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Context and purpose To achieve success following surgical treatment of MRONJ, complete wound closure has been considered necessary; open wound management has not been generally recommended. Therefore, various closure techniques using local flaps have been reported. However, these techniques often increase surgical invasiveness, and there is minimal evidence regarding whether complete wound closure is preferable to open wound management following surgical treatment of MRONJ. The aim of this study was to clarify whether complete wound closure is necessary for successful healing following surgical treatment of MRONJ. Procedures This retrospective study included 52 patients with stage 2 and 3 MRONJ who underwent surgical treatment. Twenty-seven of the 52 patients received open wound management, while the remaining 25 received complete wound closure management. The outcomes of both groups were evaluated at the 6-month follow-up visit; ‘success’ was defined as complete mucosal covering without symptoms and ‘failure’ was defined as the presence of residual bone exposure or progression of disease. Main findings In the open wound group, 23 patients (85.1%) exhibited ‘success’ and four patients (14.8%) exhibited ‘failure’; in the closed wound group, 21 patients (84.0%) exhibited ‘success’ and four patients (16.0%) exhibited ‘failure’. These outcomes were not significantly different between groups. Principal conclusions Although complete wound closure has many advantages with respect to the healing process, open wound management is also acceptable for patients with difficulty achieving complete wound closure, as well as for surgeons who wish to reduce surgical invasiveness.

Objective: To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. Summary Background Data: BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). Methods: This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. Results: Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. Conclusions: Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Summary Background Wound closure in the head and neck region is challenging, primarily due to aesthetic concerns. Tissue adhesives have been prized for their ease of use. This study aimed to compare the effectiveness of tissue adhesives as a suitable alternative to other conventional wound closure techniques, in the head and neck region. Methods A systematic review was conducted in line with PRISMA guidelines. Available English literature from 2009 to 2019 was reviewed from PubMed, Scopus and Google Scholar. Randomized controlled trials and controlled clinical trials with wounds in the head and neck region were included in this study. Results Sixteen articles were found to meet the inclusion criteria. Main outcomes assessed included the following: cosmesis, pain, swelling, bleeding, wound dehiscence, time and cost. There was significant heterogeneity in results for pain, swelling and bleeding. No significant difference was observed in wound dehiscence and long-term cosmetic outcome when tissue adhesives were compared with sutures and staples. The time taken for wound closure with tissue adhesives was faster than sutures but were conflicted when compared with staples. Cost was found to be similar. Conclusion Overall, there is a consensus that there is no long-term difference in cosmetic outcome and wound dehiscence between tissue adhesives and other wound closure techniques. Tissue adhesives have the benefit of being easy and quick to use with excellent patient satisfaction levels. We recommend tissue adhesives as a suitable alternative for wound closure in low tension areas in the head and neck region.

To introduce a novel technique of using incisional vacuum-assisted closure (VAC) after 1-stage incision suture combined with closed suction irrigation system (CSIS) for treating early deep surgical site infection (SSI) after posterior lumbar fusion with instrumentation and to compare it with traditional CSIS.This was a retrospective study. Patients with early deep SSI after posterior lumbar fusion with instrumentation from January 2013 to May 2020 who were treated by meticulous debridement followed by either CSIS or incisional VAC after 1-stage incision suture combined with CSIS were identified. The demographic characteristics, treatment features, and outcomes were analyzed and compared between the 2 treatment methods.A total of 48 patients (48/5016, 0.96%) developed early deep SSI, 46 of whom were enrolled in this study. This included 24 patients in the CSIS group (group 1) and 22 patients in the incisional VAC after 1-stage incision suture combined with CSIS group (group 2). All patients received follow-up, with an average of 19.7 months (range, 13-30 months). There were no significant differences in demographic characteristics in both groups (P0.05). The number of VAC foam dressing or ordinary dressing changes (P0.001), number of debridements (P = 0.028), intravenous antibiotic duration (P = 0.042), oral antibiotic duration (P = 0.019), and hospital stay (P = 0.029) in group 1 were significantly higher than those in group 2. The irrigation duration in group 1 was significantly shorter than that in group 2 (P = 0.007). All patients were eventually cured with satisfactory outcomes.Compared with CSIS, incisional VAC after 1-stage incision suture combined with CSIS may be recommended considering that it has fewer dressing changes, fewer debridements, longer irrigation duration, shorter duration of antibiotic use, shorter hospital stay, and more convenient nursing care.

Wound closure with surgical sutures is a critical challenge for flexible endoscopic surgeries. Substantial efforts have been introduced to develop functional and smart surgical sutures to either monitor wound conditions or ease the complexity of knot tying. Although research interests in smart sutures by soft robotic technologies have emerged for years, it is challenging to develop a soft robotic structure that possesses a similar physical structure as conventional sutures while offering a self-tightening knot or anchor to close the wound. This paper introduces a new concept of smart sutures that can be programmed to achieve desired and uniform tension distribution while offering self-tightening knots or automatically deploying secured anchors. The core technology is a soft hydraulic artificial muscle that can be elongated and contracted under applied fluid pressure. Each suture is equipped with a pressure locking mechanism to hold its temporary elongated state and to induce self-shrinking ability. The puncturing and holding force for the smart sutures with anchors are examined. Ex-vivo experiments on fresh porcine stomach and colon demonstrate the usefulness of the new smart sutures. The new approaches are expected to pave the way for the further development of smart sutures that will benefit research, training, and commercialization in the surgical field.

An extended endoscopic endonasal approach (EEA) has become standard for parasellar and midline skull base lesions. However, postoperative leakage of cerebrospinal fluid (CSF) can result from dural defects after lesion removal. We present a simple and effective technique, the Osaka sliding knot, to prevent CSF leakage. Between November 2018 and March 2021, a total of 41 patients underwent reconstruction of skull base defects with intraoperative high-flow CSF leaks after extended EEA by using this closure technique, of whom only 1 patient experienced postoperative CSF leakage. This technically simple and efficient method seals the dural defect to prevent CSF leakage after surgeries using an extended EEA.

Background Elective stoma closure is a common, standardized procedure in digestive surgery. Objective This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure. Design This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure. Setting This study was performed at a French tertiary hospital between January 2016 and June 2018. Patients Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III. Outcome measures The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation). Results Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations. Limitations This was a single-center study. Conclusion In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583. Resultados a corto plazo del cierre de estoma ambulatorio un estudio observacional y prospectivo ANTECEDENTES:El cierre electivo de un estoma es un procedimiento comun y estandarizado en cirugia digestiva.OBJETIVO:Evaluar la viabilidad de la cirugia ambulatoria para el cierre electivo de estomas.DISENO:Un estudio prospectivo, unicentrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario frances entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incision local con una puntuacion de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de exito de la cirugia ambulatoria en la poblacion general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la poblacion por protocolo (pacientes que no cumplian con ninguno de los criterios de exclusion preoperatorios o perioperatorios). Los resultados secundarios (en la poblacion por protocolo) fueron la tasa de morbilidad general (segun la clasificacion de Clavien-Dindo), la tasa de morbilidad mayor (puntuacion de Clavien ≥ 3) y los criterios de calidad de la cirugia ambulatoria (consulta no planificada, hospitalizacion no planificada y reoperacion no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la poblacion general; edad media ± desviacion estandar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusion y constituyeron la poblacion por protocolo. La tasa de exito de la cirugia ambulatoria fue del 17% (40 de 236 pacientes) en la poblacion general y del 80% (40 de 50 pacientes) en la poblacion por protocolo. En la poblacion por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugia ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalizacion no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSION:En pacientes seleccionados, la cirugia ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legitimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.

OBJECTIVE: With the increase in cardiovascular implantable-electronic devices (CIEDs), complications from insertion and healing are also increasing. Therefore, the objective of this study was to compare the intracutaneous stapling method to the absorbable suture technique in terms of complications, procedure time, and pocket closure time. METHODS: An observational study was conducted over the course of three months on patients with CIED implantation. The patients were divided in two groups according to pocket closure technique. Group 1 included patients with pocket closure using intracutaneous sutures; whereas in Group 2, the pocket was closed by intracutaneous staples. Data were collected regarding patient characteristics and wound problems. The endpoints were wound problems, including early and late wound problems (primary), total procedure time, and the time taken for pocket closure (secondary). RESULTS: One hundred and nineteen patients and 107 patients were allocated to Group 1 and Group 2, respectively. During the three-month observation period, 27 (22.6%) patients in Group 1 and 13 (12.1%) patients in Group 2 suffered from early wound problems, and the combined primary endpoint reached was statistically significant (p=0.021). Minor and major bleeding events were more common in Group 1 [Odds ratio (OR): 4.49, p=0.024; OR: 0.96, p=0.052]. The time to close the pocket was markedly reduced in Group 2 (7.29±1.42 vs. 3.98±1.19, p

Background: Delayed sternal closure (DSC) has been used for patients who develop bleeding, chest wall edema, and malignant arrhythmia following cardiopulmonary bypass. Multiple factors can influence the timing of when to perform DSC. We aimed to describe our DSC experience in neonates and infants by comparing outcomes between patients undergoing early ( 48 hours). We explored the associations between specific clinical and laboratory variables and the timing of DSC. Methods: Retrospective chart review of neonates and infants (Results: A total of 121 patients were included in the analysis, 34% (n = 41) met late DSC criteria. The overall cohort had a 75% survival rate and a median time for open sternum of 42.5 hours (Q1:23-Q3:65). The median time for open sternum in the early and late DSC groups was 24 hours (Q1:21-Q3:43) and 93 hours (Q1:65-Q3:141), respectively ( P < .01). There was no statistical difference in mortality rate between groups. Patients with late DSC endured longer intensive care unit stays (median 24.3 days [Q1:13-Q3:35.3] vs 36.8 [Q1:23.9, 73.6]; P< .01) and a two-fold longer hospital stay compared to the early DSC group (multivariable analysis: relative risk = 2, 95% CI: 1.5-2.7; P < .01). Univariate analysis revealed patients with late DSC had higher median lactates both intraoperatively (7.6 [Q1:5.9-Q3:10.7] vs 9.3 [Q1:7.5-Q3:12.1]; P < .01) and 24 hours postoperatively (6.5 [Q1:4.3-Q3:10.3] vs 8.7 [Q1:5.7-Q3:14.70]; P = .03). A higher vasoactive inotrope score at 36 hours was associated with late DSC (odds ratio = 1.1, 95% CI: 1.01-1.2; P = .02). Conclusions: Future research that explores additional clinical and laboratory variables that can help guide DSC decision-making and timing is needed.

Surgical site infection is a major surgical complication and has been studied extensively. However, the efficacy of changing surgical instruments before wound closure remains unclear.The aim of this study was to investigate the efficacy of changing surgical instruments to prevent incisional surgical site infection during lower GI surgery.This was a randomized controlled trial.This study was conducted at the Hyogo College of Medicine in Japan.Patients undergoing elective lower GI surgery with open laparotomy were included.Patients were randomly assigned to 1 of 2 groups. In group A, the surgeon changed surgical instruments before wound closure, and in group B, the patients underwent conventional closure.The primary end point was the incidence of incisional surgical site infection. The secondary end point was the incidence of surgical site infection restricted to clean-contaminated surgery.A total of 453 patients were eligible for this trial. The incidence of incisional surgical site infection was not significantly different between group A (18/213; 8.5%) and group B (24/224; 10.7%; p = 0.78). In the clean-contaminated surgery group, the incidence of incisional surgical site infection was 13 (6.8%) of 191 in group A and 9 (4.7%) of 190 in group B (p = 0.51).This was a single-center study.Changing surgical instruments did not decrease the rate of incisional surgical site infection in patients undergoing lower GI surgery in either all wound classes or clean-contaminated conditions. See Video Abstract at http://links.lww.com/DCR/B701.ANTECEDENTES:La infección del sitio quirúrgico es una complicación importante y se ha estudiado ampliamente. Sin embargo, la eficacia de cambiar los instrumentos quirúrgicos antes del cierre de la herida sigue sin estar clara.OBJETIVO:El objetivo de este estudio es investigar la eficacia de cambiar el instrumental quirúrgico en la prevención de la infección del sitio quirúrgico en cirugía gastrointestinal inferior.DISEÑO:Estudio aleatorio controlado.AJUSTE:Este estudio se realizó en la Facultad de Medicina de Hyogo en Japón.PACIENTES:Se incluyeron pacientes sometidos a cirugía electiva de tubo digestivo bajo con laparotomía abierta.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente a uno de dos grupos. En el grupo A, el cirujano cambió el instrumental quirúrgico antes del cierre de la herida, y en el grupo B, los pacientes se sometieron a un cierre convencional.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la incidencia de infección del sitio quirúrgico de la incisión. El criterio de valoración secundario fue la incidencia de infección del sitio quirúrgico restringida a la cirugía limpia contaminada.RESULTADOS:Un total de 453 pacientes fueron elegibles para este ensayo. La incidencia de infección del sitio quirúrgico no fue significativamente diferente entre el grupo A (18/213; 8,5%) y el grupo B (24/224; 10,7%) (p = 0,78). En el grupo de cirugía limpia-contaminada, la incidencia de infección del sitio quirúrgico incisional fue 13/191 (6,8%) en el grupo A y 9/190 (4,7%) en el grupo B (p = 0,51).LIMITACIÓN:Estudio de un solo centro.CONCLUSIÓNES:El cambio de instrumentos quirúrgicos no disminuyó la tasa de infección del sitio quirúrgico en todas las clases de heridas o condiciones limpias-contaminadas. Consulte Video Resumen en http://links.lww.com/DCR/B701.

BACKGROUND The optimum timing for temporary ileostomy closure after low anterior resection is still open. OBJECTIVE This trial aimed to compare early (2 wk) versus late (12 wk) stoma closure. DESIGN The study included 2 parallel groups in a multicenter, randomized controlled clinical trial. SETTINGS The study was conducted at 3 Swiss hospitals. PATIENTS Patients undergoing low anterior resection and temporary ileostomy for cancer were included. INTERVENTIONS Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity. MAIN OUTCOME MEASURES The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection. Secondary end points included safety (morbidity), feasibility, and quality of life 4 months after low anterior resection. RESULTS The trial was stopped for safety concerns after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients). There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0; p = 0.139) and 4 months (108.6 vs 107.1; p = 0.904) after index surgery. Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3; p = 0.011), adhesions (visual analog scale: 61.3 vs 46.2; p = 0.034), leak of colonic anastomosis (19% vs 0%; p = 0.012), leak of colonic or ileal anastomosis (24% vs 0%; p = 0.002), and reintervention (16% vs 0%; p = 0.026) were significantly higher after early closure. The concept of early closure failed in 10 patients (27% vs 0% in the late closure group (95% CI for the difference, 9.4%-44.4%)). LIMITATIONS The trial was prematurely stopped because of safety issues. The aimed group size was not reached. CONCLUSIONS Early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure. See Video Abstract at http://links.lww.com/DCR/B665. CIERRE DE LA ILEOSTOMA TEMPORAL VERSUS SEMANAS POSTERIOR A LA RESECCIN RECTAL POR CNCER UNA ADVERTENCIA DE UN ESTUDIO MULTICNTRICO CONTROLADO RANDOMIZADO PROSPECTIVO ANTECEDENTES:El momento optimo para el cierre temporal de la ileostomia posterior a la reseccion anterior baja es aun controversial.OBJETIVO:Este estudio tuvo como objetivo comparar el cierre del estoma temprano (2 semanas) versus tardio (12 semanas).DISENO:Estudio clinico controlado, randomizado, multicentrico, de dos grupos paralelos.ENTORNO CLINICO:El estudio se llevo a cabo en 3 hospitales suizos.PACIENTES:Se incluyeron pacientes sometidos a reseccion anterior baja e ileostomia temporal por cancer.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente al cierre del estoma temprano o tardio. Antes del cierre, se examino la integridad de la anastomosis colonica.PRINCIPALES MEDIDAS DE VALORACION:El principal resultado de eficacia fue el Indice de Calidad de Vida Gastrointestinal 6 semanas despues de la reseccion. Los criterios secundarios incluyeron la seguridad (morbilidad), factibilidad y calidad de vida 4 meses posterior a la reseccion anterior baja.RESULTADOS:El estudio se detuvo por motivos de seguridad despues de que 71 pacientes fueron asignados aleatoriamente a cierre temprano (37 pacientes) o cierre tardio (34 pacientes). Hubo datos de referencia comparables entre los grupos. No se produjeron diferencias en la calidad de vida 6 semanas (indice de calidad de vida gastrointestinal, media 99,8 vs. 106; p = 0,139) y 4 meses (108,6 vs 107,1, p = 0,904) despues de la cirugia inicial. Tendencia intraoperatoria de supuracion (escala analogica visual 35,8 vs 19,3, p = 0,011), adherencias (escala analogica visual 61,3 vs 46,2, p = 0,034), fuga de anastomosis colonica (19% vs 0%, p = 0,012), fuga de anastomosis colonica o ileal (24% vs 0%, p = 0,002) y reintervencion (16% vs 0%, p = 0,026) fueron significativamente mayores despues del cierre temprano. El concepto de cierre temprano fracaso en 10 pacientes (27% vs ninguno en el grupo de cierre tardio (intervalo de confianza del 95% para la diferencia: 9,4% a 44,4%)).LIMITACIONES:El estudio se detuvo prematuramente debido a problemas de seguridad. No se alcanzo el tamano del grupo previsto.CONCLUSION:El cierre temprano del estoma no proporciona una mejor calidad de vida hasta 4 meses posterior a una reseccion anterior baja, esto se ve afectado por efectos adversos significativos durante su realizacion y una mayor morbilidad en comparacion con el cierre tardio. Consulte Video Resumen en http://links.lww.com/DCR/B665.

BACKGROUND Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. METHODS Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, debridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. RESULTS Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdebridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). CONCLUSIONS Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background: A significant cohort of patients who undergo cardiac surgery suffer from diabetes and atherosclerosis. These patients have impaired tissue perfusion, hence a reduction in antibiotic concentration in the subcutaneous tissues at the side of the mammary artery harvesting. Topical application of gentamicin and vancomycin before wound closure broadens the antibiotic spectrum and reduces the incidence of deep sternal wound infection. In this article, we compare the use of single versus dual application of vancomycin and/or gentamicin in sternotomy wounds in a single tertiary center. Methods: An observational cohort analysis with three sequential patient groups (N = 2550) was performed at Ain Shams University Hospital in Cairo. A control group (N = 850), vancomycin only group (N = 850), and vancomycin plus gentamicin group (N = 850) were included in the study, during the three-year period from January 2017 to December 2019. Patients who had minimal access surgery were excluded from this study. The presence of an infected postoperative sternotomy wound was assessed in all patients. Results: The presence of an infected sternotomy wound (El Oakley class 2B) was present in 38 patients (4.5%) in the control group, in 19 patients (2.2%) in the vancomycin group, and in nine patients (1.1%) in the dual antibiotic group, respectively (P < .001). In contrast to the usual, we had a proliferous growth of gram-negative organisms 29 (3.4%) in the control group, 10 (1.2%) in the vancomycin group, and five (0.6%) in the dual antibiotic group, respectively (P < .001). Conclusion: Deep sternal wound infection is a major cause of post-cardiac surgery morbidity and prolonged hospital stay. Adding the simple step of topical application of vancomycin and gentamicin to the sternotomy wound at the end of the procedure appeared to significantly reduce deep wound infection rates.

This study described the subcapsular technique for primary closure castration in donkeys with special regard to its efficiency and welfare impacts. The study was conducted on twelve adult male donkeys, allocated randomly into two groups; subcapsular castration (SC) and open castration (OC) groups, whether the donkeys were subjected to surgical castration either by subcapsular or open castration techniques, respectively. Testosterone, cortisol, lactate, glucose, total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglyceride (TG), and nitric oxide (NO) were measured before and after castration. Pain-associated behavioral activities were recorded post-castration. The SC was successfully performed in donkeys through a single paramedian scrotal incision. The SC was efficient as OC in reducing testosterone levels. The pain score decreased in the SC compared to the OC over time. The SC was an efficient and reliable technique for primary closure castration in donkeys with minimal postoperative complications and care and good cosmetic, physiological, and behavioral outcomes. It can be an alternative to other castration techniques in equines.

Study objective To determine whether the combination of skin tapes and tissue adhesive is superior to either method alone for laceration repair. Methods This was a prospective, longitudinal experiment on six anesthetized swine. Thirty-six full-thickness linear wounds were created using a metal template, then closed using one of three methods: skin tapes over benzoin, tissue adhesive, or a combination of both. The study was done in two parts. Group 1 (immediate excision) animals were euthanized at day zero for skin excision and tensile strength testing following wound repair. Group 2 (delayed excision) had initial wound repair; animals were euthanized at day 35 for skin excision and tensile strength testing. Results In Group 1, the combination of skin tapes and tissue adhesive provided the strongest immediate wound closure. Average mean force for disruption immediately after wound repair was 19.9 lbs. for the tapes and tissue adhesive group compared to 9.6 lbs. for adhesive alone and 8.9 lbs. for tapes alone. The difference in mean force for combination repair vs. tapes alone was 10.3 lbs. (95% CI 4.1, 16.7), and combination vs. adhesive alone was 10.9 lbs. (95% CI 4.7, 17.3). In Group 2, the mean force required for laceration disruption for those repaired with both tape and tissue adhesive was 188.9 lbs. The mean force until wound disruption for tape only was 165.6 lbs., and the mean force until wound disruption for tissue adhesive alone was 118.9 lbs. The difference in mean force required for wound disruption for those repaired with adhesive alone vs. combination repair is 66.5 lbs. (95% CI 21.2, 111.9). The difference in mean force required for wound disruption between the other two groups was not statistically significant. Conclusions This study demonstrates that the combination of skin tapes and tissue adhesive provides superior immediate wound closure strength to either of these methods alone in a porcine model.

Objective To evaluate the clinical application and surgical efficacy of the chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap for the reconstruction of the large area of deep wound in foot and ankle. Methods Clinical data of 32 cases who underwent chimeric anterolateral thigh perforator flap to repair the large area of deep wound of the foot and ankle from January 2015 to December 2018 were retrospectively analyzed. The sizes of the defects ranged from 18 cm × 10 cm to 35 cm × 20 cm, with exposed tendon and bone and/or partial defects and necrosis, contaminations, accompanied by different degrees of infection. Following the radical debridement and VSD, chimeric anterolateral thigh perforator flap was employed to repair the deep wounds according to the position, site and deep‐tissue injury of the soft‐tissue defects. The skin flap and muscle flap were fanned out on the wound, and single‐ or two‐staged split‐thickness skin grafting was performed on the muscle flap. The operation time and blood loss were recorded. The survival and healing conditions of the operational site with chimeric anterolateral thigh perforator flap were evaluated post‐operationally. Complications at both recipient site and donor site were carefully recorded. Results The mean time of the operation was 325.5 min and average blood loss was 424.8 mL. Among the 32 cases, two cases developed vascular crisis, which were alleviated with intensive investigation and treatment; Four cases suffered from partial necrosis of the flap or skin graft on the muscle flap or on the residual local wound, which were improved after treatment of further dressing change and skin grafting. Another four cases experienced post‐traumatic osteomyelitis accompanied by bone defect were treated with simple bone grafting or Mesquelet bone grafting at 6–8 months after wound healing. Postoperatively, the wounds were properly healed, and the infection was effectively controlled without sinus tract forming. Overall, all 32 cases received satisfactory efficacy, without influencing subsequent functional reconstruction, and observed infection during the 12–36 months post‐operational follow‐up. Conclusion The chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap provides an effective and relative safe procedure for the repair of a large area of deep wound in the foot and ankle, particularly with irregular defect or deep dead space., Large area of deep wound in the foot and ankle with bone and tendon exposed. Harvested chimeric anterolateral thigh perforator flappedicled with descending branch of lateral circumflex femoral artery. Place the chimeric anterolateral thigh perforator flap near the wound of the foot and ankle. The chimeric flap was used to fan out on the wound, the muscle flap covers the bone exposed wound. All wounds were reconstructed by the flap and the skin grafting on the muscle flap or on the residual local wound.

Correction of prominent ears should also address any associated prominent ear lobes. If this is not done then the patient can end up with ear lobes that look even more prominent that they did before the procedure. We have very successfully corrected prominent lobes during a Pinnaplasty procedure by a simple modification of the incision used for the procedure. Using this technique would help plastic surgeons improve their results.

Background Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. Methods A systematic review of the literature was conducted. Results Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. Conclusion Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.

Purpose. To compare the efficacy and safety of zip-type skin closure device (SCD) and staple in total knee arthroplasty (TKA). Methods. Potential academic articles were identified from PubMed, Springer, ScienceDirect, and Cochrane Library from the inception of electronic databases to July 2020. The statistical analyses were performed with RevMan 5.1. Results. One randomized controlled trial (RCT) and 5 non-RCTs met the inclusion criteria. Present meta-analysis reveals that SCD is associated with lower wound pain score, scar score, and readmission compared with a staple. No significant differences are identified in terms of wound total complications, dehiscence, blisters, and infection. Conclusions. Comparing with a staple, zip-type SCD is a less painful skin closure method with fewer medical cost undergoing TKA.

Surgical residencies have implemented boot-camps for early acquisition of basic technical skills for interns. However, educators worry that retention is poor. We hypothesized that a structured boot-camp curriculum would improve skills.Interns underwent eight boot-camp sessions at the beginning of residency. Interns completed pre-, post-boot-camp, and end-of-year skills assessments, as well as post-boot camp and end-of-year porcine procedure labs. Proficiency was measured on a 5-point scale and by completion time.After boot-camp, interns improved all domains of knot-tying. Median time decreased for skin-closure (8.3 vs 9.9 min, p 0.01), peg transfer (57 vs 87 s, p 0.01), intracorporeal (178 vs 300 s, p 0.01), and extracorporeal knot-tying (140 vs 259 s, p 0.01). At the end-of-year assessment, interns exhibited retention of all skills and improved in knot-tying and central line skills. During the retention porcine lab, interns progressed basic but not complex skills.An eight-week boot-camp effectively improved technical skills among surgery interns. Interns retained all skills and improved upon techniques frequently practiced during intern year.

The management of complex diabetic foot wounds with large skin defects poses a challenge for surgeons. We presented a simple skin stretching system and negative pressure wound therapy for the repair of complex diabetic foot wounds to examine the effectiveness and safety.A total of 16 patients with diabetic foot ulcers were retrospectively reviewed between January 2015 and October 2020. All patients underwent the treatment by 3 stages. In stage 2, these difficult-to-close wounds of diabetes foot were residual. This method was applied to the wounds with a median defect size of 20.42 cm2 (range, 4.71–66.76 cm2).The median time for closure of complex diabetic foot wounds was 14 days ranging from 8 to 19 days. With respect to the absolute rates of reduction, it was observed with a median of 1.86 cm2/day, ranging from 0.29 cm2/day to 8.35 cm2/day. In accordance with the localization of the defect, the patients were divided into 3 groups: side of the foot (37.5%), dorsum of the foot (50.0%), and others (12.5%). There was no statistical difference between side of the foot and dorsum of the foot in terms of the median defect size with P = 0.069 (Kruskal–Wallis test). Otherwise, there were statistically significant differences regarding the median time and the median absolute rates (P < 0.05; Kruskal–Wallis test). No severe complications were encountered in this study.In summary, our results show that application of the simple skin stretching system and NPWT is an effective and safe approach to complex diabetic foot wounds. Nevertheless, more attention should be paid to the appropriate patient selection and intraoperative judgment to ensure wound closure and avoid undue complications.

Background Tracheostomy is commonly used for managing the airway of trauma patients. Complications are common and result in increased length of stays and treatment cost. The aim of this study is to evaluate whether the utilization of skin sutures or foam barrier dressings affect tracheostomy complication rates. Materials and methods This is a single-center retrospective review of patients who underwent a tracheostomy by the trauma service between January 2014 and December 2017. Collected variables included demographics, patient history, treatment variables, complications, and outcomes. Univariate and multivariate analyses were constructed to identify significant predictors for the development of complications. Results A total of 268 patients were included. The median age was 43.5 y, 221 (82.5%) patients were men, and the median BMI was 28 (IQR 24.6, 32.2). Most (87.3%) of the procedures were performed in the operating room and 82.5% were open. Skin sutures were used in 46.3% and 53.4% had a foam barrier dressing placed. Current smoking [OR 8.1 (95% CI 1.5, 43.6)] and BMI [OR 1.1 (95% CI 1.03, 1.2)] significantly increased the risk of developing pressure necrosis. Use of sutures or foam dressings was not associated with pressure necrosis, bleeding, or surgical site infection. There were no unexpected tracheostomy decannulations regardless of the use of skin sutures. Conclusions Suturing the tracheostomy or applying a foam barrier dressing was not associated with overall complications or decannulation rates. Based on our data, we suggest that skin sutures may be safely abandoned.

Alteration of wound healing increases the risk of a patient's morbidity and mortality. This can lead to scarring, infection, malignant transformation and a reduction in quality of life. Management of wounds costs the UK an estimated £5.3 billion annually which is paid for by the state, with further financial burden due to health related productivity loss. Wound care is managed by a broad spectrum of different health professionals leading to different standards of care. For example, only 16% of lower leg wounds have either an ankle-brachial pressure index measurement or Doppler scan. Due to this variation in wound care, we have summarised all available NICE guidelines and guidance up to February 2021 on the topic of wound healing listed in the National Institute for Health and Care Excellence (NICE) archives. The goal is to provide an easy to access summary of wound care interventions. Our search provided us with 18 technology appraisals related to wound healing which have been summarised.

Highlights • Despite a UK national lockdown, the incidence of open lower limb fractures presenting to our trauma centre was comparative to pre-pandemic levels. • Road traffic accidents continue to be the most common mechanism of injury, possibly related to an increase in speeding. • High energy injuries predominate in males. • Time to initial debridement and definitive wound coverage was not significantly affected. The average length of stay in hospital was reduced., Background: COVID-19 has created huge pressures on healthcare systems. The ongoing provision of major trauma services during this time has proved challenging. We report our experience of managing open lower limb fractures (oLLFs) during the pandemic in a London major trauma centre (MTC). Methods: This was a prospective study of all open lower limb fractures presenting to our unit over the initial 48 days of UK government lockdown - 24th March till 10th May 2020. Results were compared to the same time period in 2019 retrospectively. Epidemiological data, mechanism, Gustilo-Anderson (G-A) severity grading, time to initial debridement and definitive coverage were analysed. Results: There was a 64% reduction in emergency department (ED) attendances (25,264 vs 9042). There was an 18% reduction in oLLFs (22 vs 18). Approximately three-quarters of injuries were in males across both cohorts (77% vs 78%) and tended to occur in younger patients (median age, 37 vs 35). Road-traffic-accidents (RTAs) were the most common injury mechanism in both 2019 and lockdown, but a rise in jumpers from height was seen in the latter. A similar pattern of G-A severities were seen, however only 3 injuries during lockdown required major soft tissue reconstruction. There was no significant difference in times taken for initial debridement (p = 0.72786) or definitive wound coverage (p = 0.16152). A greater proportion of independent operating was seen during lockdown between orthopaedics and plastic surgery. Conclusions: Despite government lockdown measures, oLLFs still placed significant burden on our MTC. Notwithstanding significant staffing alterations and theatre pressures, we have been able to ensure these lower limb emergencies remain a surgical priority and have managed to utilise resources appropriately.

BACKGROUND Although many repair methods for postsurgical lip defects have been described, the literature lacks a comprehensive review of these methods. OBJECTIVE To perform a systematic review of lip defect repair methods after Mohs surgery or excisions. MATERIALS AND METHODS Terms related to perioral anatomy, Mohs surgery and excision, and reconstruction were used to search 8 databases. Articles were included if they reported postsurgical lip repair data for 4 or more patients, were in English, and were published from 2004 onward. Two reviewers screened all titles and abstracts, followed by the full texts of the remaining articles. Data were then extracted including author specialties, study design, demographic, tumor, and defect information, surgical procedures, outcomes, and complications. RESULTS Forty-two studies were eligible, including a randomized trial, 25 case series, and 16 cohort studies. Most were written by dermatologic or plastic surgeons, and most studies were small, with an average subject number of 61. Very few studies used structured outcome measures. Many repair methods were described, the most common of which were linear closures and various flaps. CONCLUSION Many repair methods for lip defects have been published, but overall, the quality of the available evidence is low.

A ventral midline surgical approach for fish celiotomy is commonly performed in veterinary clinical medicine and research, although the relevant ventral body wall anatomy of many fish species is not well documented. Histological evaluation of tissue samples from the ventral body wall of 12 fish species was performed to provide a reference for surgical approach and closure decisions. The width between muscle bundles running parallel to the long axis and total thickness of tissue layers varied among species. An appreciable space between longitudinal muscles of the ventral body wall and a lack of muscle, vessels and nerves on midline in all species examined supports recommendations of ventral midline incisions to spare important structures. Dense connective tissue consistent with an aponeurosis between musculature along the ventral body wall was not observed in any species evaluated. Connective tissue was concentrated within the dermis of all species evaluated, with an additional layer of collagen along the coelomic membrane in Russian sturgeon Acipenser gueldenstaedtii, koi Cyprinus carpio, goldfish Carassius auratus, black drum Pogonias cromis, black seabass Centropristis striata, tomtate Haemulon aurolineatum and scup Stenotomus caprinus. A sufficiently wide space on ventral midline for practical targeting during the surgical approach is present in A. gueldenstaedtii, C. carpio, striped bass Morone saxatilis, H. aurolineatum, P. cromis, rainbow trout Oncorhynchus mykiss and brown trout Salmo trutta. Sand perch Diplectrum formosum, C. auratus, S. caprinus, grey triggerfish Balistes capriscus and black sea bass Centropristis striata have a negligible space between longitudinal muscles on midline. The variation in ventral body wall structure observed in this study helps inform surgical decision making for celiotomy incision and closure in these species.

Objectives Sternal instability and wound infections are major causes of morbidity following cardiac surgery, which is further amplified in high risk patients that include diabetics and patients with high body mass index (BMI). We compare the different outcomes of different sternal wire closure techniques following median sternotomy for cardiac surgery in obese patients. Methods A comprehensive electronic literature search was undertaken according to PRISMA guidelines from inception to July 2020 to identify all published data comparing single wire sternal closure to either double wire or figure-of-8 techniques following median sternotomy for cardiac surgery in obese patients, defined as a BMI ≥ 30. Results Eight studies met the final inclusion criteria; single wire versus double wire sternal closure (n = 2) and single wire versus figure-of-8 wire closure (n = 6). Higher rate of sternal instability was noted in single wire versus double wire closure (22/150 [14.7%] patients vs. 6/150 [4%] patients, p = 0.003, odd ratio [OR] 0.25 [95% confidence interval [CI] 0.10-0.63]). Similarly, sternal instability was higher in single wire vs figure-of-8 wire closure technique (33/2422 [1.3%] vs. 11/8035 [0.1%], p = 0.04 OR 0.30 [95% CI, 0.09-0.96]), respectively. Conclusion There is benefit in the use of either double or figure-of-8 sternal wire closure techniques over single wire closure in terms of sternal instability. However, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing the optimal sternal closure technique in this high risk group of patients.

Background: Loop ileostomy has an important role in mitigating the serious effects of anastomotic leakage in colorectal surgery. However, the morbidity and mortality associated with ileostomy reversal cannot be overlooked. We investigated the possible risk factors for complications following ileostomy reversal. Methods: All patients who underwent loop ileostomy closure between 2008 and 2017 at Inje University Busan Paik Hospital were identified. Medical records on patient characteristics, preoperative management, surgical techniques, postoperative management, chemotherapy/radiotherapy, and complications were retrospectively analyzed in a prospectively collected database. Results: A total of 354 patients underwent loop ileostomy closure. The overall complication rate was 23.7%, with Clavien-Dindo grade I as the most common (15.8%), 5.6% in grade II, 2.2% in grade III–V, and three patients died. The two most common complications were wound infection (11.6%) and small bowel obstruction (4.8%). In univariable and multivariable analyses, closure technique or chemotherapy did not affect the outcome, but low serum albumin

Summary Background The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair. Method From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, Result The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002). Conclusion The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

Annals of thoracic and cardiovascular surgery (2020). doi:10.5761/atcs.oa.19-00293, Published by Medical Tribune, Tokyo

Background Laparoscopic procedure has inherent merits of smaller incisions, better cosmesis, less postoperative pain, and earlier recovery. In the current study, we presented our method of purely laparoscopic feeding jejunostomy and compared its results with that of conventional open approach. Methods We retrospectively reviewed our patients from 2012 to 2019 who had received either laparoscopic jejunostomy (LJ, n = 29) or open ones (OJ, n = 94) in Chang Gung Memorial Hospital, Linkou. Peri-operative data and postoperative outcomes were analyzed. Results In the current study, we employed 3-0 Vicryl, instead of V-loc barbed sutures, for laparoscopic jejunostomy. The mean operative duration of LJ group was about 30 min longer than the OJ group (159 ± 57.2 mins vs 128 ± 34.6 mins; P = 0.001). There were no intraoperative complications reported in both groups. The patients in the LJ group suffered significantly less postoperative pain than in the OJ group (mean NRS 2.03 ± 0.9 vs. 2.79 ± 1.2; P = 0.002). The majority of patients in both groups received early enteral nutrition (P = 0.143). Conclusions Our study demonstrated that purely laparoscopic feeding jejunostomy is a safe and feasible procedure with less postoperative pain and excellent postoperative outcome. It also provides surgeons opportunities to enhance intracorporeal suture techniques.

Background Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures. Methods We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission. Results A total of 118 patients were included in the study, with a mean age of 62.8 years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques. Discussion We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

Background Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful. Objective This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses. Design This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016. Settings The patients were treated at a tertiary referral center in Thailand. Patients Eighty-six patients with acute anorectal abscesses without previous surgery were included. Interventions Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings. Main outcome measure The main outcome measure was the 90-day healed rate. Results Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively. Limitations The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon's expertise. Conclusions Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451. Exploracin interesfintrica con ligadura del trayecto en la fstula interesfintrica o intento de cierre del orificio interno en abscesos anorrectales agudos ANTECEDENTES:Los abscesos anorrectales agudos de origen criptoglandular, comunmente se manejan mediante incision y drenaje, lo que resulta en el desarrollo de una fistula hasta en un 73% de los casos, requiriendo posteriormente cirugia definitiva de la fistula. Sin embargo, dado que los trayectos de la fistula ya pueden estar inicialmente presentes, puede ser util el cierre primario del trayecto, como prevencion secundaria en la formacion de la fistula, mediante la ligadura del trayecto de la fistula interesfinterica.OBJETIVO:El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploracion interesfinterica, con ligadura del trayecto de fistula interesfinterica o intento de cierre del orificio interno para abscesos anorrectales agudos.DISENO:Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016.AJUSTES:Los pacientes fueron tratados en un centro de referencia terciario en Tailandia.PACIENTES:Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugia previa.INTERVENCIONES:Se realizo diseccion interesfinterica. La intervencion quirurgica adicional dependio de los hallazgos interesfintericos.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado, fue la tasa de cicatrizacion a 90 dias.RESULTADOS:De los 86 pacientes, hubo 3 abscesos interesfintericos bajos, 26 abscesos transesfintericos bajos, 25 abscesos transesfintericos anteriores altos, 27 abscesos transesfintericos posteriores altos y 5 abscesos interesfintericos altos. La ligadura del tracto de la fistula interesfinterica, con tracto interesfinterico identificable, se realizo con exito en 66 pacientes. Se realizo exploracion interesfinterica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de exito fueron 86% y 70% respectivamente. Orificio interno no identificado y patologia interesfinterica, fueron factores de riesgo para la falta de cicatrizacion. Ningun paciente reporto incontinencia fecal posoperatoria.LIMITACIONES:La limitacion de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar segun la experiencia de cada cirujano.CONCLUSIONES:En la mayoria de los casos de abscesos anorrectales agudos, se encontro formacion de trayectos fistulosos. La cirugia definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.

Background Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. Methods Retrospective review 2007–2018 evaluating outcomes of patients undergoing single-stage surgery. Results 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. Conclusion Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible.

Fasciotomy is indicated to relieve compartment syndrome caused by electric burns. Many techniques are available to close the fasciotomy wounds including vacuum-assisted closure, skin grafting, and healing by secondary intention. This study assessed the shoelace technique in fasciotomy wound closure in patients with electric burns. The study included 19 fasciotomy wounds that were treated by shoelace technique (Group ST, n = 10 fasciotomy wounds) or by skin grafting/healing by secondary intention (Group C, n = 9 fasciotomy wounds). Data were collected for wound surface area, time to intervention, time to wound closure, rate of decrease in wound surface area after application of shoelace technique and associated complications. The mean time to intervention after fasciotomy was significantly lower in Group ST—7.6 ± 3.8 days as compared to 15.8 ± 5.3 days in Group C (P = .004). The median time to closure was also significantly lower in Group ST—7 days (range 6–10) as compared to Group C—20 days (range 12–48) (P < .001). Primary closure was achieved in 80% cases in the group ST and no complications were recorded. The shoelace technique is an economical, fast, and effective method of fasciotomy wound closure in electric burns, especially in high volume centers and resource-limited areas.

Purpose To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. Methods A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. Results Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. Conclusion Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. Level of Evidence Level III.

Background Primary closure of the surgical wound during neurosurgical procedures is sometimes difficult because of limited ability to expand the scalp, or because the skin defect is large. Hence, our institution recently adopted the technique of intraoperative tissue expansion using a Foley catheter for these cases. We describe this easily accomplished, readily available, effective, economical technique and describe our experience performing the technique. Methods With this procedure, the subcutaneous tissue (usually the subperiosteal layer) surrounding the skin defect is dissected to make a subcutaneous pocket in which to place a 20-French Foley catheter. The standard expander is a 30-mL balloon. The catheter is inserted into the subcutaneous pocket, and the balloon is inflated with 10–30 mL of saline for 5 minutes, after which the balloon is deflated for 3 minutes in a cyclic loading manner. After sufficient expansion, the primary closure of the surgical wound is achieved with minimal tension on the surrounding skin. Results Between November 2018 and February 2020, we performed this technique in 5 patients, each with a large surgical defect in the scalp. Primary closure was achieved, and postoperative wound healing was excellent in all 5 patients. Conclusions Intraoperative skin expansion using a Foley catheter—which is easily performed, readily available, and economical—can be used to achieve surgical wound closure during various neurosurgical procedures.

INTRODUCTION Cesarean deliveries are commonly performed throughout the world. Although the uterine closure technique following this procedure may influence how the uterine scar heals, there is insufficient evidence for choosing the appropriate technique and so preventing long-term negative consequences. This prospective, randomized study examined the effects of single- and double-layer uterine closure techniques on uterine scar healing following cesarean delivery. MATERIAL AND METHODS This study assessed a total of 282 women aged 18-45 years who were in gestational weeks 24-41 of singleton pregnancies. None had previously undergone uterine surgeries. These participants completed their first cesarean deliveries at the time of study and were randomized into the following two treatment groups: single-layer closure with locking and double-layer closure with locking in the first layer, but not in the second layer (NCT03629028). However, the decidua was not included for treatment in either group. Participants were evaluated at 6-9 months after cesarean section by saline infusion sonohysterography to assess cesarean delivery scar defects. These procedures were conducted by experienced sonographers who were not aware of the uterine closure technique. RESULTS Of the 225 final participants, 109 received the single-layer closure technique, whereas 116 received the double-layer technique. The niche rates were 37% (n = 40) for the single-layer group and 45.7% (n = 53) for the double-layer group (P = .22, relative risk 1.4, 95% CI = 0.8-4.4). CONCLUSIONS The single- and double-layer closure techniques did not produce different impacts on uterine scar niche development.

Background Intraoperative findings during gastroschisis surgery are the main predictor associated with increased mortality. The aim of our study was to determine the type of surgical findings associated with inpatient mortality in a cohort of patients with gastroschisis from a university hospital in Western Mexico. Materials and methods Infants with surgically repaired gastroschisis during the period 2011-2017 at the Dr. Juan I. Menchaca Civil Hospital of Guadalajara (Guadalajara, Mexico) were studied. Data regarding demographics, perinatal history, and intraoperative findings were collected and compared according to whether they were nonsurvivors (cases) or survivors (controls) at hospital discharge. Data were analyzed using logistic regression, determining its adjusted odds ratio (aOR) and its respective 95% confidence intervals (95% CIs). The proper adjustment of the model was verified using the Hosmer and Lemeshow test. Results Ninety-four patients with gastroschisis were studied, of which 13 were nonsurvivors (13.8%), and 81 (86.2%) were survivors at hospital discharge. In the group of survivors, primary surgical closure was performed more frequently (P = 0.018), whereas staged reduction with a silo predominated in the group of nonsurvivors (P = 0.018), and an increased frequency of complex gastroschisis (0.0001). After logistic regression analysis, intraoperative findings associated with nonsurvival were severe bowel matting (aOR: 7.3; 95% CI: 1.2-44), and prolapse of the small intestine and large intestine, plus any other organ (aOR: 15.9; 95% CI: 1.1-219.6). Conclusions Mortality in our cohort was high (13.8%) and was significantly associated with severe bowel matting, and the prolapse of the small and large intestines, plus any other organ.

The purpose of this study was to evaluate the effectiveness of a wound closure method using a combination of subcuticular sutures and subcutaneous closed-suction drainage (SS closure) for preventing incisional surgical site infection (SSI) in loop ileostomy closure. A total of 178 consecutive patients who underwent loop ileostomy closure at Nara Medical University Hospital between 2004 and 2018 were retrospectively assessed. The patients were divided into 2 groups: the conventional skin closure (CC) group from 2004 to 2009 (75 patients) and the SS closure (SS) group from 2010 to 2018 (103 patients). The incidence of incisional SSI was compared between the two groups, and the factors associated with incisional SSI were examined by univariate and multivariate analyses. Incisional SSI occurred in 7 cases (9.3%) in the CC group but was significantly reduced to only 1 case (0.9%) in the SS group (p = 0.034). In the univariate analysis, the hemoglobin levels, serum creatinine levels, and SS closure were associated with incisional SSI. SS closure was the only independent preventive factor for incisional SSI according to the multivariate analysis (hazard ratio = 0.24, p = 0.011). The combination of subcuticular sutures and subcutaneous closed-suction drainage may be a promising way of preventing incisional SSI in loop ileostomy closure.

Background: Mohs micrographic surgery is worldwide used for treating skin cancers. After obtaining tumor-free margins, choosing the most appropriate type of closure can be challenging. Objectives: Our aim was to associate type of surgical reconstructions after Mohs micrographic surgery with the characteristics of the tumors as histological subtype, anatomical localization and especially number of surgical stages to achieve complete excision of the tumour. Methods: Transversal, retrospective analyses of medical records. Compilation of data such as gender, age, tumor location, histological subtype, number of stages to achieve clear margins and type of repair used. Results: A total of 975 of facial and extra-facial cases were analyzed. Linear closure was the most common repair by far (39%) and was associated with the smallest number of Mohs micrographic surgery stages. This type of closure was also more common in most histological subtypes and anatomical locations studied. Using Poisson regression model, nose defects presented 39% higher frequency of other closure types than the frequency of primary repairs, when compared to defects in other anatomic sites (p< 0.05). Tumors with two or more stages had a 28.6% higher frequency of other closure types than those operated in a single stage (p< 0.05). Study limitations: Retrospective study with limitations in obtaining information from medical records. The choice of closure type can be a personal choice. Conclusions: Primary closure should not be forgotten especially in surgical defects with fewer stages and in non-aggressive histological subtypes in main anatomic sites where Mohs micrographic surgery is performed.

Diaphragm metastases in ovarian cancer can be safely resected robotically in selected patients. The technique is similar to laparotomy, whether it is a peritoneal or full-thickness excision. Trocar placement is very important for successful resection and is dependent on the location of the disease. Metastases involving the left diaphragm and the ventral aspect of the right diaphragm are accessed with trocars placed slightly cranial to the umbilicus. Metastases in the dorsal aspect of the right diaphragm are removed with trocars in the upper quadrants. Metastases located in the lateral portion of the right diaphragm are excised using an infrahepatic approach, and those in the medial aspect are removed using a suprahepatic approach. In peritoneal resection, monopolar instruments must be kept at 10 W to 15 W to prevent contraction of the diaphragm and pleural perforation. Intraoperative pleural decompression is performed via an aspirating catheter. A video of the technique described in this report is available online (Supplementary Video 1).

We performed an updated meta-analysis to compare the efficacy of the zipper device and sutures for wound closure after surgery. A computerised literature search was performed for published trials in PubMed, Web of Science, the Cochrane Library, and Google Scholar. Two reviewers independently scrutinised the trials, extracted data, and assessed the quality of trials. The primary outcome was surgical site infections (SSI). The secondary outcomes were wound dehiscence, total wound complications, wound closure time, and scar score. Statistical analysis was performed in the Stata 12.0. Of the 130 citations, eight trials (1207 participants) met eligibility criteria and were included. The zipper device achieved a lower SSI rate (RR: 0.63, [95% CI: 0.41-0.96, P = 0.032]), a shorter wound closure time (SMD: -8.53 [95% CI: -11.93 to -5.13, P = 0.000]) and a better scar score (SMD: 0.42 [95% CI: 0.22-0.62, P = 0.000]) than sutures. No significant difference was shown in the incidence of wound dehiscence and total wound complications. Therefore, the zipper device provides the advantages of anti-infection, time-saving, and cosmesis for wound closure.

The complications caused by early closure (EC) or late closure (LC) after temporary ileostomy in rectal cancer patients have not been compared systematically. We conducted this meta-analysis to explore the details surrounding this issue, based on a search of PubMed, ScienceDirect, Scopus, Web of Science, Ovid MEDLINE, the Cochrane Library, Embase, and Google Scholar. The comparative indices included total complications, severe complications, and various individual complications before or after closure. Four randomized-controlled trials (RCTs), including the EASY trial, were analyzed, involving a collective total of 324 patients. EC tended to result in more postoperative complications than LC for rectal cancer patients with temporary ileostomy. This difference was mainly embodied in wound complications. Nevertheless, LC resulted in more complications than EC before closure, such as leakage outside the appliance bag and skin irritation. There was no obvious difference in severe postoperative complications or medical complications. With fewer overall and wound-related complications, LC tended to be more suitable than EC for rectal cancer patients with a temporary ileostomy; however, the complications before closure should also be considered.

Background: Most patients with perianal Crohn's disease fistulas receive medical treatment with anti-TNF. So far, outcomes of anti-TNF have not been directly compared to chronic seton drainage or surgical closure. We hypothesized that chronic seton drainage would result in fewer re-interventions compared to anti-TNF and surgical closure. Methods: This multicentre, randomised trial was performed in 19 European centres. Patients with high perianal Crohn's fistulas with a single internal opening were randomly assigned in a 1:1:1 ratio to chronic seton drainage, long-term anti-TNF therapy, or surgical closure using a central web-based system without stratification. Patients were analysed according to the intention-to-treat principle. The primary outcome was the cumulative number of patients with fistula-related re-intervention(s) at 1.5 year. Patients refusing randomisation due to a specific treatment preference were included in a parallel prospective PISA registry cohort. Findings: Between September 14, 2013 and November 20, 2017, 44 of the 126 planned patients were randomised. The study was stopped by the data safety monitoring board because of futility. Seton treatment was associated with the highest re-intervention rate (10/15, versus 6/15 anti-TNF and 3/14 surgical closure patients, P = 0·02). No substantial differences in perianal disease activity and quality of life between the three treatment groups were observed. Interestingly, in the PISA prospective registry (n = 50), inferiority of chronic seton treatment was not observed for any outcome measure. Interpretation: The results imply that chronic seton treatment should not be recommended as the sole or superior treatment for perianal Crohn's fistulas. However, the statistical inferiority of seton treatment should be interpreted with caution, due to the crucial aspects of small numbers and as this inferiority could not be confirmed in the PISA registry data. Trial Registration Number: The trial is registered with the Dutch Trialregister.nl number NTR4137. Funding Statement: The Netherlands Organization for Health Research and Development and the Crohn and Colitis Foundation. Declaration of Interests: KAW, EJdG, MES, MGD, MFG, JMJ, AP, SAvT, DDZ, KFB, JvdB, MWM, WAB, and CJB have no conflicts of interests to declare. GRD’H has served as advisor for Abbvie, Ablynx, Allergan, Amakem, Amgen, AM Pharma, Arena Pharmaceuticals, AstraZeneca, Avaxia, Biogen, Bristol Meiers Squibb, Boerhinger Ingelheim, Celgene/Receptos, Celltrion, Cosmo, Covidien/Medtronics, Echo Pharmaceuticals, Eli Lilly, Engene, Ferring, DrFALK Pharma, Galapagos, Genentech/Roche, Gilead, Glaxo Smith Kline, Gossamerbio, Hospira/Pfizer, Immunic, Johnson and Johnson, Lycera, Medimetrics, Millenium/Takeda, Mitsubishi Pharma, Merck Sharp Dome, Mundipharma, Nextbiotics, Novonordisk, Otsuka, Pfizer/Hospira, Photopill, Prometheus laboratories/Nestle, Progenity, Protagonist, Robarts Clinical Trials, Salix, Samsung Bioepis, Sandoz, Seres/Nestle, Setpoint, Shire, Teva, Tigenix, Tillotts, Topivert, Versant and Vifor; received speaker fees from Abbvie, Biogen, Ferring, Johnson and Johnson, Merck Sharp Dome, Mundipharma, Norgine, Pfizer, Samsung Bioepis, Shire, Millenium/Takeda, Tillotts and Vifor. CYP has served as adviser for Abbvie, Takeda, and Pliant, declares a grant from Takeda, and received speaker’s fees from Abbvie, Tillotts, and Takeda. KBG has served as speaker and/or advisor for Amgen, AbbVie, Biogen, Boehringer Ingelheim, Ferring, Hospira, MSD, Pfizer, Samsung Bioepis, Sandoz, Takeda and Tigenix. AS has served as speaker and/or advisor for Takeda. SD has served as a speaker, a consultant and an advisory board member for Abbvie, Ferring, Hospira, Johnson & Johnson, Merck, Millennium Takeda, Mundipharma, Pfizer, Tigenix, UCB Pharma, and Vifor. Ethics Approval Statement: The study was performed in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines, and is reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The trial received central approval from the medical ethics committee at the Amsterdam UMC, location AMC, and from the corresponding committees in all participating centres.

Background and aim Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large colorectal lesions. However, colorectal ESD is associated with a high frequency of adverse events (AEs), and the efficacy of prophylactic endoscopic closure after ESD for preventing AEs is still controversial. This meta-analysis was conducted to assess the efficacy of closure on AEs following colorectal ESD. Methods We searched PubMed, Embase, and the Cochrane Library for eligible studies. The chi-square-based Q statistics and the I2 test were used to test for heterogeneity. Pooling was conducted using a fixed or random effects model. Results We identified eight eligible studies that compared the effects of closure vs non-closure with respect to delayed bleeding, delayed perforation, and post-ESD coagulation syndrome. Compared with non-closure (5.2%), closure was associated with a lower incidence (0.9%) of delayed bleeding (pooled odd ratios [ORs]:0.19, 95% CI: 0.08-0.49) following ESD. The pooled ORs showed no significant differences in incidence of delayed perforation (pooled OR: 0.22; 95% CI: 0.05-1.03) or post-ESD coagulation syndrome (pooled OR:0.75; 95% CI: 0.26-2.18) between the closure and non-closure groups. Conclusion Prophylactic endoscopic closure may reduce the incidence of delayed bleeding following ESD of colorectal lesions. Future studies are needed to further illuminate risk factors and stratify high risk subjects for a cost-effective preventive strategy.