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Salvage of the injured spleen is important in the trauma patient. Loss of the spleen can result in both early and late infectious complications due to immunologic and phagocytic deficits. Splenic salvage techniques include the use of polyglycolic acid (PGA) mesh to wrap and tamponade the damaged and bleeding spleen. However, the use of mesh may increase the incidence of infection in the presence of intraperitoneal contamination. We examined whether mesh in the contaminated field increases the infection rate compared to splenectomy in a murine model. Sixty male Sprague-Dawley rats were divided into three groups of 20 each: splenectomy, splenic wrap with PGA, and control (with splenic mobilization). All rats were subjected to a standard inoculum of enteric bacteria at the time of celiotomy. Sixteen (80%) of the splenectomy rats, 10 (50%) of the PGA mesh wrapped rats, and four (20%) of the control rats expired (P < 0.5). In surviving rats, necropsy at 7 days demonstrated abscess formation in all four (100%) of splenectomy, four of 10 (40%) in PGA mesh wrapped, and two of 16 (13%) of control rats. All of the abscesses in the wrap group involved the mesh. Overall infection rates (including fatal peritonitis, abscess formation, and empyema) were 100% for splenectomy, 75% for PGA mesh wrapped, and 30% for control rats (P < 0.05). We conclude in this experimental model that the use of PGA mesh wrap does increase susceptibility to infection, but much less so than splenectomy in the presence of intraperitoneal contamination.

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OBJECTIVE: To analyze whether the histologic subtype acral lentiginous melanoma confers independent prognostic significance. DESIGN: Case series retrospective review. SETTING: Academic surgical practice. PATIENTS OR OTHER PARTICIPANTS: Fifty-six patients with histologically confirmed acral lentiginous melanoma identified from patients with malignant melanoma consecutively treated by the faculty of the Department of Surgical Oncology at the University of Illinois at Chicago. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Lymph node metastases, disease-free survival, and overall concurrent or subsequent survival. RESULTS: The average age of our patients with acral lentiginous melanoma was 61.1 years. Thirty-four (61%) were white, and the remaining 22 (39%) were African-American, Hispanic, or Asian. Thirty (54%) were male and 26 (46%) were female. The primary tumor occurred on the lower extremity in 46 (82%) of the cases and on the upper extremity in the remaining 10 (18%). Twenty-four primary tumors (43%) were greater than 4.00 mm thick. Analyzed by means of a logistic regression model, the rate of lymph node metastases did not significantly differ among patients with acral lentiginous melanoma, superficial spreading melanoma, and nodular malignant melanoma. Furthermore, when corrected for tumor thickness, disease-free and overall survival were the same for the three histologic groups. Multifactorial analysis identified only thickness as a prognostic variable for disease-free survival and overall survival. CONCLUSIONS: Despite the greater age, diverse ethnic background, and distinctive tumor characteristics of our patients with acral lentiginous melanoma, this histologic subtype does not, in itself, affect the outcome of these patients.

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The charts of 81 consecutive patients with penetrating colonic trauma were reviewed. Sixty-five patients were considered for evaluation. Penetrating abdominal trauma index, associated injuries, length of operative procedure, wounding agent, length of hospital stay, method of treatment, and septic complications were evaluated. Twenty-eight patients were treated with colostomy at the site of injury: five with diverting colostomy proximal to repair, 30 with primary repair (either single or multiple injuries), and two with exteriorization and early drop back. Overall septic morbidity was 15 of 65 (23 percent) patients. No statistically significant difference was found in morbidity between colostomy, 9 of 33 (27 percent), and primary repair, 6 of 30 (20 percent). The two patients with exteriorized repairs had no morbidity. No deaths were reported among the 65 patients studied. Thirty-two of the 33 (97 percent) colostomies were later closed with morbidity in 7 of 32 (22 percent). The mean length of stay for primary repair patients was 10.3 +/- 2.8 days and for colostomy patients, 25.7 +/- 3.8 days, counting days for both initial and colostomy closure admissions (P less than .05). Colostomy was not mandated by anatomic location or number of colonic injuries, circumference of colonic wall involved, presence of fecal contamination, or involvement of mesenteric blood supply. This study indicates that primary repair does not carry an increased risk of septic complications and saves the patient the significant risk and increased hospital stay of colostomy closure. Prospective studies addressing this area are indicated.

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The preferred method for the treatment of penetrating injuries to the colon remains a source of controversy. In our retrospective review of 65 patients with penetrating colon injuries, 33 patients were managed by colostomy formation, 30 were treated by primary repair, and two had exteriorized repair with early return to the abdominal cavity (drop back). The anatomic location of injury was ascending colon in 19 (29%), transverse colon in 20 (31%), descending colon in 22 (34%), and multiple sites in four (6%). The average penetrating abdominal trauma index (PATI) was 24 (ascending colon injuries, 23; transverse colon, 26; descending colon, 24; and multiple colon sites, 28). Overall septic morbidity was 15/65 (23%). Colostomy closure was later done in 32/33 (97%), with a morbidity of 7/32 (22%). The mean length of hospital stay for primary repair was ten days and for colostomy (including both required hospital stays), 26 days (P less than .05). These data suggest that primary repair is as safe as colostomy formation for the management of penetrating colon injuries, regardless of anatomic site of injury.

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