking = 4keywords = closure (Clic here for more details about this article) |
4/58. Occult wound leak diagnosed by ultrasound biomicroscopy in patients with postoperative hypotony.PURPOSE: To describe the ability of high-frequency ultrasound biomicroscopy (UBM) to diagnose occult wound leaks as a cause for hypotony after cataract surgery. methods: Six patients with persistent hypotony after cataract surgery were sent for UBM examination. Slitlamp examination and gonioscopy of the 6 eyes had not revealed a cause for the hypotony. RESULTS: Ultrasound biomicroscopy showed subtle wound separation with shallow conjunctival elevation at the site of the cataract wound in the 6 patients. Two eyes had surgical repair of the subconjunctival wound leak, and the other 4 were treated medically. In the 2 eyes with surgically repaired wounds, the hypotony cleared after wound closure. Of the 4 medically treated eyes, hypotony resolved in 2 and 1 had a recurrence of hypotony. The other 2 eyes had fluctuating intraocular pressure for an extended period. CONCLUSIONS: Hypotony after cataract surgery occurred in 6 eyes due to subtle wound leaks difficult to detect by clinical observation. Ultrasound biomicroscopy can be a helpful aid to clinical examination in detecting these leaks.- - - - - - - - - - ranking = 1keywords = closure (Clic here for more details about this article) |
5/58. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy.BACKGROUND: Benign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications. methods: charts of 6 patients with a benign tracheoneo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed. RESULTS: Three men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake. CONCLUSIONS: A benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.- - - - - - - - - - ranking = 1keywords = closure (Clic here for more details about this article) |
6/58. Endoscopic repair of bronchial dehiscence after lung transplantation.We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue.- - - - - - - - - - ranking = 1keywords = closure (Clic here for more details about this article) |
7/58. vacuum-assisted closure in the treatment of complex gynecologic wound failures.BACKGROUND: Complex wound failures are a source of significant morbidity and mortality. They are costly and time consuming to treat, and may evolve into chronic, debilitating conditions. vacuum-assisted closure is a novel wound healing technique applying subatmospheric pressure to wounds to expedite healing. CASES: We report the successful use of vacuum-assisted closure therapy on three patients on a gynecologic oncology service with complex wound failures of various chronicity. In all cases, vacuum-assisted closure therapy was well tolerated and demonstrated efficacy within 48 hours of initiation. CONCLUSION: We conclude that vacuum-assisted closure therapy should be included in the armamentarium of the gynecologist addressing complex wound failures.- - - - - - - - - - ranking = 8keywords = closure (Clic here for more details about this article) |
8/58. Gastrobronchial fistula repair followed by esophageal leak--rescue by transesophageal drainage of the pleural cavity.A gastrobronchial fistula (GBF) associated with bilateral aspiration pneumonia was diagnosed six years after an esophagectomy with gastric pull-up. After failed surgical repair, an uncontained esophagopleural leak developed. Fistula closure was attempted by implanting a Wilson-Cook endoprosthesis, which quickly became dislodged. Transesophageal drainage was positioned endoscopically through the suture-line defect and led to closure of the leak after 10 days.- - - - - - - - - - ranking = 2keywords = closure (Clic here for more details about this article) |
9/58. The management of the postoperative disrupted abdominal wall.BACKGROUND: Dehisced abdominal wounds are common. Their management is generally difficult and often prolonged, with incisional hernias a common occurrence. A new technique is presented that results in accelerated delayed primary healing with full thickness skin and subcutaneous tissue coverage. methods: The technique involves a combination of vigorous wound toilette, the judicious use of sutures and tissue expansion produced by the application of specially designed external tissue expanders. Gradual approximation of the wound edges is achieved and final suture allows closure by full thickness skin and subcutaneous tissue. RESULTS: Sixteen patients, 10 with one or more intestinal fistula, developed abdominal wall dehiscences. At discharge all wounds were closed, from 2 days in wounds averaging 12 x 5 cm to 18 days in a 29 x 24 cm wound. The follow-up, both in numbers and length, was limited for various reasons. CONCLUSIONS: The technique appears to be generally successful. The simplicity allows easy learning and may avoid a major operative procedure. Accelerated delayed primary closure by full thickness skin and subcutaneous tissue has considerable economic benefits for the patient and the health service.- - - - - - - - - - ranking = 2keywords = closure (Clic here for more details about this article) |
10/58. Successful salvage of infected PTFE mesh after ventral hernia repair.Rates of hernia recurrence following repair of abdominal wall hernia defects have been shown to be lower when prosthetic biomaterials are used, but their presence may be associated with a higher rate of infectious complications. Traditional surgical teaching has advocated removal of contaminated or exposed prosthetics, although the morbidity of these revisions is high. The case presented involves a ventral hernia repair complicated by methicillin-resistant staphylococcus aureus infection and exposed polytetrafluoroethylene mesh. The open abdominal wound was successfully managed with a combination of intravenous antibiotics, local wound debridement, vacuum-assisted closure, and soft tissue coverage of the mesh. Eighteen months following surgical closure of the wound, no hernia recurrence or infection was evident.- - - - - - - - - - ranking = 2keywords = closure (Clic here for more details about this article) |
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