Diverting ileostomy is a common procedure in rectal cancer surgery, but it is sometimes associated with a nonnegligible rate of complications. The primary aim of this study was to analyze the incidence and types of stoma-related complications for ileostomy creation after rectal cancer resection. The secondary aims were to report the indications, the technical details, and the efficacy of stoma care provided by ostomy nurses. From 15 February to 31 December 2022, consecutive patients who underwent protective ileostomy after anterior rectal cancer resection were enrolled for prospective data collection at 45 Italian colorectal surgery centers. Univariate and multivariate analyses were performed to evaluate factors that influenced the occurrence of stoma-related complications. In all, 287 patients were enrolled in the analysis. The short- and long-term postoperative stoma-related morbidity rates were 33.8

Aim: Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. Method: COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Results: Some 725 patients (median age 68.0years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] =1.56, 95% CI: 0.48-5.02, p=0.457) or earlier detection (hazard ratio [HR] =1.07, 95% CI: 0.61-1.90, p=0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR=1.26, 95% CI: 0.67-2.36, p=0.478), delayed hospital discharge (HR=1.11, 95% CI: 0.91-1.36, p=0.303) or increased risk of SSIs (OR=1.61, 95% CI: 0.87-2.99, p=0.128). Conclusion: This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Abstract Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

BACKGROUND:We retrospectively reviewed charts of 42 postbariatric patients who underwent mastopexy and breast reduction for body contouring to determine whether a significant relationship existed between cigarette smoking and postoperative wound infections and to determine the relative risk given by cigarettes and a cut-off value to predict infections.METHODS:We excluded patients with ongoing clinical infections, recent bariatric surgery (within 1 year), recent antibiotic courses, or systemic diseases such as arteriosclerosis and diabetes mellitus.RESULTS:All patients underwent bariatric surgery with the laparoscopic adjustable gastric bending technique and mastopexy with breast reduction for body contouring. Postoperative infections were present in 35.7% (n = 15) of patients, and 60% of these (n = 9) were superficial. Furthermore, 66.7% of them occurred in smoker patients, and 41.7% of smokers vs. 27.8% of nonsmokers developed infections. Significant differences between infected vs. infection-free patients were present for the number of pack years (p < 0.001) and the overall estimated cigarettes smoked (p < 0.001). A cut-off value of approximately 6.85 pack years (50,000 overall estimated cigarettes) distinguished between infections vs. infections-free patients, with 25% of false positives and 8% of false negatives. Relative risk conferred by smoking was 3.8.CONCLUSIONS:The incidence of infections in our series of postbariatric patients undergoing mastopexy and breast reduction is 35.7%. A cut-off of 6.85 pack years (50,000 estimated overall cigarettes) was determined and, according to this value, the relative risk conferred by smoking was 3.8.

BACKGROUND:This prospective study followed patients who underwent breast reductions to determine the influence of smoking and the amount of tissue removed on postoperative wound infections. METHODS:Patients who had received breast reductions were considered eligible for the study. The study excluded postbariatric patients and those with ongoing clinical infections, a recent antibiotic course, or systemic diseases that could impair tissue oxygenation. Smokers were instructed to quit smoking at least 4 weeks before surgery. RESULTS:By March 2004, the study had enrolled 87 patients. Postoperative infections were present in 24 cases (27.9%). Infections included 16 in smokers (37.2%), 8 in nonsmokers (18.2%; p < 0.05), 14 in patients with large resections (>0.85 kg; 70%), and 10 in patients with small resections (14.9%; p < 0.001). Significant differences were found between the patients who experienced infections and those who were infection free in terms of the overall estimated cigarettes smoked (mean, 146,000; range, 29,200-228,125 vs mean, 10,950; range, 9,125-54,750; p < 0.001), the number of pack years (mean, 20; range, 4-31 vs mean, 2; range, 1-8; p < 0.001), and the amount of tissue removed (mean, 0.9 kg; range, 0.5-2 kg vs mean, 0.5 kg; range, 0.2-1.4 kg; p < 0.001). The analysis for all the patients determined an odds ratio of 2.04 for smoking and 4.7 for the amount of tissue removed. CONCLUSIONS:Smoking and the amount of tissue removed are important issues in aesthetic breast surgery that need to be addressed accurately by the plastic surgeon. If future larger studies confirm these data, surgeons could have a simple and easy method for stratifying patients according to their risk for the development of wound infections and for prescribing specific preventive measures.

Background The incidence and risk factors of gastrointestinal diseases in pre-liver transplant population are still a matter of debate. In a retrospective analysis, we addressed two questions: (1) Are there any lesions that occur at a higher prevalence than in the general population, and (2) are there patient characteristics that could predict their presence? Materials and methods All asymptomatic patients that successfully entered the waiting list of liver transplantation were recorded. We also compared results with those obtained from a control group of non-cirrhotic patients undergoing screening for colorectal cancer. Main outcome measures were the incidence and description of upper/lower gastrointestinal findings after screening endoscopic examination. Results We retrospectively evaluated from April 2004 to July 2007 a total of 80 liver transplant candidates. The most frequent pathologies were esophageal varices (71.2% of subjects), portal hypertensive gastropathy (51.2%), hemorrhoids (22.5%), and colonic polyps (18.7%). Comparison with 80 non-cirrhotic patients matched for age and sex demonstrated an increased frequency in the cirrhotic group of ulcerative colitis (6.2 vs 0%; p = 0.02) and portal hypertensive colopathy (12.5 vs 0%; p = 0.001) in non-cirrhotic of diverticulosis (10 vs 25%; p = 0.01) and hemorrhoids (22.5 vs 40%; p = 0.02). The univariate analysis showed no significant correlation between colonic polyps and patients’ variables, except a mild correlation with age not confirmed at the multivariate analysis. Conclusions The incidence of some benign gastrointestinal pathologies in liver transplant candidates is different from the asymptomatic population but not that of colorectal cancer or colonic polyps.

BACKGROUND:A large retrospective analysis examined primary aesthetic breast augmentations to find specific factors that could favor or counteract the occurrence of infections.METHODS:Data were collected from the personal databases of two different surgeons at the Crown House Hospital, Oldbury, Birmingham, United Kingdom, from January 1999 to December 2004. All the patients who received primary aesthetic breast augmentation with or without associated mastopexy were recorded.RESULTS:A total of 3,002 women were reviewed. Infections were experienced by 33 patients (1.1%). The analysis showed that Mentor prostheses and local antibiotics both were protective against the occurrence of infections (p < 0.05). On the contrary, the use of drains significantly increased the risk fivefold (p < 0.05).CONCLUSIONS:The incidence of infections in aesthetic breast augmentations is 1.1%, and Mentor prostheses, antibiotics in the pocket, and the use of drains seem associated with their occurrence.

Background The authors present a new type of dual-plane mammaplasty and preliminary results obtained with it. The technique is aimed at improving the final natural appearance of breasts without adding additional risks of dislocation. Methods The eligibility criteria specified patients with sufficient breast tissue to disguise the implant, patients with asymmetric hypoplasia, and patients with an intense workout activity. The exclusion criteria specified patients with very little breasts. The technique is based on combined subglandular positioning in the superior part of the breast and retrofascial– precostal positioning in the inferior part. Results Beginning in January 2000, 57 patients were recruited. No postoperative bleedings, hematomas, or seromas were observed. In 93% of cases, good final shapes were obtained. After 1 year of follow-up evaluation, no displacement, asymmetry, or rupture was recorded. Only three patients (5.3%) showed mild monolateral capsular contractures (Baker II type), which resolved using capsulotomy without prostheses removal. Conclusions “Reverse” dual-plane mammaplasty is a new technique that gives a good anatomic final appearance with no risk of displacement. The low risk of complications renders it feasible and safe for aesthetic breast augmentation. Further studies are necessary to compare this technique with retroglandular and retropectoral approaches.

BACKGROUND:A large retrospective analysis was performed on a homogeneous group of patients undergoing primary aesthetic breast augmentations to define complication rates and find associated factors.METHODS:Data were collected from the personal databases of two different surgeons working at the Crown House Hospital, Oldbury, Birmingham, United Kingdom. The period considered was January 1996 to December 2001. All patients who received primary breast augmentation with or without associated mastopexy for cosmetic purposes were recorded.RESULTS:A total of 3,002 women were included in the study. Hematomas were present in 46 patients (1.5%), infections in 33 patients (1.1%), breast asymmetries in 23 patients (0.8%), rippling in 21 patients (0.7%), and capsular contractures in 14 patients (0.5%). The multivariate analysis found that implant placement and the technique used for pocket creation were variables associated with complications (p < 0.05). Capsular contractures carried a progressive cumulative risk and, in our series, appeared 5 years after surgery. No association was found between contractures and hematomas or infections.CONCLUSIONS:The overall incidence of complications in our series was relatively high (4.6%). Surgical placement of prostheses and the technique used for pocket creation were associated with complications. However, few patients required reoperation (1.6%), and the overall satisfaction rate was acceptable (visual analog score, 7).

Background and Objectives: We reviewed our case-load of patients with Toxic Epidermal Necrolysis (TEN) and analysed this oncologic disease in order to define the prevalence of this comorbidity and find eventual clinical and prognostic differences, specific of this subgroup of patients.Materials and Methods: We reviewed charts from January 1995 to December 2005. Only those patients with a TEN diagnosis proved with an histologic examination were included. Causative drugs, symptoms, management and outcome were recorded and analysed. Results: We found 32 patients with TEN and 9 of them (28%) had also cancer. The comparison among oncologic vs. the rest of patients showed no significant differences in age, delay of referral, % surface area epidermal detachment, blood chemistry, immunoglobulins therapy and bacterial isolation of species throughout the recovery (p > 0.05).Conclusions: Oncologic diseases were the most frequent comorbidities in our series. There were no differences in the length of stay, duration of disease or mortality between patients with and without cancer. However, due to the small number of patients, future larger prospective studies are necessary to confirm these findings.

BACKGROUND AND OBJECTIVEToxic epidermal necrolysis and Steven Johnson syndrome are rare diseases that usually follow drug-exposures. The authors present one retrospective study with their management and focus their retrospective analysis on finding prognostic factors.MATERIALS AND METHODSWe reviewed charts of admitted patients from January 1995 to December 2005. Only those with an histologic-proved diagnosis were included in the study. Causative drugs, symptoms, management and outcome were recorded and analysed.RESULTSWe found 32 patients that met inclusion criteria. Mortality rate was 34.4% (11/32). Age, delay of referral, Total Burn Surface Area, white blood cells, creatinine, blood sodium, immunoglobulins therapy and more than two different types of blood bacterial species isolated were significantly correlated with death (p < 0.05).CONCLUSIONSThese data confirm prognostic factors already present in literature and find that the number of different bacterial species isolated from blood increase mortality. Further prospective studies are necessary to confirm these findings.

The systemic pathophysiologic changes following thermal injuries affect multiple organs and body systems leading to clinical manifestations including shock, intestinal alterations, respiratory and renal failure, immunosuppression and others. Recent advances in the comprehension of mechanisms underlying systemic complications of thermal injuries have contributed to uncover part of the cellular and molecular basis that underlie such changes. Recently, programmed cell death (apoptosis) has been considered playing an important role in the development of such pathological events. Therefore, investigators utilizing animal models and clinical studies involving human primates have produced a large body of information suggesting that apoptosis is associated with most of the tissue damages triggered by severe thermal injuries. In order to draw the attention on the important role of apoptosis on systemic complications of thermal injuries, in this review we describe most of these studies, discuss possible cellular and molecular mechanisms and indicate ways to utilize them for the development of therapeutic strategies by which apoptosis may be prevented or counteracted.

In this prospective study, we followed patients after laparoscopic adjustable gastric banding for morbid obesity who underwent abdominoplasty for body contouring. Our purposes were: 1) to determine if a significant relationship between cigarette smoking and postoperative wound infections existed, 2) the relative risk conferred by cigarettes and 3) a cut-off value for the increased risk.

Background: In a retrospective study the influence of several clinical data and prognostic indexes on the length of hospital stay in burned patients was investigated. Methods: We recorded all admitted patients from January 2004 to December 2005 except for electrical and chemical injuries or patients that died during recovery. Age, gender, weight, height, body surface area, fluid, caloric and protein delivery, Total Burn Surface Area, full thickness burn surface area, Roi index, Baux score, Unit Burn Standard index, Abbreviated Burn Severity Index and the length of hospitalization were registered. A univariate and multivariate analysis was performed to look for correlations between these parameters and the length of hospitalization. Results: We recorded eligible 233 patients. The univariate analysis showed that age, protein and caloric delivery, Roi index and ABSI were significantly related with the length of hospitalization while, at the multivariate analysis, only Roi index was related (p < 0.05). However, Roi index was able to predict only 5.5-6% of cases. Conclusions: A correlation exists between the length of hospital stays and the Roi index in burned patients but does not explain the bulk of evidence. Further studies are required to investigate this relation, to screen other parameters and to correlate them with measures of outcome, i.e. functional (the range of motion of articulations) or aesthetic (patient's self assessment of his body image). (c) 2006 Elsevier Ltd and ISBI. All rights reserved.

We describe the case of a delayed bleeding that occurred concomitantly with an abdominoperineal resection. The patient underwent endoscopy without apparent complications. During surgery, and in the immediate postoperative hours, 4 blood units were required to achieve stable conditions even if the surgical technique was correct, no major bleeding occurred and no blood was seen inside the lumen at bowel transection. On the 7th postoperative day (9th from polypectomy) the patient shocked for the first time. Two days later, massive clots appeared from the stoma and he shocked again. CT scan found the bleeding occurring from the polypectomy site and angiographic embolization finally ended the hemorrhage. The increased risk of delayed hemorrhages and their dramatic clinical manifestations render the post-polypectomy "window" period worth to be followed-up strictly. We believe that further invasive procedures, especially major surgery, should be postponed unless emergent and necessary to save the patient's life.

The authors describe their personal experience with the management of mammary asymmetries. A review of their database from January 1998 to January 2005 identified 177 patients with idiopathic breast asymmetries. All these cases had been classified previously into six groups. Bilateral asymmetric hypertrophy and unilateral hypertrophy were treated with reduction mammaplasty. Unilateral hypertrophy with amastia or hypoplasia of the contralateral side was managed with reduction and augmentation mammaplasty. Unilateral amastia or hypoplasia (Poland's syndrome) was treated with a single monopedicle transverse rectus abdominis muscle (TRAM) flap, and asymmetric bilateral hypoplasia was managed with augmentation mammaplasty. Unilateral mammary ptosis was treated with mastopexy and augmentation mammaplasty. The proposed classification, derived from the authors' experience in this field, gives an idea of how they usually treat these patients. It is useful for a first evaluation, but after that, every treatment must always be individualized on a patient-by-patient basis.

Corresponding Author: Gianpiero Gravante, MD; e-mail: ggravante@hotmail.com Dear Editor, materials and techniques used for nasal reconstructions have always been a matter of discussion and still no clear guidelines are present. In the beginning, autologous cartilage grafts were extensively used for its low resorption and complication rates1-2. Recently, authors have preferred synthetic materials for the immediate availability, no donor-site morbidity, better adaptability, good immediate results and minor costs3-5. Even if most of rhinoplasties are now performed with synthetic materials, autologous grafts have not been completely abandoned and we believe that they are more versatile especially in particularly difficult cases such as post-traumatic deformities. A 25 years-old male patient presented with an evident nasal pyramid deformity and obstruction following a primary aesthetic rhinoplasty (Figure 1). We operated him on February 2002 with an “open” rhinoplasty technique using cartilage grafts harvested from the 11th rib. One year later aesthetic results were unremarkable (Figure 1). On September 2003, he suffered a nasal trauma while playing basketball that gave him a new lateral septum deviation and a dislocation of the previous graft (Figure 2). We removed the old graft, enveloped it with a piece of temporoparietal fascia and reimplanted it on the same site. Thirty months later (February 2006), aesthetic results are still positive and the respiratory activity completely restored (Figure 2). Although the debate about types of grafts to be employed in aesthetic rhinoplasty is far from being solved and even if many surgeons actually favours synthetic materials, we believe that cartilage grafts are indicated in anticipated difficult cases such as post-traumatic nasal deformities. Cartilage grafts are more elastic and flexible than bone grafts. They are easy to harvest and have a long-lasting thickness with a minimal resorption rate. In this case, the cartilage graft has proven useful for reinsertion even after 18 months from the initial grafting.

In this study we investigated the association of patient’s clinical severity with the dermal apoptotic rate in order to investigate the possible influence of systemic factors on the local response to the heat. To achieve this purpose we gathered cutaneous biopsies of deep partial thickness burns within 7 days from injury from 24 patients and correlated their apoptotic rate with some prognostic mortality indexes commonly used in burn centres (Baux score, Unit Burn Standard index and Abbreviated Burn Severity Index) 1-4 . We excluded from the study patients with comorbidities that could impair the tissue oxygenation such as diabetes, cardiovascular/respiratory diseases and venous or arterial insufficiency. Specimens were processed with TUNEL and antibodies for Fas receptors as previously described 1 . The apoptotic rate was expressed as the ratio of the number of apoptotic cells out of the total number of nucleated cells in each field 1 . Patients demographic and clinical characteristics at admission are summarized in Table I. The hystologic analysis showed that apoptotic cells were present and this further confirmed our previous findings (Figure 1) 1 . Pearson’s Correlation index was ‐0.11 for the Baux score, ‐0.26 for the Unit Burn Standard index and ‐0.08 for the Abbreviated Burn Severity Index. However, the simple linear regression analysis demonstrated that all indexes were not associated significantly with the apoptotic rate (p > 0.05). These data confirm the presence of apoptosis in deep partial thickness burns and, with particular regard to the specific purpose of this study, the apoptotic rate seems not to be influenced by the severity of general clinical conditions. The lack of association with the common prognostic mortality indexes used in burned patients suggests that the skin damage and its apoptotic response are probably local processes not significantly influenced by the patient’s general status but mainly by his dermal oxygenation.