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Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

ABSTRACT: BACKGROUND:Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. METHOD:A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. RESULTS:From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16-110) after LT. Biliary reconstruction included duct-to-duct (n = 9) and hepatico-jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in-hospital death. In the follow-up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. CONCLUSIONS:In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

SUBMITTER: Komorowski AL

PROVIDER: S-EPMC4764012 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature

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Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

Komorowski Andrzej L AL Li Wei-Feng WF Millan Carlos A CA Huang Tun-Sung TS Yong Chee-Chien CC Lin Tsan-Shiun TS Lin Ting-Lung TL Jawan Bruno B Wang Chih-Chi CC Chen Chao-Long CL

Journal of hepato-biliary-pancreatic sciences 20160120 2

<h4>Background</h4>Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances.<h4>Method</h4>A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR.<h4>Results</h4>From January 2009 to July 2013, 20 (3.6% ...[more]

PMID: 26692574

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Project description:BackgroundThe purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC.MethodsWe performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index.ResultsPatients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = -0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02-6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m, and CRP of greater than 250 mg/L.ConclusionsEarly and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study.Level of evidencePrognostic study, level III; Therapeutic study, level IV.

Project description:BackgroundOur objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function.MethodsWe performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury.ResultsThe HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003).ConclusionHypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury.Level of evidencePrognostic study, level II.

Project description:BACKGROUND:To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN:We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS:Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS:Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE:Therapeutic study, level IV.

Project description:One- or two-staged bone grafting is sometimes required for tunnel malposition and/or tunnel widening in revision anterior cruciate ligament (ACL) reconstruction. The aim of this procedure is to restore the correct position of the ACL graft in the revision setting to provide a stable and functional ACL, thereby reproducing normal knee kinematics. We present a technique that allows for a cost-effective, convenient tunnel grafting of a femoral head allograft bone dowel into both femoral and tibial defects in revision ACL reconstruction. Technique Video Video Use of the cannulated Coring Reamer System (Arthex, Naples, FL) to perform the harvest. A 2.4-mm guide pin is placed through the femoral head and neck allograft, parallel to the neck axis. A coring reamer and plunger should be used to harvest a core diameter identical to that of the reamed tunnels. The coring reamer’s centralizing plunger with its guide pin should be left in its already cannulated position through the harvested core. This entire construct will be used to easily graft the associated tunnel. The allograft dowel is then marked 5 mm greater than the corresponding depth of the femoral socket, in accordance with the prior reaming depth. This step allows for compression of the cancellous portion of the bone dowel into the tunnel. At this mark, a narrow rongeur is used to weaken the bone dowel circumferentially, leaving a small bone bridge. The entire construct is then introduced via the tibial tunnel or anteromedial portal, depending on the trajectory previously used to ream the femoral tunnel. The plunger-pin-dowel construct is then advanced into the femoral tunnel by gently tapping a pin puller that is solidly gripping the guide pin. Once the femoral dowel is fully seated and flush with the opening of the femoral defect, the dowel’s bone bridge is then broken at the previously weakened site with the use of a probe. The remaining dowel is removed from the knee using a powered wire driver. (It will come out easily with the plunger-pin construct en bloc.) The remaining dowel is then repositioned into the tibial tunnel and tapped into position as desired. Using the remainder of the first dowel, a second one can be harvested easily if the tibial tunnel is not completely grafted.

Dataset Information

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

Publications

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

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