Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review

OBJECTIVE

Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes.

METHOD

A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'.

RESULTS

A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery.

CONCLUSION

The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men

BACKGROUND

The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique.

OBJECTIVES

To present and discuss the Transgender Standard of Care and our personal experience.

METHODS

Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed.

RESULTS

Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis.

CONCLUSIONS

A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.

Conceptual Paper: Abdominoplasty and Liposuction in Systemic Sclerosis

Surgical interventions in patients with systemic sclerosis (SSc), in particular plastic procedures, might cause undesired consequences. Notably, liposuction seems to possess greater risk as adipose tissue has been shown to play an important role in treating wounds and ulcers in patients with SSc. While anticentromere antibodies were found to be correlated with vasculopathy in SSc, patients with SSc and anticentromere antibodies might be more vulnerable to surgical wound complications following liposuction. A 46-year-old female patient, who had been diagnosed with SSc at the age of 31 years, had antinuclear as well as anticentromere antibodies. She underwent abdominoplasty with liposuction and developed severe skin necrosis of the abdomen following the procedure and at the site of liposuction. The correlation with anticentromere and the role of liposuction in skin necrosis in SSc are presented.

Anastomotic dehiscence following retroflexion in surveillance colonoscopy: a case report

Anastomotic dehiscence following colonoscopy for routine surveillance after anterior resection for colorectal cancer is unreported in the English literature. It is a potentially fatal complication requiring awareness, quick recognition and management. We present the case of a 45-year-old woman who presented 12 hours after a routine follow-up colonoscopy with peritonitis due to anastomotic rupture diagnosed on computed tomography. The patient was taken to theatre for emergency laparotomy and formation of an end colostomy. Her postoperative recovery and follow-up were optimal.

Relationship between perioperative blood transfusion and surgical site infections in pediatric general and thoracic surgical patients

BACKGROUND

Recently, perioperative transfusions were demonstrated to be associated with higher rate of surgical site infections (SSIs) in neonates. We sought to examine whether a similar relationship exists between perioperative blood transfusions and SSI among non-neonatal pediatric general surgical patients.

METHODS

We conducted an IRB-approved retrospective study reviewing non-neonatal patients (age greater than 28days and less than 18years) who underwent a general or thoracic surgical procedure in 2012, 2013, 2014, in the American College of Surgeons National Safety and Quality Improvement Project-Pediatric (ACS-NSQIP-P) Participant User Files. We used Chi-square analyses to perform a bivariate analysis comparing proportions of SSI's between patients who received blood transfusion to those who did not. Multiple logistic regression analyses compared the odds of SSIs in transfused versus nontransfused patients controlling for organ failure, steroid use, nutritional status, current infection, American Society of Anesthesiologists (ASA) Physical Status classification, and wound classification.

RESULTS

There were 55,133 patients with 1779 patients who received blood transfusion (≥25ml/kg body weight) during or within 72h of surgery. Bivariate analysis showed at least twice the rate of infection in transfused patients compared to nontransfused patients (p<0.01): superficial SSI 3.5% vs 1.5%; deep SSI 0.8% vs 0.2%, organ space SSI 3.8% vs 1.6%; deep dehiscence 2% vs 0.3%. Total wound infections and dehiscence for transfused patients were 10.5% vs 3.8% in nontransfused patients (p<0.01). Multiple regression analysis showed that nutritional issue, current infection, and wounds not classified as "clean" have statistically significant correlation with SSI. Although there was significant interaction between ASA and transfusion (p<0.0001), we found statistically significant associations between transfusions and SSI for ASA class 1-2 (OR=5.51, 95% CI 3.47-7.52), ASA class 3 (OR=2.06, 95% CI 1.63-2.61), and ASA class 4-5 (OR=1.67, 95% CI 1.15-2.42).

CONCLUSION

In non-newborn pediatric general and thoracic surgery patients, transfusions were associated with higher risk of SSI or wound dehiscence. Although there was a significant interaction between ASA and transfusion, OR for SSI was stronger for lower ASA classes.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

II.

[Routine fluoroscopic investigations after primary bariatric surgery]

BACKGROUND

Staple line and anastomotic leakages are life-threatening complications after bariatric surgery. Upper gastrointestinal (GI) tract X-ray examination with oral administration of a water-soluble contrast agent can be used to detect leaks. The aim of this study was to evaluate the impact of routine upper GI tract fluoroscopy after primary bariatric surgery.

METHODS

Between January 2009 and December 2014 a total of 658 bariatric interventions were carried out of which 442 were primary bariatric operations. Included in this single center study were 307 sleeve gastrectomies and 135 Roux-en-Y gastric bypasses. Up to December 2012 upper GI tract fluoroscopy was performed routinely between the first and third postoperative days and the detection of leakages was evaluated.

RESULTS

In the investigation period 8 leakages (2.6 %) after sleeve gastrectomy, 1 anastomotic leakage in gastrojejunostomy and 1 in jejunojejunostomy after Roux-en-Y gastric bypass occurred. All patients developed clinical symptoms, such as abdominal pain, tachycardia or fever. In one case the leakage was detected by upper GI fluoroscopy and in nine cases radiological findings were unremarkable. No leakages were detected in asymptomatic patients.

CONCLUSION

Routine upper GI fluoroscopy is not recommended for uneventful postoperative courses after primary bariatric surgery.

Results of a retrospective comparative study: material cost for managing a series of large wounds in subjects with serious morbidity with a hydrokinetic fiber dressing or negative pressure wound therapy

This retrospective observational study analyzed lesions with regard to healing trends and cost of materials.

MATERIALS AND METHODS

The observed lesions were mostly postsurgical or stage IV pressure ulcers in patients with serious morbidity. The wounds were treated with a hydrokinetic fiber dressing (sorbion Sachet S, sorbion Gmbh & Co, a BSN medical company, Senden, Germany) (n = 26) or negative pressure wound therapy (NPWT) (n = 16).

RESULTS

Primary healing trends (ie, reduction of wound size, change from necrosis to granulation tissue, and change from granulation tissue to epithelium) and secondary healing trends (ie, periwound conditions) were similar for wounds treated with the hydrokinetic dressing when compared to wounds treated with NPWT. Cost of materials was substantially lower for wounds treated with the hydrokinetic fiber dressing compared to the NPWT, with cost reductions of $1,640 (348%) to $2,242 (1794%) per wound, depending on the criteria used for the analysis.

CONCLUSION

In this set of wounds, the hydrokinetic fiber dressing was shown to lead to similar healing results while providing substantial reductions of the cost of materials. For the types of wounds presented in this observational study, the hydrokinetic fiber dressing seems to be an effective substitution for negative pressure wound therapy.

Management of long-standing partially torn and flipped laser in situ keratomileusis flaps

We describe 2 cases of traumatized and torn laser in situ keratomileusis (LASIK) flaps, partially flipped anteriorly or posteriorly, fixed for 8 months or 4 months, and accompanied by epithelial ingrowth. The 2 patients had had uneventful bilateral LASIK 6 years and 1 year before the trauma. In Case 1, the anteriorly flipped flap was removed with transepithelial phototherapeutic keratectomy. Next, mitomycin-C 0.04% was applied for 30 seconds. In Case 2, the portion of the flap that was flipped posteriorly and buried under the remaining intact LASIK flap was restored to its original normal position and epithelial ingrowth was removed mechanically with a microcurette. Irrigation with 20% ethanol was performed to inhibit the recurrence of interfacial epithelial ingrowth. The stretched amniotic membrane overlay over the cornea and sclera was sutured tightly to the episclera as the biologic pressure patch for the inhibition of epithelial re-ingrowth. Good visual acuity was restored in both cases.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Management of traumatic wound dehiscence of a functional graft 34 years after penetrating keratoplasty

A functional corneal graft 34 years after penetrating keratoplasty (PKP) is rare and even rarer is its survival after wound dehiscence. We present a case of a 69-year-old man who had presented to the emergency services in January 2012 with corneal wound dehiscence OS extending to 8 o'clock following blunt trauma. His vision was perception of light. The best corrected visual acuity (BCVA) of the patient prior to graft dehiscence was 20/30. The patient had undergone optical penetrating keratoplasty for healed keratitis in OS in 1978 followed by phacoemulsification with intraocular lens implantation in 2009. Suturing of the graft was performed under topical anaesthesia. At 18 months follow-up, the BCVA was 20/60 with clear graft centrally and specular count was 865 cells/mm(2). This case highlights that early and appropriate management of corneal graft dehiscence can achieve good functional outcome even 34 years following PKP.

[Bronchus sutures failure in lung cancer surgery]

Main methods of bronchus suturing after lung resection are presented in the article. The safest methods of bronchus closure are manual and mechanical suturing with use of UB apparatus. Use of UO or TL-TLH apparatus with longitudinal orientation of tantalic brackets significantly increases the frequent of bronchus suture failure. It is determined by deterioration of bronchus blood supply and poor trophic healing of bronchus wound.

Intracoronary dehiscence of radiopaque ring of a guiding catheter and its retrieval

Intracoronary dehiscence of the radiopaque ring of a guiding catheter is a rare complication, which could lead to myocardial infarction, emergency surgery, or even death. We describe the percutaneous retrieval of the catheter material from the right coronary artery, thus avoiding surgery and related complications.

The use of mersilene mesh for wrapping of hydroxyapatite orbital implants: mid-term result

PURPOSE

To report the results of Mersilene mesh wrapped hydroxyapatite orbital implantation.

MATERIALS AND METHODS

Records of 63 patients operated between April 2002 and March 2006 were retrospectively reviewed. Parameters studied included sex, cause of enucleation, length of follow-up after operation, implant exposure, secondary implantation, and surgeon experience. Student's t-test and χ(2) were used for comparison group having implant exposure and those without implant exposure.

RESULTS

The rate of exposure with use of Mersilene mesh was found to be 4.7%. Gender and cause of enucleation did not influence incidence of implant exposure in this study. The surgeon related factor, reported in terms of oculoplasty surgeon and non-oculoplasty surgeon, was a statistically significant factors that affected implant exposure.

CONCLUSION

Mersilene showed favorable results in wrapping of hydroxyapatite orbital implants.

Surveillance of late-onset bleb leak, blebitis and bleb-related endophthalmitis--a UK incidence study

AIMS

To determine the incidence of late-onset bleb leak (BL), blebitis (B) and bleb-related endophthalmitis (BRE) after trabeculectomy surgery, and report the management approaches employed by UK ophthalmologists.

METHODS

Prospective case ascertainment study reporting of incident cases fulfilling the study definitions of BL, B and BRE through the reporting mechanism provided by the British Ophthalmic Surveillance Unit (BOSU; United Kingdom) for the period July 2007 to August 2008 (13 months). Two questionnaires completed at initial reporting and 6 months later were used to collect clinical details related to presentation, early and late management and outcome.

RESULTS

Ninety-eight cases were reported to the British Ophthalmic Surveillance Unit during the study period. Seventy-one first questionnaires were returned (response rate 72.4%). Of these, 11 were erroneous/duplicated. Sixty second questionnaires were sent out, and of these 37 fully completed questionnaires were returned. Analysis was, therefore, based upon 60 initial and 37 follow-up questionnaires. Overall incidences were estimated for isolated bleb leak (0.22%), blebitis without bleb leak (0.1%), blebitis with bleb leak (0.11%), and BRE with or without bleb leak (0.17%). Visual outcome in the BL group was good; however, in the BRE group half the patients ended with visions of perception of light or worse. There was a great variance in the initial and late management of these conditions. Surgical intervention for bleb leak seemed to result in the best chance of leak closure.

CONCLUSIONS

These complications of trabeculectomy surgery are relatively low but potentially visually devastating. This study updates the knowledge of the incidence of these complications, and suggests that no consistent management approach to any of the reported conditions was practised. In view of the potentially catastrophic consequences of these complications, formal guidance as to best practice would be beneficial, and further research to establish this is required.

Conservative management of minor anastomotic leakage after open elective colorectal surgery

INTRODUCTION

The utility of prophylactic drainage in colorectal surgery is controversial. The aim of the present article is to study the role of drainage tubes on the management of minor anastomotic dehiscences.

PATIENTS AND METHODS

We retrospectively review clinical reports of 18 consecutive patients with anastomotic dehiscence after open elective colorectal surgery. The mean age was 63 years and the male - female ratio was 5:1. Nine (50%) patients underwent re-operation for fecal peritonitis (group A) while the remaining nine (50%) were managed conservatively (group B). The parameters evaluated in both groups were: time of the anastomotic breakdown, clinical findings, amount of fluid drained the day of the dehiscence, diagnostic means used, length of stay and mortality.

RESULTS

Anastomotic leakages were observed medially after 3, 6 days from surgery in group A and after 5.6 days in group B. The most frequent clinical manifestations were: fecal material through the tubes (88.9%), pelvic pain (88.9%) and fever (77.8%). Patients in group A had a median faecal fluid flow of 235cc the day of the dehiscence and 130cc those in group B. Imaging was employed only in three cases in group A and in all cases in group B. The length of hospital stay was longer in patients treated surgically: 37 days versus 29 in those treated conservatively.

CONCLUSIONS

Minor anastomotic leakages generally occur later than greater ones, they have a milder clinical presentation and can be managed conservatively with the use of drain tubes.

Nitinol thermoreactive clips for secondary sternal closure in cases of noninfective sternal dehiscence

Postoperative sternal dehiscence is a potentially catastrophic sequela to median sternotomy that can cause not only chest-wall discomfort and pulmonary dysfunction but infection, both superficial and mediastinal. Nitinol thermoreactive clips use a novel material in the treatment of sternal dehiscence. We sought to determine whether the use of these clips is an effective remedy for noninfective sternal dehiscence. From January 2008 through December 2011, we retrospectively studied the data on 10 patients whose sternums had been closed with nitinol thermoreactive clips after the development of noninfective sternal dehiscence. Diagnosis was made on the bases of clinical criteria, chest radiography, and microbiological investigation. There was no control group. No procedure-related sequelae occurred. There was no recurrent sternal instability and dehiscence, sternal-related hemorrhage, superficial wound infection, or mediastinal infection. We believe that the use of nitinol thermoreactive clips is a safe, easy, and efficient method of secondary sternal closure for noninfective sternal dehiscence.

Characteristics of traumatic cataract wound dehiscence

PURPOSE

To characterize the clinical course of cataract wound dehiscence.

DESIGN

Retrospective, comparative case series.

METHODS

Charts of open globe injuries (848 injuries in 846 patients) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Time from original surgery to wound dehiscence, type of initial surgery, Ocular Trauma Score, age, gender, mechanism of injury, and visual acuity were analyzed.

RESULTS

Of 846 patients with 848 open globe injuries, 63 experienced cataract wound dehiscence. The majority of these cataract wounds (89%) were extracapsular cataract extraction (ECCE), with only 7 (11%) phacoemulsification wounds. The mean patient age in the wound rupture group was 78.2 years. Female patients comprised the majority (67%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (23%), and motor vehicle accident (7%). The median raw ocular trauma score was 47 in wound dehiscence patients. Visual acuity at presentation was light perception in the wound dehiscence group. The best postoperative visual acuity was significantly worse in the wound dehiscence group (hand motion) than in the remaining patients (20/40; P=.0002). When considering the phacoemulsification patients alone, these patients fared much better, with a median postoperative vision of 20/60.

CONCLUSIONS

Despite recent advances in cataract surgery, wound dehiscence remains a significant source of visual disability, mainly in the geriatric population. Rupture ECCE wound patients have a poor visual prognosis. Fortunately, patients with phacoemulsification site dehiscence appear to regain the majority of their vision after open globe repair.

[Early diagnosis of anastomotic dehiscence after colonic surgery]

BACKGROUND

Anastomotic leaks are often responsible for severe sepsis can lead to death. Rapid diagnosis and early intervention are needed to improve prognosis.

AIM

To identify predictors of early diagnosis of anastomotic leakage after colonic resection followed by immediate anastomosis without protective stoma to ensure a rapid therapeutic care and improve prognosis.

METHODS

This retrospective study involved patients who had a colonic resection over a period from 1st January 1998 to December 31st, 2009. The diagnosis of anastomotic dehiscence was selected on clinical, radiological and / or surgery. Statistical analysis was undertaken to identify clinical and biological changes leading to early diagnosis. The significance level was set at 0.05.

RESULTS

Anastomotic leaks were identified in 28 patients, a rate of 8.9%. Revision surgery was indicated in 23 patients. Univariate analysis identified 3 preoperative factors associated with anastomotic dehiscence (ASA score, the urgency of intervention, and neoplastic etiology), and 5 postoperative factors (parietal complications, respiratory problems, the cardiac disorders, neurological disorders, and bloating). Multivariate analysis identified only three factors related to the anastomotic dehiscence, they were respiratory symptoms, bloating, and neurological disorders. The median length of stay was 15.6 days (5-84). The mortality rate was 1.2%. It was higher in patients with leakage (7.4%) than in patients without leakage (0.7%).

CONCLUSION

Better knowledge of these early clinical and laboratory manifestations related to anastomotic leaks, can ask the early indication of a radiological drainage or reoperation, which can improve the prognosis of this dreaded disease.

Airway dehiscence after lung transplantation in a patient with cystic fibrosis

The presence of resistant pathogens in the lower airways of patients with cystic fibrosis (CF) is not an absolute contraindication for lung transplantation. We describe a case in which a patient with CF died as a result of an anastomotic dehiscence, ischemia, and infection with linezolid-resistant methicillin-resistant Staphylococcus aureus. We review infection issues during the post-lung-transplant period and related anastomotic dehiscence in CF.

[Determination of creatinine in drained liquid. Urinary leak or lymphocele?]

BACKGROUND

Liquid collections around the renal graft that are displayed in 51% of cases implicate a diagnostic challenge and a risk for graft function. We undertook this study to determine the usefulness of creatinine concentration measurement in drainage in patients with renal transplantation.

METHODS

We selected patients with surgically corrected urinary leak and patients with lymphocele from November 1, 1999, to November 30, 2008, in whom we determined the creatinine concentration in liquid drainage, plasma and urine.

RESULTS

We included five patients with urinary leak and six patients with lymphocele. Two patients had urinary leak before the lymphocele. The t value of the plasma creatinine (Pcreat), drainage (Dcreat) and urine (Ucreat) was 0.89, 0.045 and 0.63, respectively. The diagnostic criteria of urinary leak represented a value between the creatinine of the drainage and plasma (D/Pcreat) >6, between urine and drainage (U/Dcreat) <3 and between urine and plasma (U/ Pcreat) <7. When we compared both groups the χ(2) values were 0.018, 0.007 and 0.094, respectively.

CONCLUSIONS

There is a statistically significant difference among the creatinine drainage liquid values. Our study shows that D/Pcreat ratio >6 after the first week or U/Dcreat ratio <3 at any time during the postoperative period represents a six-times higher possibility of urinary leak.

Early changes in clear cornea incision after phacoemulsification: an anterior segment optical coherence tomography study

PURPOSE

We aimed to investigate the ultrastructures of clear corneal incisions 24 hours after phacoemulsification using anterior segment optical coherence tomography (AS-OCT).

METHODS

Sixty eyes of 60 patients scheduled for cataract surgery were randomly selected. All eyes underwent the same phacoemulsification procedure carried out by one experienced surgeon. Two-plane temporal clear corneal tunnel incisions were performed. The same types of intraocular lens and implant system were used in all patients. Images of the ultrastructures of the corneal incisions were taken using AS-OCT before and 1 day after surgery.

RESULTS

Corneal thickness increased at the incision site after surgery in all eyes (p < 0.001). Epithelial bulla in the incision region was seen in two eyes (3%). Gaping at the internal aspect of the corneal wound was seen in 42 eyes (70%). Eyes with gaping had thicker localized cornea (p = 0.002). Descemet's membrane detachment was seen in 49 eyes (82%); this seemed to be associated with lower preoperative intraocular pressure (p = 0.01).

CONCLUSIONS

 Anterior segment OCT provides sensitive and detailed measurements of the ultrastructures in clear corneal incision.

[Optimal surgical tactics in resection of terminal part of ileum]

The possibilities of terminal ileo-ileo, ileo-coeco and ileo-ascendoanastomoses formation in the small bowel resection on urgent indications for ileus and peritonitis were studied up. It was established, that the primary anastomosis formation in these portions is assumed, taking into account intramural hemodynamics, intraintestinal pressure etc. For the prognosis of the intestinal anastomoses insufficiency occurrence it is trustworthy to use transilluminate angiotensiometry and pulsomotorography widely, and for prophylaxis - nasointestinal intubation with decompression, the small bowel sanation and enterosorption, laser-magnetic therapy of anastomotic zone, prolonged intramesenterial lymphotropic therapy.

[Diagnosis and treatment of the bile diverting anastomosis sutures insufficiency]

The results of complex diagnosis and treatment of 64 patients, in whom bilediverting anastomoses sutures insufficiency (BDASI) had occurred, were analyzed. It was established, that dynamical ultrasonographic investigation and laparoscopy constitute the principal methods of BDASI early diagnosis. In 25 patients conservative methods of treatment were used effectively, in 34--relaparotomy was performed and in 5--videolaparoscopic interventions. Eighteen patients died.

[Defects of facial nerve canal according to a character and localisation of lesions in middle ear]

AIM

The aim of this study is the assessment the occurence of facial nerve canal (Fallopian canal) dehiscence in patients operated due to chronic medial otitis (depending on the location and type of inflammatory lesions) and in patients operated due to otosclerosis. Facial nerve paresis in patients with dehiscence found during surgery was also assessed.

MATERIAL AND METHODS

The study group consisted of 456 patients operated at the Department of Otolaryngology at the University Hospital in Krakow, 359 due to chronic otitis media and 97 due to otosclerosis. Facial nerve canal dehiscence was found during surgery in 26 patients (6% of operated patients) more frequently in men.

RESULTS

In most cases (54%) dehiscence was observed in patients with chronic medial otitis with cholesteatoma (27% with choleseatoma and 27% with cholestatoma and granulation), and equally (23% each) dehiscences were observed in patients with granulation and even in patients with otosclerosis and chronic simple otitis media. In over than half (54%) of patients with dehiscence inflammatory lesions involved all the middle ear spaces, in 15% the tympanic cavity, attic and antrum while in 4% of patients inflammatory lesions were limited to the tympanic cavity, attic or antrum.

CONCLUSIONS

The facial canal nerve dehiscence is observed in majority in patients with cholestatoma and granulation, especially in tympanic region. In some cases its coexistence with circuit canals dehiscence.

[Ischemic anastomotic bowel perforation during treatment with bevacizumab 10 months after surgery]

BACKGROUND

Bevacizumab (Avastin) is a monoclonal antibody against vascular endothelial growth factor (VEGF) receptor that has demonstrated increased overall survival when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. Gastrointestinal perforation is a known risk factor of unknown etiology associated with the use of bevacizumab.

OBJECTIVE

We report a 61-year-old woman with adenocarcinoma of the colon ascendens who underwent hemicolectomy and adjuvant chemotherapy with oxaliplatin, 5-fluorouracil, and leucovorin. Eight months after the operation, we started therapy with bevacizumab combined with irinotecan, 5-fluorouracil, and leucovorin due to disease progression. Two months after completion of this therapy, ischemic anastomotic bowel perforation occurred and a resection of the anastomosis was performed. Because of anastomotic insufficiency 8 days later, a further revision had to be done and the terminal ileum and the colon were brought out through a stoma.

DISCUSSION

This case is unusual because the time interval between the primary operation and the application of bevacizumab is regarded as safe with regard to the risk of perforation. An ischemic genesis of the perforation was considered on the basis of the histopathological workup. In case of perforations during therapy with bevacizumab, a safe surgical approach should be preferred, i.e., a transient stoma instead of a primary reconstruction of the bowel passage.

[Postoperative monitoring of anastomosis after radical retropubic prostatectomy Transrectal ultrasound can replace cystography?]

OBJECTIVE

We determined if transrectal ultrasound (TRUS) is as reliable as cystography in detecting vesicourethral extravasates after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Between October 2005 and February 2006 we prospectively investigated 100 consecutive patients undergoing RRP. The vesicourethral anastomosis was proven 6 days after operation by a combined investigation with TRUS and cystography.

RESULTS

In the majority of patients (79%) the vesicourethral anastomosis was watertight on postoperative day 6 (POD) or showed minimal leakage (8%) so that the urinary catheter was removed. Different degrees of paravasates were detected in 21 patients. Because of small, moderate, or marked paravasations the indwelling catheter was removed on POD 9, 14, and 21 in 5, 3, and 5 patients, respectively. Every paravasate documented by cystography had been detected by TRUS before. Therefore, TRUS showed no false-negative result in detecting insufficient anastomosis. In two patients paraurethral fluid was detected by TRUS mimicking anastomotic paravasation, without confirmation by cystography.

CONCLUSIONS

TRUS can safely replace cystography to detect anastomotic leakage after radical prostatectomy.

Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases

INTRODUCTION

Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome.

METHODS

Retrospective review of 3,828 gastric bypass procedures.

RESULTS

Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037).

DISCUSSION

Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak.

Risk factors for mediastinitis after cardiac surgery - a retrospective analysis of 1700 patients

Background

Mediastinitis is a rare, but serious complication of cardiac surgery. It has a significant socioeconomic impact and high morbidity. The purpose of this study was to determine pre-, intra-, and postoperative predictors of mediastinitis.

Methods and results

In 1700 consecutive patients, who underwent cardiac surgery in 2001, 49 variables were retrospectively assessed. Forty-five patients (2.65%, 95% CI [1.88; 3.41]) developed postoperative mediastinitis. None of these patients died during their hospitalization. Multivariate analysis identified three of the 49 variables as highly significant independent predictors for the development of mediastinitis: obesity (OR 1.03, 95% CI [1.01; 1.04] p = 0.001), chronic obstructive pulmonary disease (OR 3.30, 95% CI [1.58; 6.88], p = 0.001), and bilateral grafting of the internal mammary artery (OR 3.18, 95% CI [1.20; 8.43] p = 0.02). The model is reliable in terms of its goodness of fit, it also discriminates well. Additionally, univariate analysis identified diabetes mellitus, CCS class and the number of intraoperatively transfused units of fresh frozen plasma as variables with a significant impact.

Conclusion

The present study suggests that bilateral IMA grafting, chronic obstructive pulmonary disease and obesity are important predictors of mediastinitis.

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

STUDY OBJECTIVE

The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences.

DESIGN

Observational case series (Canadian Task Force classification II-3).

SETTING

Large, urban, university teaching hospital.

PATIENTS

All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed.

INTERVENTIONS

Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate.

MEASUREMENTS AND MAIN RESULTS

From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH.

CONCLUSIONS

Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.

[Traumatic wound dehiscence following penetrating keratoplasty]

BACKGROUND AND PURPOSE

Blunt ocular trauma to a corneal transplanted eye represents a higher risk for wound rupture at the donor-recipient interface. We have evaluated the causes, clinical characteristics, treatment and outcome, particularly the graft's clarity, in patients with traumatic wound dehiscence after penetrating keratoplasty.

METHODS

Between March 1996 and April 2006, over a period of 10 years, 4 patients who had previously undergone successful penetrating keratoplasty and subsequently sustained traumatic wound dehiscence were treated at our department. All eyes underwent primary wound closure with interrupted 10-0 nylon sutures.

RESULTS

Over the 10-year period, the incidence of traumatic wound dehiscence in which penetrating keratoplasty was performed was 2.35 % (4 of 170 patients). The ages of our patients at the time of injury were 6, 76, 78 and 39 years. The interval between penetrating keratoplasty and trauma varied from 12 through 16 and 17 to 30 months. All corneal dehiscences occurred at the graft-host junction. All dehiscences were at the temporal-superior quadrant (4 of 4 eyes) and at superior-nasal and temporal quadrants in 3 of 4 eyes. Two eyes that were pseudophakic had lost their implants and required anterior vitrectomy. In one of these patients (a 76-year-old women) delayed-onset expulsive choroidal haemorrhage occurred at the end of surgical repair. Visual outcome was correlated with the force of trauma, previous eye conditions and complications during surgery. All of the resutured grafts retained clarity.

CONCLUSION

Traumatic wound dehiscence is a serious and not uncommon complication following penetrating keratoplasty. Despite severe trauma, graft transparency was achieved in all cases and there was no need for regrafting.

Indocyanine Green Staining Facilitates Detection of Bleb Leakage During Trabeculectomy

PURPOSE

To report a new technique to visualize bleb leakage using indocyanine green (ICG) staining during trabeculectomy.

PATIENTS AND METHODS

The ICG solution was widely applied over the filtering bleb including the conjunctival wound before completion of trabeculectomy. This procedure was performed in 48 eyes of 44 consecutive patients undergoing trabeculectomy between December 2004 and October 2005.

RESULTS

Without staining, bleb leakage was not identified by the direct observation under the operating microscope. ICG staining clearly visualized aqueous leakage from the bleb in 5 eyes (10.4%). The bleb leakage in these eyes was easily repaired with 10-0 nylon sutures, and no eyes, including these 5 cases, showed bleb leakage after surgery. There were no intraoperative and postoperative complications related to ICG application.

CONCLUSIONS

The application of ICG during trabeculectomy is a simple and useful technique to facilitate detection and repair of the bleb leakage.

Corneal wound architecture and integrity after phacoemulsification

PURPOSE

To compare the effects of microincision bimanual phacoemulsification, standard coaxial phacoemulsification, and microincision coaxial phacoemulsification on clear corneal incision architecture and wound integrity.

SETTING

Department of Ophthalmology, Duke University, Durham, North Carolina, USA.

METHODS

A prospective study of 15 human cadaver eyes (3 groups of 5 eyes) ranging 1 to 4 days postmortem had simulated phacoemulsification by bimanual phacoemulsification (1.2 mm incision), standard coaxial phacoemulsification (2.75 mm), or microincision coaxial phacoemulsification (2.2 mm). All phacoemulsification settings were kept constant across each group. After phacoemulsification, intraocular pressure (IOP) was cyclically raised and lowered from 0 to 125 mm Hg. Two eyes in each group had India ink placed above the wound, and the IOP was varied as above. Entry of India ink into the wound or aqueous leakage from the wound was recorded. The same 2 corneas in each group were removed for histopathologic review of India ink penetration. Scanning electron microscopy was used to evaluate wound architecture in 1 eye in each group.

RESULTS

Spontaneous wound leakage was evident in all 5 eyes having bimanual phacoemulsification, in 1 eye (20%) having standard coaxial phacoemulsification, and no eye having microincision coaxial phacoemulsification. India ink penetration was grossly evident in 2 of 2 eyes having bimanual phacoemulsification, 1 of 2 eyes having standard coaxial phacoemulsification, and neither of the 2 eyes having microincision coaxial phacoemulsification. Scanning electron microscopy showed increased endothelial cell loss and greater compromise to Descemet's membrane with bimanual phacoemulsification than with standard coaxial phacoemulsification or microincision coaxial phacoemulsification.

CONCLUSION

Results in this experimental setting suggest microincision coaxial phacoemulsification and standard coaxial phacoemulsification induce less wound stress and alteration of wound morphology leading to wound leakage than microincision bimanual phacoemulsification.

Clear corneal incision leakage after phacoemulsification––detection using povidone iodine 5%

The purpose of this work was to study the incidence of clear corneal wound leakage at the conclusion of standard co-axial phacoemulsification in a prospective observational series of 100 consecutive cataract cases in a single surgeon's institutional practice. At the conclusion of standard co-axial phacoemulsification using a 2.75 mm temporal single plane clear corneal incision with a 1 mm clear corneal side-port incision, the wounds were hydrated and checked for water-tightness. Povidone iodine 5% (P-I) was then evenly dripped over the cornea and the wounds were inspected visually. Any leakage of aqueous observed was recorded. The amount of leakage was graded as small or large from each wound. Leaky wounds were further hydrated and retested with P-I until sealed. Wound integrity was reassessed on the first postoperative day by use of fluorescein. Of the 100 cases, wound leakage was observed for 31 eyes (31%)-ten main incisions, nineteen side-port incisions, and both incisions in two cases. Wound leakage was easily detected as a ribbon of clear fluid streaming from the incision amid a pool of brown solution. Povidone iodine was not observed within the tract in any incision. All wound leakage was small except for one from the main incision and two from the side-port incision. None of the eyes developed wound leakage the day after surgery and none developed endophthalmitis. In conclusion, leakage from clear corneal incisions at the conclusion of phacoemulsification occurs in almost a third of cases, predominantly from the side incision. It is easily detected by use of the P-I test.

Abduktorennahtversagen und Nervenschädigung beim transglutealen Zugang zur Hüfte

BACKGROUND

When used for total hip replacement, the lateral approach is associated with two frequently iatrogenic, but virtually insoluble problems: limping attributable to abductor insufficiency and pain at the greater trochanter. They can result from injury to the inferior branch of the superior gluteal nerve and/or failure of the abductor repair.

MATERIAL AND METHODS

These complications are due to the interruption of a voluminous abductor mass at the trochanter, which has to be done to allow undisturbed work on the femoral shaft and implantation of a straight femoral component while the leg is in the classic figure 4 position. When the lateral approach is used they cannot be avoided except by application of a technique that does not require the hip to be forced into flexion by the figure 4 position. This is possible with only slight detachment of anterior parts of the abductors, as described by Watson-Jones, and preparation of the femoral shaft as reported by Röttinger, with the hip in extension.

RESULTS

In comparison with the Röttinger technique, in which the surgeon manages without detaching the abductors, the technique with the slight detachment lessens the traction on the abductors and lowers the risk of nerve damage in the interval between abductor and tensor.

CONCLUSION

Whichever technique is ultimately selected, it is of decisive importance that in the case of an approach to the hip joint by way of an anterior capsulotomy with the abductors shifted in the posterior direction, the femoral shaft is prepared with the hip in extension.

Postoperative Infektion unter Adalimumab

Tumor necrosis factor (TNF) blocking agents, such as adalimumab, are well tolerated and provide improvement in the symptoms and signs of rheumatoid arthritis (RA). Due to its immunosuppressive effect, an increased risk of infection has been suggested, but so far no differences between adalimumab and placebo groups have been found in pivotal trials. Patients with RA succumb to postoperative complications because they have a systemic disease and use medication with immunosuppressive effects. We report on a patient with longstanding, active RA who had received adalimumab 40 mg every other week with prolonged infection, wound dehiscence and pseudoarthrosis following reconstructive forefoot surgery due to deformities secondary to RA. The postoperative infection occurred although adalimumab therapy had been stopped 8 days before surgery. The half-life of adalimumab is 10.0-13.6 days following a single intravenous dose. Whether patients under therapy with adalimumab are at an increased risk of developing postoperative complications is unclear, a retrospective analysis of the pivotal studies would be helpful in estimating the risk of perioperative (wound) infections in patients receiving anti-TNF. Moreover, it is not clear when therapy should be stopped prior to surgical intervention. Obviously prospective clinical trials would be more convincing.

Late leakage of filtering bleb in a patient with orbital pseudotumor

PURPOSE

To report an unusual case of spontaneous late leakage of filtering bleb in a patient with orbital pseudotumor.

METHODS

Single case report.

RESULTS

A 53-year-old woman developed spontaneous leakage of bleb in her right eye 23 years after trabeculectomy with application of mitomycin-C (MMC). Two weeks later, her symptoms were blurring of vision, increasing redness, and dull ocular pain in the right eye. The inflammatory signs were suggestive of endophthalmitis, orbital cellulites, or pseudo-tumor. Absence of ophthalmoplegia, fever, and raised white cell count, together with the computed tomographic scan finding, confirmed the diagnosis of orbital pseudotumor. She responded well to oral steroids.

CONCLUSIONS

Orbital pseudotumor may initially present with spontaneous late leakage in a bleb augmented by MMC. Orbital pseudotumor should be added to the list of differential diagnoses when facing a patient with an inflamed, chemotic, proptotic eye in the presence of a late bleb leak.

Abdominal wound dehiscence: A review

Wound dehiscence and its complications plague surgical practice. This study aims to identify the clinical features, etiological factors, and preventive measures of abdominal wound dihiscence (AWD). A Medline search from 1966 to February 2004 was done, using the terms abdominal wound dehiscence, burst abdomen, and abdominal wound closure. Accessible full texts of these, relevant references from them, and publications found in medical libraries were studied. Data extracted included authors' names, presenting symptoms and signs of AWD, ages of the patients, presumed etiology of dehiscence, methods of wound closure, and complications and outcome of both the dehiscence and its treatment. These were analyzed under selected headings. Abdominal wound dehiscence is as old as surgery. Predisposing factors are either patient or surgeon related. Despite several incisions and suture materials, controversy remains, with no consensus on the ideal methods or materials for closure of abdominal wounds to prevent dehiscence. At best, the incidence of AWD can be reduced.

Airway Complications After Pulmonary Resection

Airway complications following pulmonary resection remain a challenging problem. A high degree of clinical suspicion, contrasted CT imaging, and early reoperation are crucial in preserving viable lung parenchyma following the anatomic compromise of lobar torsion. Likewise, early recognition and expeditious drainage of the pleural space in the setting of bronchial dehiscence may help prevent the aspiration pneumonia and consequent respiratory failure that is the leading cause of death in this patient population; A variety of interventions to manage stump dehiscence are possible, but successful management still remains difficult and requires an individualized approach. Attention to technical details and avoidance of extensive dissection and tension should yield acceptably low rates of postoperative stenosis following bronchoplastic resection. These common themes of precise surgical technique, vigilance in the perioperative period, and classic sound judgment in addressing problems effectively and expeditiously remain pivotal in the minimization of sequelae from morbid airway complications.

Predicting anastomotic disruption after emergent small bowel surgery

BACKGROUND/AIMS

Small bowel anastomoses performed in the emergent setting have a high risk of leakage. Attention to technical detail is imperative but does not guarantee success in these situations. We sought out factors that could play a role in the process of anastomotic dehiscence under these conditions.

METHODS

70 patients underwent 74 emergency small bowel anastomoses over a 21-month period in our institution during this prospective study. Patients with anastomotic disruption formed the case group and those without, the control group. Several preoperative, intraoperative and postoperative variables identified at the outset of the study were analyzed for possible associations with anastomotic dehiscence.

RESULTS

Suture line disruption occurred in 26 of 74 anastomoses (35%). The duration of symptoms before presentation did not differ significantly between groups. Hypoalbuminemia (p = 0.004), hyponatremia at presentation (p = 0.012), and intraoperative hypotension (p = 0.042) were found to be significantly associated with disruption. Neither the nature of the primary pathology in the bowel nor the anastomotic level had a significant bearing on anastomotic leakage.

CONCLUSION

Risk factors for leakage of emergent small bowel anastomoses include hypoalbuminemia, hyponatremia at presentation, and intraoperative hypotension. Under these circumstances, the creation of a temporary stoma or exteriorization may be a wiser option than primary anastomosis.