Objective:To evaluate the impact of a multidisciplinary program on dehydration risk after ileostomy creation. Background:Dehydration after ileostomy creation is a significant complication and the most common reason for readmission. We implemented a multidisciplinary program to address this problem, including improved perioperative education and increasing wound ostomy and continence nurse (WOCN) support. Methods:We queried patients who underwent ileostomy creation from 2010-2019. We evaluated patient characteristics (including sex, age, comorbidities), operative characteristics (including approach, class, duration, estimated blood loss), and perioperative characteristics (including WOCN consultation, antimotility agents, ileostomy output, length of stay [LOS], follow up, and adverse events). Primary outcome was 60-day readmission for dehydration. Univariate and multivariate logistic models were created to identify factors associated with dehydration. Results:Nine hundred and ninety-eight patients underwent ileostomy creation, with a median LOS of 6 days. The readmission rate for dehydration was 5.4% (vs 11.5% previously), with a median time to readmission of 8.5 days. Patients readmitted for dehydration had slightly higher ileostomy output prior to discharge (750 vs 500 mL/24h) and later post-operative follow up (13 vs 11 days). On multivariate analysis, risk factors associated with dehydration were diabetes (p = 0.001), open surgery (p = 0.001), adverse events (p < 0.001), and higher ileostomy output (p = 0.004). Conclusions:Readmission for dehydration after ileostomy creation has significantly decreased with the implementation of a multidisciplinary program. A potential area of improvement is close follow up within 1 week for high-risk patients to identify and address early signs of dehydration.
Burns are a common condition presenting to the emergency room. Most of them are thermal burns. Burn wound healing is a complex process characterized by inflammation, proliferation, repair, and remodeling stages. A Special Burn Care Cream (SBCC) improves burn wound healing. We report a case of burns after a gunpowder explosion. A 36-year-old male patient was transferred to the burn center of a state hospital in Ankara, Turkey, following a gunpowder explosion on his face and neck. He had showed up with a second- to third-degree burn injury, about 14% total body surface area. He presented to our outpatient clinic 5 days later. Twice surgical debridement was performed to treat burn wounds on the face and neck. All the necrotic tissues were removed. Daily, the burn wound beds were cleaned by irrigation of the wound surface with gauze and saline. Then SBCC was applied to the wound area and left open. On the 10th day of treatment, complete recovery was achieved. No adverse effects were recorded. The SBCC increases the healing rate of burn wounds by promoting cell adhesion, proliferation, and differentiation. The cream promotes the proliferation and differentiation of fibroblasts and keratinocytes. In addition to other treatments, the SBCC application may be an alternative treatment approach for closure of burn wounds that have failed to heal with conventional treatments. Prospective and randomized controlled studies are needed to demonstrate the efficacy of SBCC.
The aim of this research was to prove the functionality of a smart tibial sensor for use during total knee replacements. The accuracy of such device provides surgeons with an objective tool for load balancing in the knee, where currently the joint is balanced based on the surgeon’s ‘feel’ of a balanced knee. Literature surrounding the kinematics and tibiofemoral joint forces through the flexion arc coupled with qualitative feedback from an orthopedic surgeon provided a basis for proving thefunctionality of the smart-sensor. Two full body cadavers underwent a cruciate-retaining total knee replacement using Zimmer’s Persona Knee System. Varying thicknesses adjusted the height of the tibial smart-sensor between 10 mm to 13 mm in increments of 1 mm. The contact points and loads were observed through the flexion arc (0°, 45°, and 90°). The results found similar results between the literature surrounding both the compartmental forces and contact points throughout the range of motion. Moreover, qualitative feedback determined that the smart-sensor was robust and durable throughout its use in both cadavers demonstrating its potential as a reusable device. Minor adjustments to the graphical user interface would improve the ease of use for the surgical team. This sensor demonstrated the functionality of the smart-sensor through cadaveric testing in predicating both the load and location throughout a range of motion. Continued development of this sensor would provide surgeons with an accurate and robust tool for intraoperative joint balancing which could extend to all joints in the body.
Since its first description almost four decades ago in the plastic surgery field, the angiosome theory has shown encouraging clinical success in Chronic Limb-Threatening Ischemia (CLTI) revascularization in recent years. Gradual scientific knowledge and evidence-based feedback are necessary to assess its usefulness and to overcome various challenges lingering in its practical application at the patient’s bedside. Despite the increasing number of publications in recent years indicating its acceptable suitability in clinical practice, only a few provide conspicuous information regarding the applicability of angiosome-guided Direct Revascularization (DR) compared with the analysis of hurdles in the vascular approach, regardless of its clinical results. The current review aimed to provide an updated interpretation of DR applicability rates in daily practice, delineated through tangible assessments of feasibility, clinical match, and technical success (as previously mentioned). This analysis considered the applicability of DR, Indirect Revascularization via collaterals, (IRc), and “Wound-Targeted Revascularization” (WTR) within the broader perspective of “Intentional Topographic Revascularization” (ITR) in patients with CLTI foot. ITR affords a novel conceptualization of regional foot reperfusion via deliberate anatomical and functional orientation of the foot arterial flow to the ischemic zones (owing specific pedal arteries and regional collaterals). The analysis of data revealed significant differences in the current clinical definitions, interpretation, and application methods of TR. Inconsistent views on DR were also observed in the context of “wound-dependent” localization and the identification of the most suitable target foot artery for treatment. Unfortunately, a standardized definition of angiosome-oriented DR, IR, IRc, and WTR has not been established. Owing to the lack of a universally accepted definition and unified anatomical and functional foot arterial occlusive disease stratification, evidence supporting the applicability of ITR (by all its variants) is still awaited.
Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.
Introduction: Venous congestion, even with a patent deep venous anastomosis, can afflict some DIEP (Deep Inferior Epigastric Perforator) flaps and various techniques of superficial venous supercharging have been described, although the indications for its use are not consensual. The main goal of this study is to confirm that superficial venous supercharge of DIEP flaps, utilizing the contralateral Superficial Inferior Epigastric Vein (SIEV) as an interposition vein graft, is feasible and functional. Materials and Methods: We retrospectively reviewed all DIEP flap breast reconstruction patients treated at our institution between June 2016 and December 2017 and that met all the inclusion criteria: Unilateral breast reconstruction with a DIEP flap; flap weighing more than 750 gm; supercharging of the ipsilateral superficial venous system; contralateral SIEV interposition graft; implantable doppler probe in the superficial system for at least 5 days. In the technique described here, the contralateral SIEV graft was harvested and anastomosed to the ipsilateral SIEV, obtaining this way a long vein that easily reaches the recipient vein (distal end of the Internal Mammary Vein - IMV). A Doppler probe was implanted in the superficial system, for at least 5 postoperative days, to monitor the function of this supercharging. We also analyzed the patient’s history, flaps weight, number and perforator rows, recipient vessels, SIEV graft length and diameter and all perioperative complications. Results: Ten patients met all inclusion criteria. They were treated using this technique and analyzed. Two patients had some type of alteration of the Doppler signal and clinical signs of venous congestion. They were surgically revised with success and were analyzed in detail. No total or partial flap failures were found. Clinical fat necrosis was also absent. Conclusion: This technique seems to be feasible, functional and adds an extra length to ipsilateral SIEV to reach a recipient vein. This way, the flap inset is not compromised by a short SIEV. No further significant morbidity is added for SIEV harvest that is in the same operative field, unlike the saphenous or cephalic veins. In selected patients, it could be an alternative supercharging technique.
Although an early diagnosis and treatment would be ideal for head and neck tumors, sometimes it isn´t possible for patients who live in some regions of Africa. We treated some of these patients with tumors rarely seen today in well-developed countries. Materials and Methods: We retrospectively reviewed all free flap reconstructions for advanced head and neck tumors in Africa rescued patients between June 2014 and December 2017. Patient age, surgical treatment and reconstruction, complications and outcomes were analyzed. Results: Twelve patients have been treated. There were 5 fibular bone flaps, 2 anterolateral thigh flaps, 2 profunda artery perforator flaps, 2 vertical rectus abdominal myocutaneous flaps and 1 latissimus dorsi muscle flap. No flap failures have been recorded. Two serious postoperative complications have been detected (one cerebrovascular event and one nosocomial infection) and one patient was diagnosed with distant disease in the follow-up. No locoregional relapse has been detected. Conclusion: Surgical resection and microsurgical reconstruction may be safe and effective in these advanced head and neck tumors, although it isn`t without potential serious complications.
The aim of this study is to describe the characteristics, the management and the outcome of a series of patients with no-option critical limb ischemia (CLI) treated with a conservative multidisciplinary combined approach including best wound care, NPWT and dermal substitutes. The primary end was limb salvage and 1-year amputation-free survival. The secondary end was mortality and healing time of lesion. Between January 2016 and January 2021, 76 patients with no options CLI were admitted. In 14 patients, there was a failure in distal revascularization with a persistent CLI after the procedure. In 58 patients, revascularization was not feasible. Despite the persistent CLI, a group of patients of this cohort obtained no progression of CLI, complete wound healing treated with surgical debridement or distal amputation and application of NPWT in association with dermal substitute .Any superimposed infection was treated with antimicrobials. Pain was controlled with analgesics. Overall limb was saved in 72 % of the cases. A 1-year survival was 84%.Use of NPWT, dermal substitutes combined with a conservative foot surgery with an approach with minor amputation in patients with no-option CLI may save patient limb and life
1.1.Background: Renal Cell Carcinoma (RCC) accounts for approximately 3% of all malignant diseases.As the population in the Western world grows older more patients are treated with Dual Antiplatelet Therapy (DAPT) for cardio-vascular diseases.We sought to understand the morbidity associated with open surgical for presumably malignant renal masses in patients undergoing open renal surgery.1.2.Methods: 2,913 patients underwent renal surgery between 2011 and 2021.Out of these patients we identified 19 patients who underwent surgery on continued clopidogrel and aspirin DAPT.Surgery was performed by one single surgeon.Institutional review board permission was granted to perform this analysis.
We report a case of a 62-year-old man with a right-sided single coronary ostium supplying the complete myocardium. This case was diagnosed based on an aberrant exercise tolerance test and complementary angiography. The patient was revascularized by a coronary artery bypass graft to the single coronary artery because of a significant stenosis in its course.
Floating hip describes a rare combination of fractures/dislocation and is usually seen in multiple injured patients, more often in young males involved in high-energy automotive/motorcycle trauma. These fractures are often associated to chest trauma, other skeletal fractures or polytrauma. A “floating hip” injury is rare but a surgical challenging. Each case needs to be planned and addressed. We present a case of floating hip injury in a male patient, treated successfully with ORIF, followed by an uneventful postoperative period.
SI-NETs: Small Intestinal Neuroendocrine Tumors; TMB: Tumor mutation burden; NET (G1): Grade 1; Mut/Mb: Total number of somatic/acquired mutations per coding area of a tumor genome; mCi: millicurium; TP53: cellular tumor antigen P53 (PTHR11447:SF6); RB1: Retinoblastoma associated protein (PTHR13742:SF17); CDKN1B: Cyclin dependent kinase inhibitor 1B (PTHR10265:SF9); KRAS: GTPase KRAS (PTHR24070:SF388); NRAS: GTPase NRAS (PTHR24070:SF189); MET: Hepatocyte growth factor receptor; HGNC: 7029
Background: Ventral hernias are commonly encountered problems in the field of general surgery. Less data is available as to its natural history and hence surgeons prefer surgical treatment. Incisional hernia is a common complication following abdominal surgery that requires reoperation. Aims and Objectives: To study the incidence of ventral hernias, its causes and modes of presentation with the changing trends, various treatment modalities and complications of surgeries and mortality and morbidity owing to ventral hernia. Materials and Methods: This prospective observational study was conducted in the Department of Surgery, Goa Medical College, on a total of 100 patients between May 2019 to March 2021. Detailed history was recorded in all cases. This includes age, sex, weight of the patients. Presence of predisposing factors like obesity and particulars regarding diseases like hypertension, diabetes and other complications were elicited and treatment for the same was undertaken. The data was analyzed using SPSS software. Results: Females were affected more than males. 49% patients complained of swelling, while 23% complained of swelling and pain and about 20% complained of only pain. Para umbilical and incisional hernias were the most common types of hernias diagnosed in the study majority (86 out of 100) had no complications. However, those who did have complications, the most common was infection which was seen among 14% of the participants. 8% had seroma and 5% each had ileus and dehiscence. The recurrence rate was only 3%. Conclusion: Ventral hernia tend to present mainly in the 40- to 60-year age with male to female ratio tends to be 2:1. Para umbilical with umbilical hernia were most common types followed by Incisional hernia. Swelling and pain were the major presenting symptoms. Mesh repair was being more frequently used, compared to primary suture repair.
Ancient schwannoma is a rare subtype of schwannomas that is generally benign and primarily discovered incidentally through imaging findings. The tumor is characteristically slow-growing and frequently seen to undergo transformative changes such as cystic or myxoid degeneration which can at times lead to erroneous diagnosis of a malignant growth. Ancient schwannomas derive from Schwann cells and can arise at any location with nerve sheaths however they are typically found in the head and neck and less commonly so in the pleura. Here, we report a case of a primary posterior mediastinal ancient schwannoma of the pleura discovered incidentally in a man who initially presented with a chief complaint of cough.
Aims: To investigate the outcome of Cholecystostomy drains in the management of Acute Cholecystitis at Cumberland Infirmary. To develop a Cholecystostomy Pathway for patient selection, management and post procedure management. Method: A retrospective study of all patients with Cholecystostomy drains over the last 3 years at Cumberland Infirmary. 58 Inpatients at Cumberland Infirmary and West Cumberland Hospital who had cholecystostomy drains inserted for Acute Cholecystitis from January 2019 to January 2022 were included in the study. The patient list was collected from the Information Department at Cumberland Infirmary, with the Cholecystostomy code J 24.1 used in the search. Results: CRP ranged from 10-450 (mean 200) pre-insertion and on 5th post-procedure day, 37(63.79%) patients had a CRP of less than 50. Similar trends have been observed with the WBC counts. Follow-up investigations post drain insertion varied between CT abdomen, ultrasound abdomen and tubogram. The overall morality in the study group was 8(13.79%). Non of the mortalities were Cholecystostomy related. Reported over all complications were 2 (3.44%) which were sub-phrenic abscess and Cholo-Cutaneous fistula. Conclusion: We conclude that Insertion of a Cholecystostomy drain is a useful and safe procedure for the management of Severe Cholecystitis, especially in critically ill patients, with good early and late outcomes, and a low mortality rate. It can be used as a temporary management option with plan for Interval Laparoscopic Cholecystectomy, or can be the Definitive Management, especially in those patients with High Operative Risk
Ventriculo-peritoneal shunt is the procedure of choice for hydrocephalus. Various complications of ventriculoperitoneal shunts were reported. Abdominal complications involving the distal tip of the catheter make the majority of the complications. In this case report we present a case of incisional hernia occurring in a patient who underwent fixation of ventriculoperitoneal shunt followed by revision of the shunt after a while
Introduction: The establishment of skin banks is especially important in providing crucial cadaveric skin for burn treatments. Although the 2015 Formosa Fun Coast Explosion Disaster resulted in tragic casualties, it raised public awareness of the importance of having a well-functioning skin bank and led to the initiation of a skin bank development project, as well as the establishment of the first high standard skin bank in Taiwan. Methods: We standardized the size of our procured skin to avoid broken or disrupted skin graft, fit properly on a Zimmer Dermacarrier® for mesh expansion, and to be convenient for storage. We also integrated gamma radiation with the glycerol stored skin method for our skin preservation which effectively eradicates all contamination. Results: From 2016 to 2020, 453,100 cm2 of skin were procured from 62 donors and stored in the NTUH skin bank; 254,000 cm2 of which were utilized in the treatment of 75 patients. Between 2016 and 2017, 141 microbiological examinations were administered with six were positive. Since the introduction of gamma radiation, no contamination has been observed hereafter in our examinations. Conclusions: We report the success of establishing a high standard and well-functioning skin bank at NTUH that supply sufficient skin allografts in Taiwan. It is the first interhospital supply of charitable skin allografts across Taiwan. Being humanitarian, our skin bank is passing great love forward.
Introduction: Obesity is worldwide epidemic associated with serious complications both physical and psychological.Weight loss can be achieved with either medications or surgery, however the non-surgical options lacks durability more than two years. The weight loss surgical approaches classifies as: restrictive (adjustable gastric banding, vertical band gastroplasty), restrictive/resective (sleeve gastrectomy), restrictive/malabsorptive (Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch) and purely malabsorptive (duodenal switch) options. Aim: Clinical review of different weight loss surgeries, mechanism of achieving weight loss, and complications of each procedure. Management of possible complications for each procedure. Results: [I] Gastric bypass (open and laparoscopic): the most commonly performed operation for long-term weight control in United States. Provides longstanding weight loss, better control of comorbidities as well as post procedure nutritional sequelae. Complications are (1) anastomotic leak (1–5.6%) and management either relaproscopy if detected early or radiological guided drainage for contained collection (2) anastomotic stricture (3- 11%) which can be managed by endoscopic dilatation or surgery (3) internal hernia require reoperation and closure of the defect. [II] Laparoscopic adjustable gastric band: the commonest weight loss surgery procedure in UK, complications are: (1) Pouch enlargement, (2) band erosion and (3) Band slip. [III] Sleeve gastrectomy: It is restrictive procedure involve neither anastomosis nor malabsortion and it is irreversible. Produce its clinical effect by early satiety from stomach volume loss and low circulating ghrelin levels. Complications (1) gastric leak: From staple line with incidence of 0.7-5%. If detected early (>4days) requires urgent surgical repair, however late presentation (5-10 day) for conservative management (2) bleeding. [IV] Biliopancreatic Diversion with Duodenal Switch (BPD/DS), components of the procedure are: (1) sleeve gastrectomy. (2) Division of duodenum between pylorus and sphincter of oddi. (3) Bypassing proximal small intestine through alimentary limb; distal 250 cm of the small intestine from ICV anastomosed end to end with post pyloric duodenum, while billiopancreatic limb has blind end proximal to sphincter of oddi anastomosed distally ileo-ileal about75 to 100 cm from ICV. Advantages are morbid obese patient can lose more weight and maintain it comparing with other bariatric procedures also it has a better control of comorbidities. Complications are: anastomotic leak, bleeding and nutritional deficiencies. Conclusion: Many surgical procedures have emerged as an acceptable bariatric surgical option for obese patients. Most of the bariatric procedures available nowadays offer beside weight loss, a better control of the obesity related comorbidities as Biliopancreatic Diversion with Duodenal Switch (BPD/DS), while others as adjustable gastric band have low complications rate which explains its popularity.
