And what are we supposed to put in its place? Isn t it possible that some collateral circules will rivascularize it?
Clinical case: multiple intestinal fistulas
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You mean if you have a large abdominal wall defect?
You can use a WoundVAC (or similar product), just do wet-to-dry dressings over the subcutaneous/fascial layer and let it granulate in, etc.
You shouldn't be leaving necrotic tissue (anywhere on the body) behind.
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Is the fascia/muscle dead or just the skin/subcu? If you've got a good barrier between air and bowel, then wound vac may be appropriate. I would not wound vac directly on to bowel/omentum/whatever if there's no wall left. One option for coverage would be vicryl mesh or alloderm/surgisys/etc, but that creates it's own set of problems.
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Necrotic abdominal wall, I suppose this is what some were alluding to earlier. When we operate early on this type of patient, things just spiral out of control. I am referring to enterotomies, multidrug resistant infections and complication after complication. Many a attending has taught me, less sometimes much better. Drain everything with interventional, nutrition, nutrition, nutrition and wait 6-12 months for the or.
I'm not sure about the depth of the necrosis, i really hope it's just skin and subcu, that's why we want to give VAC a shot; right now, we're using the medications you mentioned above. Anyways, the defect is not that big, some vessels must have stayed in their place
We definitely don't want to use the VAC directly on the bowel, we have seen the effects it has and it's nothing good.
The meshes are an interesting option, but are you sure they're fine on a bowel like that?
Btw, still nothing from the drainages
We definitely don't want to use the VAC directly on the bowel, we have seen the effects it has and it's nothing good.
The meshes are an interesting option, but are you sure they're fine on a bowel like that?
Btw, still nothing from the drainages
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I'm not sure about the depth of the necrosis, i really hope it's just skin and subcu, that's why we want to give VAC a shot; right now, we're using the medications you mentioned above. Anyways, the defect is not that big, some vessels must have stayed in their place
We definitely don't want to use the VAC directly on the bowel, we have seen the effects it has and it's nothing good.
The meshes are an interesting option, but are you sure they're fine on a bowel like that?
Btw, still nothing from the drainages
So, necrotic = dead and can't be resuscitated with medication or a vac. Is this a language issue? As others have said, you are doing very well for using a second language to describe complicated clinical problems but I'm wondering if the current phase of the conversation is due to some word-choice confusion. Do you mean ischemic? A vac would not work on an ischemic skin flap even if it was just ischemic and not actually necrotic.
As others have said, necrotic should be resected/debrided... but perhaps you are trying to describe a different issue?
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Yeah, I was hoping the above as well. Ischemic/necrotic skin? A VAC won't work on that.
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If you've got dead tissue, you've got to debride and figure out what's viable or not. Not looking is way worse than realizing that there is nothing but death between you and bowel. My approach would be:
debride abdominal wall to viability, and if I have to take muscle, fascia, etc do it. If there's an abdominal wall defect after debridement, you could consider surgysis/alloderm/vicryl to cover. You'd likely eventually get coverage if it's kept reasonably moist. There would likely be a hernia eventually, but that's the least of this guy's problems at this point.
If you debride, and there's a healthy (bleeding) layer of fascia/muscle, I think a wound vac over that would be okay. To me, leave decomposing skin/soft tissue is a disaster waiting to happen. Also, wound vacing over that may cause the dead tissue to melt, and suddenly you're doing a wound vac change and there's succus (enteric contents) in the wound bed because they vac sucked through and eroded bowel.
To my mind, you HAVE to debride dead tissue. And then solve the problem you have in front of you once you've got healthy tissue and known parameters.
Thanks for bringing this topic up -- it's been a very productive clinical discussion in my opinion. And we all appreciate your ability to restate things that are confusing in order to find a common language to discuss this complex issue.
debride abdominal wall to viability, and if I have to take muscle, fascia, etc do it. If there's an abdominal wall defect after debridement, you could consider surgysis/alloderm/vicryl to cover. You'd likely eventually get coverage if it's kept reasonably moist. There would likely be a hernia eventually, but that's the least of this guy's problems at this point.
If you debride, and there's a healthy (bleeding) layer of fascia/muscle, I think a wound vac over that would be okay. To me, leave decomposing skin/soft tissue is a disaster waiting to happen. Also, wound vacing over that may cause the dead tissue to melt, and suddenly you're doing a wound vac change and there's succus (enteric contents) in the wound bed because they vac sucked through and eroded bowel.
To my mind, you HAVE to debride dead tissue. And then solve the problem you have in front of you once you've got healthy tissue and known parameters.
Thanks for bringing this topic up -- it's been a very productive clinical discussion in my opinion. And we all appreciate your ability to restate things that are confusing in order to find a common language to discuss this complex issue.
Thank you very much, you're been very clear! And thanks for all of the compliments
I still have one doubt, if we have to remove the whole wall in that point, would a mesh be safe placed on that bowel? What material would be best?
I still have one doubt, if we have to remove the whole wall in that point, would a mesh be safe placed on that bowel? What material would be best?
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In general, if you have an open abdomen situation - exposed bowel/omentum with no fascia, soft tissue or skin coverage - then you need some sort of mesh as a barrier between your external dressing system (moist gauze, WoundVAC, etc.) and the bowel. Vicryl mesh is a cheap, temporary solution that covers the bowels, allows placement of moist dressings or a WoundVAC over the top and will eventually granulate in. The Vicryl material itself will dissolve in 8-10 weeks. If you want a more durable substance, you can use a biologic such as Alloderm, Strattice or the like. It's much more expensive (thousands of dollars vs. hundreds of dollars) and not as readily available, though.
All of these temporary options only offer coverage over exposed bowel and viscera and you are accepting the drawback of an eventual large ventral hernia. But as others have stated, if the patients survives and months later comes back to clinic with a large ventral hernia, that's a win.
If you don't have to debride muscle/fascia and only skin and soft tissue, then you can just directly place moist gauze or a WoundVAC into the abdominal wall defect without too much concern about injuring the bowel. But yes, that dead tissue needs to be debrided.
All of these temporary options only offer coverage over exposed bowel and viscera and you are accepting the drawback of an eventual large ventral hernia. But as others have stated, if the patients survives and months later comes back to clinic with a large ventral hernia, that's a win.
If you don't have to debride muscle/fascia and only skin and soft tissue, then you can just directly place moist gauze or a WoundVAC into the abdominal wall defect without too much concern about injuring the bowel. But yes, that dead tissue needs to be debrided.
I spoke to my attending and he had no doubt about doing the debridement before using the VAC, my bad i didn't get all of the informations properly (i'm actually not working in this period, i'm studying for the admission test and going to the hospital just sometimes).
He did the debridement yesterday and the necrosis involved the whole abdominal wall, so he resected a flap of 5x2 cm and put the Abthera in its place. Today he spoke to the VAC seller and she's going to provide some moist gauze; tomorrow we're going to change the VAC and put those gauzes between the Abthera and the bowel (if i got i right from the phone). Wish us luck!
He did the debridement yesterday and the necrosis involved the whole abdominal wall, so he resected a flap of 5x2 cm and put the Abthera in its place. Today he spoke to the VAC seller and she's going to provide some moist gauze; tomorrow we're going to change the VAC and put those gauzes between the Abthera and the bowel (if i got i right from the phone). Wish us luck!
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Just to clarify - you're a medical student, right? Are you in your final year?
I'm in a "limbo" because i'm a medical graduate (i graduated last july), but in Italy we have a spare year: to be actual MDs we need to take an exam similar to the USMLE (just much easier, about 1% don't pass) after 3 months of clinical rotation (medical, surgical and family medicine) and it takes place twice a year, in february or july. So, if you graduate in july or october you can take the one in february and if you graduate in march you can take the one in july. If you pass that test you can work as a family doctor's substitute or make night or weekend shifts in the territory primary care or private hospitals, but it's usually not very convenient because you have to study hard for the admission test and attend the department you want to get in.
To access the residency we have a cut-throat admission test which usually takes place in half june (mine will be on the 13th): you have some starting points from your graduation mark, thesis and exam marks, then you have to take a multiple choice test and then a written test with an open question (clinical case) corrected by the director of the school (which is usually the one you have worked for in the past year, but not necessarily).
So, in synthesis, there is one year from your graduation to the residency! During that year you usually work (for free but without particular boundaries) in the department you've chosen for your thesys and in which you'd like to work as a resident...that's my position now
On second thought, it's not completely true you have no boundaries, because if you have to access the most competitive schools (which are pediatrics, ob-gyn and internal medicine) you must attend the director's department and they usually give you atual shifts...
To access the residency we have a cut-throat admission test which usually takes place in half june (mine will be on the 13th): you have some starting points from your graduation mark, thesis and exam marks, then you have to take a multiple choice test and then a written test with an open question (clinical case) corrected by the director of the school (which is usually the one you have worked for in the past year, but not necessarily).
So, in synthesis, there is one year from your graduation to the residency! During that year you usually work (for free but without particular boundaries) in the department you've chosen for your thesys and in which you'd like to work as a resident...that's my position now
On second thought, it's not completely true you have no boundaries, because if you have to access the most competitive schools (which are pediatrics, ob-gyn and internal medicine) you must attend the director's department and they usually give you atual shifts...
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Less=More, that being said best thing for this patient would be losing the scalpel, getting dietary and nursing consults, maybe even palliative care the patient has no qaulity of life and do you guys really think you are doing him a favor by keeping on cutting, sometimes the hardest thing for us surgeons to do is not to cut. Turn the poor guy loose, let him spend time with his family and make him comfortable, and give him to god. This is one of the toughest things ever, I know went through it with my grandfather.
