Review of 197 consecutive free flap reconstructions in the lower extremity

Complications and failures after microvascular free tissue transfer for lower extremity reconstruction have a negative impact on postoperative course and final outcome. Therefore, a 10-year analysis on lower extremity reconstruction with free flaps was performed with a special emphasis on patient co-morbidities such as cardiovascular diseases, diabetes mellitus, body mass index and history of smoking, in order to identify potential risk factors. Complications such as haematoma, seroma, infection, wound dehiscence, as well as partial flap loss, postoperative thrombosis of the anastomosis and eventual total flap loss were gathered from the medical records. Limb salvage was 100%, however 40% suffered from complications ranging from minor wound dehiscence to total flap loss. None of the above-mentioned potential risk factors was associated with an increased rate of complications. However, in flaps that required revision for thrombosis, the age of the patients was significantly higher in the group of flaps that eventually failed when compared to flaps that were salvaged. In conclusion, lower extremity reconstruction with microvascular free tissue transfer is a safe and reliable procedure with a high success rate, however partial flap loss remains an important issue. Increased age was the only factor identified with an increased risk for subsequent flap loss in cases that were revised for thrombosis.

Comparison of procalcitonin and CrP in the postoperative course after lung decortication

OBJECTIVE: The objective of this prospective study was to compare the clinical value of procalcitonin (PCT) and C-reactive protein (CrP) plasma concentrations in their postoperative course after decortication. METHODS: Twenty-two patients requiring surgery for pleural empyema were chosen for this prospective study. Routine blood samples including CrP and PCT plasma concentrations were taken before the operation and on the 1st, 2nd, 3rd, and 7th postoperative day. RESULTS: Due to infection PCT and CrP were elevated preoperatively. In the postoperative course both PCT and CrP reached peak-levels on day 2 with values up to 43.55 ng/ml and 384.00 mg/l, respectively. In PCT the rise was followed by a clear decrease in 20 (90.9 %) patients until day 7. In contrast the CrP levels decreased slowly and only seven (54.5%) patients had values of 100 mg/l or below on day 7. PCT showed a better correlation with the clinic in case of septic course than CrP does. CONCLUSIONS: PCT reflects postoperative clinical course more accurately than CrP. Therefore, PCT is a more appropriate laboratory parameter to monitor patients after surgery for pleural empyema.

Hemoglobin vesicles improve wound healing and tissue survival in critically ischemic skin in mice

Local hypoxia, as due to trauma, surgery, or arterial occlusive disease, may severely jeopardize the survival of the affected tissue and its wound-healing capacity. Initially developed to replace blood transfusions, artificial oxygen carriers have emerged as oxygen therapeutics in such conditions. The aim of this study was to target primary wound healing and survival in critically ischemic skin by the systemic application of left-shifted liposomal hemoglobin vesicles (HbVs). This was tested in bilateral, cranially based dorsal skin flaps in mice treated with a HbV solution with an oxygen affinity that was increased to a P(50) (partial oxygen tension at which the hemoglobin becomes 50% saturated with oxygen) of 9 mmHg. Twenty percent of the total blood volume of the HbV solution was injected immediately and 24 h after surgery. On the first postoperative day, oxygen saturation in the critically ischemic middle flap portions was increased from 23% (untreated control) to 39% in the HbV-treated animals (P < 0.05). Six days postoperatively, flap tissue survival was increased from 33% (control) to 57% (P < 0.01) and primary healing of the ischemic wound margins from 6.6 to 12.7 mm (P < 0.05) after HbV injection. In addition, higher capillary counts and endothelial nitric oxide synthase expression (both P < 0.01) were found in the immunostained flap tissue. We conclude that left-shifted HbVs may ameliorate the survival and primary wound healing in critically ischemic skin, possibly mediated by endothelial nitric oxide synthase-induced neovascularization.

Effectiveness of an early postoperative feeding protocol

Background. The increasing emphasis on medical outcomes and cost containment has made it imperative to identify patient populations in which aggressive nutritional care can improve quality of care. The aim of this prospective study was to implement a standardized early jejunal feeding protocol for patients undergoing small and large bowel resection, and to evaluate its effect on patient outcome and cost.^ Methods. Treatment patients (n = 81) who met protocol inclusion criteria had a jejunal feeding tube inserted at the time of surgery. Feeding was initiated at 10 cc/hour within 12 hours after bowel resection and progressed if hemodynamically stable. The control group (n = 159) received usual care. Outcome measures included postoperative length of stay, total direct cost, nosocomial infection rate and health status (SF-36) scores.^ Results. By postoperative day 4, the use of total parenteral nutrition (TPN) was significantly greater in the control group compared to the treatment group; however, total nutritional intake was significantly less. Multiple regression analysis indicated an increased likelihood of infection with the use of TPN. A reduction of 3.5 postoperative days (p =.013) with 4.3 fewer TPN days per patient (p =.001) and a 9.6% reduction in infection rate (p =.042) was demonstrated in the treatment group. There was no difference in health status scores between groups at discharge and 3 months post-discharge.^ Conclusion. These positive outcomes and an average total cost savings of $4,145 per treatment patient indicate that the treatment protocol was effective. ^

Does Full Wound Rupture following Median Pilonidal Closure Alter Long-Term Recurrence Rate?

OBJECTIVE The purpose of this study was to examine the recurrence rate of wound rupture in primary pilonidal sinus disease (PSD) after median closure. SUBJECTS AND METHODS A total of 583 patients from the German military cohort were interviewed. We compared the choice of surgical therapy, wound dehiscence (if present) and long-term recurrence-free survival for patients with primary open treatment, marsupialization and primary median treatment (closed vs. secondary open, respectively). Actuarial recurrence rate was determined using the Kaplan-Meier calculation with a follow-up of up to 20 years after primary PSD surgery. RESULTS Patients with excision followed by primary open wound treatment showed a significantly lower 5- than 10-year recurrence rate (8.3 vs. 11.2%) compared to the patients with primary midline closure (17.4 vs. 20.5%, p = 0.03). The 20-year recurrence rate was 28% in primary open wound treatment versus 44% in primary midline closure without wound rupture. In contrast to these findings, long-term recurrence rates following secondary open wound treatment (12.2% at 5 years vs. 17.1% at 10 years) tended to be higher (although not significantly, p = 0.57) compared to primary open treatment (8.3% at 5 years vs. 11.2% at 10 years). There was no statistical difference in long-term recurrence rates between secondary open and primary midline closure (p = 0.7). Hence, despite only a short wound closure time experienced before wound rupture, the patient does not fully benefit from an open wound treatment in terms of recurrence rate. CONCLUSION The postoperative pilonidal sinus wound rupture of primary midline closures did not significantly increase the 5- and 10-year long-term recurrence rates compared to uneventfully healing primary midline closures.

Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection

BACKGROUND Surgical-site infections (SSIs) are the most common complications after surgery. An influence from talking and distractions during surgery on patient outcomes has been suggested, but there is limited evidence. The aim of this prospective observational study was to assess the relationship between intraoperative communication within the surgical team and SSI, and between intraoperative distractions and SSI. METHODS This prospective observational study included patients undergoing elective, open abdominal procedures. For each procedure, intraoperative case-relevant and case-irrelevant communication, and intraoperative distractions were observed continuously on site. The influence of communication and distractions on SSI after surgery was assessed using logistic regressions, adjusting for risk factors. RESULTS A total of 167 observed procedures were analysed; their mean(s.d.) duration was 4·6(2·1) h. A total of 24 SSIs (14·4 per cent) were diagnosed. Case-relevant communication during the procedure was independently associated with a reduced incidence of organ/space SSI (propensity score-adjusted odds ratio 0·86, 95 per cent c.i. 0·77 to 0·97; P = 0·014). Case-irrelevant communication during the closing phase of the procedure was independently associated with increased incidence of incisional SSI (propensity score-adjusted odds ratio 1·29, 1·08 to 1·55; P = 0·006). Distractions had no association with SSI. CONCLUSION More case-relevant communication was associated with fewer organ/space SSIs, and more case-irrelevant communication during wound closure was associated with incisional SSI.

Seroprevalence of Chagas' disease in Texas among shelter dogs in Houston and the Rio Grande Valley region and its implication for human infection

Chagas’ disease, also called American Trypanosomiasis, is a vector-borne disease caused by the protozoan parasite Trypanosoma cruzi. T. cruzi is spread by triatomine insects, commonly referred to as ‘kissing bugs.’ After the insect takes a blood meal from its animal or human host, it usually defecates near the bite wound. The parasite is present in the feces, and when rubbed into the bite wound or mucous membranes by the host, infection ensues. Chagas’ disease is highly endemic in Central and South America where it originated. Many people in these endemic areas live in poor conditions surrounded by animals, mainly dogs, that can serve as a possible link to human infection. In Chagas’ endemic countries, dogs can be used as a sentinel to infer risk for human infection. In Texas, the prevalence of Chagas’ and risk for human infection is largely unknown. This study aimed to determine the prevalence of Chagas’ disease in shelter dogs in Houston, Texas and the Rio Grande Valley region by using an immunochromatographic assay (Chagas’ Stat-Pak) to test for the presence of T. cruzi antibodies. Of the 822 samples tested, 26 were found to be positive (3.2%). In both locations, Chagas’ prevalence increased over time. This study found that dogs, especially strays, can serve as sentinels for disease activity. Public health authorities can implement this strategy to understand the level of Chagas’ activity in a defined geographic area and prevent human infection.^

Soft tissue oral wound healing in diabetic patients

This prospective observational cohort study investigated whether diabetic dental patients with poor glycemic control experience a higher risk of post-operative complications and diminished wound healing abilities after an oral surgical procedure such as implant placement. This study compared soft tissue oral wound healing complications between poorly controlled diabetic patients, well controlled diabetic patients and non-diabetic patients following surgical implant placement in the mandible with a total of 131 patients. A one week post-surgical follow-up visit involved an oral wound examination that consisted of evaluating for edema, erythema, exudate, oral pain, problems with flap closure, infection, and hematoma. Analyses were performed to determine significance differences in frequency of oral wound complications between the 3 diabetic groups. Two-by-two contingency tables using chi-square analysis were used to evaluate for significant differences in the proportion of each post-operative oral wound healing complication. This was done separately between non-diabetics and diabetics and between well-controlled and poorly controlled diabetics to calculate odds ratios. Confidence intervals were also calculated. This preliminary study showed that many of the complications were found not to be associated with diabetic status. Other complications such as edema and problems with flap closure were found to be less likely to occur in diabetics compared to non-diabetics and even in poorly controlled diabetics when compared to well-controlled diabetics. The results did not support the hypothesis that diabetic dental patients experience a higher risk than non-diabetic patients of post-operative soft tissue oral wound complications.^

Propionibacterium acnes:infection beyond the skin

Propionibacterium acnes is a Gram-positive bacterium that forms part of the normal flora of the skin, oral cavity, large intestine, the conjunctiva and the external ear canal. Although primarily recognized for its role in acne, P. acnes is an opportunistic pathogen, causing a range of postoperative and device-related infections. These include infections of the bones and joints, mouth, eye and brain. Device-related infections include those of joint prostheses, shunts and prosthetic heart valves. P. acnes may play a role in other conditions, including inflammation of the prostate leading to cancer, SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, sarcoidosis and sciatica. If an active role in these conditions is established there are major implications for diagnosis, treatment and protection. Genome sequencing of the organism has provided an insight into the pathogenic potential and virulence of P. acnes. © 2011 Expert Reviews Ltd.

The impact of routine open nonsuction drainage on fluid accumulation after thyroid surgery: a prospective randomised clinical trial.

Background: Thyroid drains following thyroid surgery are routinely used despite minimal supportive evidence. Our aim in this study is to determine the impact of routine open drainage of the thyroid bed postoperatively on ultrasound-determined fluid accumulation at 24 hours. Methods: We conducted a prospective randomised clinical trial on patients undergoing thyroid surgery. Patients were randomly assigned to a drain group (n = 49) or a no-drain group (n = 44) immediately prior to wound closure. Patients underwent a neck ultrasound on day 1 and day 2 postoperatively. After surgery, we evaluated visual analogue scale pain scores, postoperative analgesic requirements, self-reported scar satisfaction at 6 weeks and complications. Results: There was significantly less mean fluid accumulated in the drain group on both day 1, 16.4 versus 25.1 ml (P-value = 0.005), and day 2, 18.4 versus 25.7 ml (P-value = 0.026), following surgery. We found no significant differences between the groups with regard to length of stay, scar satisfaction, visual analogue scale pain score and analgesic requirements. There were four versus one wound infections in the drain versus no-drain groups. This finding was not statistically significant (P = 0.154). No life-threatening bleeds occurred in either group. Conclusions: Fluid accumulation after thyroid surgery was significantly lessened by drainage. However, this study did not show any clinical benefit associated with this finding in the non-emergent setting. Drains themselves showed a trend indicating that they may augment infection rates. The results of this study suggest that the frequency of acute life-threatening bleeds remains extremely low following abandoning drains. We advocate abandoning routine use of thyroid drains. Trial registration: ISRCTN94715414.

Effects of the basic fibroblast growth factor and its anti-factor in the healing and collagen maturation of infected skin wound

PURPOSE: The infection is one of the main factors that affect the physiological evolution of the surgical wounds. The aim of this work is to evaluate the effects of fibroblast growth factor (FGFâ) and anti-FGFâ in the healing, synthesis and maturation of collagen when topically used on infected skin wounds of rats. METHODS: An experimental study was perfomed in 60 male Wistar rats. All animals were divided in two groups (A and B). Each group was divided in three subgroups A1, B1; A2, B2 and A3, B3. After anesthesia with pentobarbital, two open squared wounds (1cm2), 4cm distant to each other, were done in the dorsal skin of all the rats. In group A (n=30) the wounds were contaminated with multibacterial standard solution, and in group B(n=30) the wounds were maintained sterile. These wounds were named F1 (for inflammation analysis) and F2 (for collagen study). The open wounds of A1 and B1 rats were topically treated with saline solution, A2 and B2 were treated with FGFâ and subgroups A3 and B3 were treated with FGFâ and anti-FGFâ. The rats were observed until complete epitelization of F2 wounds for determination of healing time and the expression of types I and III collagen, using Picro Sirius Red staining. Inflammatory reaction in F1 wounds was studied using hematoxilineosin staining. The three variable was measured by the Image Pro-Plus Média Cybernetics software. The statistical analysis was performed by ANOVA and Tukey test, considering p<0.05 as significant. RESULTS: It was observed that infection retarded significantly (p<0.05) the time of wound scarring and the topical application of FCFb reverted the inhibition of healing caused by bacteria. The inflammatory reaction was greater in the subgroup B2 than in B1 and A3, and the difference was significant (p<0.05). It was observed greater expression of type I collagen in all the subgroups treated with FCFb, when compared with the untreated subgroups. Type III collagen was significantly decreased in wounds of B3 rats, comparing to the other subgroups. CONCLUSIONS: The FCFb accelerated the healing of open infected wounds and contributed with maturation of collagen, enhancing the type I collagen density. The anti-FCFb antibody was able to attenuate the production of both type I and III collagen

Prevalence of helicobacter pylori infection in advanced gastric carcinoma

There is substantial evidence that infection with Helicobacter pylori plays a role in the development of gastric cancer and that it is rarely found in gastric biopsy of atrophic gastritis and gastric cancer. On advanced gastric tumors, the bacteria can be lost from the stomach. Aims - To analyze the hypothesis that the prevalence of H.pylori in operated advanced gastric carcinomas and adjacent non-tumor tissues is high, comparing intestinal and diffuse tumors according to Lauren’s classifi cation. Methods - A prospective controlled study enrolled 56 patients from “Hospital Universitário”, Federal University of Rio Grande do Norte, Natal, RN, Brazil, with advanced gastric cancer, treated from February 2000 to March 2003. Immediately after partial gastrectomy, the resected stomach was opened and several mucosal biopsy samples were taken from the gastric tumor and from the adjacent mucosa within 4 cm distance from the tumor margin. Tissue sections were stained with hematoxylin and eosin. Lauren‘s classifi cation for gastric cancer was used, to analyse the prevalence of H. pylori in intestinal or diffuse carcinomas assessed by the urease rapid test, IgG by ELISA and Giemsa staining. H. pylori infected patients were treated with omeprazole, clarithromycin and amoxicillin for 7 days. Follow-up endoscopy and serology were performed 6 months after treatment to determine successful eradication of H. pylori in non-tumor tissue. Thereafter, follow-up endoscopies were scheduled annually. Chi-square and MacNemar tests with 0.05 signifi cance were used. Results - Thirty-four tumors (60.7%) were intestinal-type and 22 (39.3%) diffuse type carcinomas. In adjacent non-tumor gastric mucosa, chronic gastritis were found in 53 cases (94.6%) and atrophic mucosa in 36 patients (64.3%). All the patients with atrophic mucosa were H. pylori positive. When examined by Giemsa and urease test, H. pylori positive rate in tumor tissue of intestinal type carcinomas was higher than that in diffuse carcinomas. In tumor tissues, 34 (60.7%) H. pylori-positive in gastric carcinomas were detected by Giemsa method. H. pylori was observed in 30 of 56 cases (53.5%) in tissues 4 cm adjacent to tumors. This difference was not signifi cant. Eradication of H. pylori in non-tumor tissue of gastric remnant led to a complete negativity on the 12th postoperative month. Conclusions - The data confi rmed the hypothesis of a high prevalence of H. pylori in tumor tissue of gastric advanced carcinomas and in adjacent non-tumor mucosa of operated stomachs. The presence of H. pylori was predominant in the intestinal-type carcinoma

Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented?

This case report is on a obese patient who underwent a coronary artery bypass. The immediate postoperative phase, on the 8th day, was characterized by sternal dehiscence with diastasis, from intense coughing. At present, for obese patients there are not any guidelines aimed to prevent the sternal diastasis. The use of a sternum support vest after median sternotomy could be a valuable tool in the postoperative care of our patients, in order to avoid chest wall hyperexpansion and to prevent sternal wound dehiscence and diastasis.

Characterisation of accessions and species of Macadamia to stem infection by Phytophthora cinnamomi

Phytophthora cinnamomi is a major pathogen in most macadamia plantations worldwide. Due to stem lesions, stem cankers and leaf defoliation it results in loss of productivity and tree death. In this study we examined accessions of the four Macadamia species and their hybrids, produced via rooted stem cuttings or germinated seeds, for susceptibility to stem canker and necrotic lesion caused by P. cinnamomi. Plants were wound-inoculated with agar containing P. cinnamomi. The symptoms produced in inoculated plants were used to characterize host susceptibility variation within and among the population. Lesion lengths and severity of stem canker were recorded. The four species and hybrids differed significantly in stem canker severity (P < 0.001) and lesion length (P = 0.04). M. integrifolia and M. tetraphylla hybrids were the most susceptible. M. integrifolia had the greatest stem canker severity and the most extensive lesions above and below the site of inoculation. Restricted lesion sizes were observed in M. ternifolia and M. jansenii. The effects of basal stem diameter and the method of propagation either from cuttings or seed were not significant. The genetic variation in the reactions of macadamia accessions to stem infection by P. cinnamomi is discussed.

Effects of the basic fibroblast growth factor and its anti-factor in the healing and collagen maturation of infected skin wound

PURPOSE: The infection is one of the main factors that affect the physiological evolution of the surgical wounds. The aim of this work is to evaluate the effects of fibroblast growth factor (FGFâ) and anti-FGFâ in the healing, synthesis and maturation of collagen when topically used on infected skin wounds of rats. METHODS: An experimental study was perfomed in 60 male Wistar rats. All animals were divided in two groups (A and B). Each group was divided in three subgroups A1, B1; A2, B2 and A3, B3. After anesthesia with pentobarbital, two open squared wounds (1cm2), 4cm distant to each other, were done in the dorsal skin of all the rats. In group A (n=30) the wounds were contaminated with multibacterial standard solution, and in group B(n=30) the wounds were maintained sterile. These wounds were named F1 (for inflammation analysis) and F2 (for collagen study). The open wounds of A1 and B1 rats were topically treated with saline solution, A2 and B2 were treated with FGFâ and subgroups A3 and B3 were treated with FGFâ and anti-FGFâ. The rats were observed until complete epitelization of F2 wounds for determination of healing time and the expression of types I and III collagen, using Picro Sirius Red staining. Inflammatory reaction in F1 wounds was studied using hematoxilineosin staining. The three variable was measured by the Image Pro-Plus Média Cybernetics software. The statistical analysis was performed by ANOVA and Tukey test, considering p<0.05 as significant. RESULTS: It was observed that infection retarded significantly (p<0.05) the time of wound scarring and the topical application of FCFb reverted the inhibition of healing caused by bacteria. The inflammatory reaction was greater in the subgroup B2 than in B1 and A3, and the difference was significant (p<0.05). It was observed greater expression of type I collagen in all the subgroups treated with FCFb, when compared with the untreated subgroups. Type III collagen was significantly decreased in wounds of B3 rats, comparing to the other subgroups. CONCLUSIONS: The FCFb accelerated the healing of open infected wounds and contributed with maturation of collagen, enhancing the type I collagen density. The anti-FCFb antibody was able to attenuate the production of both type I and III collagen