Secondary healing strategy for difficult wound closure in invasive vulvar cancer: a pilot case-control study

OBJECTIVES

Despite the number of surgical advances and innovations in techniques over time, radical vulvectomy frequently results in substantial loss of tissue that cannot be primarily closed without tension, the mobilization of surrounding tissues or even the rotation of myocutaneous flaps. The aim of this study was to evaluate the feasibility of leaving the surgical vulvar open wound for secondary healing in situations where primary closure of the vulvar wound is not possible.

METHODS

This case-control pilot study analyzed 16 women with a diagnosis of squamous cell carcinoma of the vulva who first underwent inguinofemoral lymphadenectomy, 6-week sessions of chemotherapy and 25 daily sessions of radiotherapy. Afterward, excision of the vulvar lesion with free margins was performed between January 2011 and July 2017. Twelve patients underwent primary closure of the wound (control), and in 4 patients, the surgical wound was left open for secondary healing by means of a hydrofiber (case). The inclusion criteria were a) FIGO-2009 stage II up to IIIC; b) squamous cell carcinoma; and c) no evidence of pelvic or extrapelvic disease or pelvic nodal involvement. The exclusion criteria were extrapelvic disease or pelvic nodal involvement, another primary cancer, or a poor clinical condition. ClinicalTrials.gov: NCT02067052.

RESULTS

The mean age of the patients at the time of the intervention was 62.1. The distribution of the stages was as follows: II, n=6 (37 %); IIIA, n=1 (6%), IIIB, n=1 (6%) and IIIC, n=8 (51%). The mean operative time was 45 minutes. The hospital stay duration was 2 days. Full vulvar healing occurred after an average of 30 days in the control group and after an average of 50 days in the case group.

CONCLUSION

A secondary healing strategy may be an option for the treatment of vulvar cancer in situations of non-extensive surgical wounds when primary closure of the wound is not possible.

Costs and outcomes in evaluating management of unhealed surgical wounds in the community in clinical practice in the UK: a cohort study

OBJECTIVE

To evaluate the patient pathways and associated health outcomes, resource use and corresponding costs attributable to managing unhealed surgical wounds in clinical practice, from initial presentation in the community in the UK.

METHODS

This was a retrospective cohort analysis of the records of 707 patients in The Health Improvement Network (THIN) database whose wound failed to heal within 4 weeks of their surgery. Patients' characteristics, wound-related health outcomes and healthcare resource use were quantified, and the total National Health Service (NHS) cost of patient management was estimated at 2015/2016 prices.

RESULTS

Inconsistent terminology was used in describing the wounds. 83% of all wounds healed within 12 months from onset of community management, ranging from 86% to 74% of wounds arising from planned and emergency procedures, respectively. Mean time to healing was 4 months per patient. Patients were predominantly managed in the community by nurses and only around a half of all patients who still had a wound at 3 months were recorded as having had a follow-up visit with their surgeon. Up to 68% of all wounds may have been clinically infected at the time of presentation, and 23% of patients subsequently developed a putative wound infection a mean 4 months after initial presentation. Mean NHS cost of wound care over 12 months was £7300 per wound, ranging from £6000 to £13 700 per healed and unhealed wound, respectively. Additionally, the mean NHS cost of managing a wound without any evidence of infection was ~£2000 and the conflated cost of managing a wound with a putative infection ranged from £5000 to £11 200.

CONCLUSION

Surgeons are unlikely to be fully aware of the problems surrounding unhealed surgical wounds once patients are discharged into the community, due to inconsistent recording in patients' records coupled with the low rate of follow-up appointments. These findings offer the best evidence available with which to inform policy and budgetary decisions pertaining to managing unhealed surgical wounds in the community.

Pain Reduction with Negative Pressure on Surgical Site Incisions

Postoperative pain management for surgery in the lower extremities has historically been managed mechanically through the use of elevation, ice, compression and drains. Pharmacological management includes the use of nerve blocks and analgesics. Due to the current opioid crisis, new methods are being sought to reduce post-operative pain so that patients are at lower risk for opioid addiction. Postoperative edema control is vital to reduce tension on the incision, since increased incisional tension may cause an increase in pain at the surgical site. Ice, elevation, compression and drains all contribute to edema reduction, and thereby reduce pain and incisional tension. This report introduces a new method for post-operative pain control in lower-extremity surgery. In the author's present clinical experience with 15 patients, the application of negative pressure at the incision site using the PREVENA™ Incision Management System (KCI USA, Inc., San Antonio, TX) was associated with a decrease in post-operative pain as well as a decrease in the use of narcotics for post-operative pain management.

n-Butyl-2-cyanoacrylate tissue adhesive (Histoacryl) vs. subcuticular sutures for skin closure of Pfannenstiel incisions following cesarean delivery

BACKGROUND

Tissue adhesives are now routinely used for skin closure in various surgeries. This study aimed to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate (NBCA) tissue adhesive in cesarean delivery by comparing it with the safety and efficacy of subcuticular suture closure.

METHODS AND FINDINGS

A retrospective chart review was undertaken of all patients who underwent cesarean delivery via Pfannenstiel skin incision. During the study period, a total of 209 patients had NBCA (Histoacryl®) closure and 208 patients had suture closure. Wound complications and Vancouver scar scale (VSS) scores were compared between the 2 groups.

RESULTS

There were no significant differences between the two groups in indications for cesarean deliveries or number of previous cesarean deliveries. Incidences of wound disruption and infection were also similar between the two closure groups (p = 0.322 and 0.997, respectively). The rate of wound complications was 3.4% in the NBCA group and 5.3% in the suture group. All complications healed uneventfully with topical antibiotics or closure strips. VSS scores at 6-8 weeks after operation were not significantly different between the two groups (p = 0.858). These results were corroborated by propensity score-matching analysis.

CONCLUSIONS

NBCA may be a useful skin closure of Pfannenstiel skin incisions after cesarean delivery.

Assessment of the quality of the change of surgical wound dressings by the nursing staff in a university hospital of Tunis

BACKGROUND

Infection of surgical wounds is the main cause of nosocomial infections. In the event of a defect in the care chain, in particular, during the change of the postoperative dressings, the infectious risk would be increased.

AIM

To evaluate the gestures of change of dressing practiced by nurses of a university hospital department of surgery, in order to observe the insufficiencies.

METHODS

We conducted a two-month-duration prospective, descriptive study having a qualitative approach, consisting of a protocol for observing nursing procedures carried out during the implementation of postoperative dressings in a university hospital surgery department from Tunis. A five-item observation grid was developed based on the nursing procedures that should be performed during dressing rehabilitation.

RESULTS

This observation was made on 48 changes of dressings made by 13 nurses (eight women and five men). Inadequacies were noted during the preparation of the gesture, the preparation of the equipment, the execution of the act, the storage of the equipment and the transmission of the care to the rest of the nursing staff.

CONCLUSION

The results of our study are consistent with a deficiency of the quality of repair of wounds by the nurses. They show a poor application of the rules of asepsis when repairing surgical wounds. This would be only partly due to inadequate staff training, as the majority of participating nurses were found to be familiar with the basics of the means and methods used to prevent infection of a wound. Other causes are lack of staff and work overload, lack of adequate material for the given care as well as lack of self-responsibility for its nursing practice. The resolution of these problems requires the setting up of an epidemiological surveillance system and the in-service training of the staff involved.

The effect of 22.5 kHz low-frequency contact ultrasound debridement (LFCUD) on lower extremity wound healing for a vascular surgery population: A randomised controlled trial

The aim of this study was to compare changes in wound size and appearance and health complication rates in patients with vasculopathy and lower-extremity wounds treated with or without low-frequency contact ultrasound debridement (LFCUD) This study was a randomised controlled trial. The study was conducted in a vascular surgery service, including outpatient wound clinic and inpatient ward, in a tertiary care academic centre. In total, 70 patients with vasculopathy and lower-extremity wounds of mixed aetiology were enrolled in the trial; 68 completed the study. Patients were randomised to receive LFCUD plus usual care (n = 33) or usual care (n = 37) at 4 weekly visits, and were followed thereafter for up to 12 wk. The main outcome measures included closed wounds, change in wound surface area (WSA), and wound appearance by the revised Photographic Wound Assessment Tool (revPWAT). After 4 weekly LFCUD treatments, patients in the LFCUD group had significantly better wound appearance (total revPWAT score) compared with the control group treated only with usual care (P = <0.05). LFCUD-treated wounds also had a significant reduction in WSA over 4 wk that was not found in the UC group. LFCUD treatment was also associated with a greater number of healed wounds, odds ratio 5.00 (95% CI 1.24-20.25), and fewer instances of wound deterioration. Weekly LFCUD applications to patients with significant vasculopathy resulted in superior healing outcomes when compared with current usual wound care practice.

The Effect of Heated CO2 Insufflation in Minimising Surgical Wound Contamination During Open Surgery

The primary source of infections in open surgeries has been found to be bacteria and viruses carried into the surgical wound on the surfaces of skin particles shed by patients and surgical staff. In open cardiac surgeries, insufflation of the wound with carbon dioxide is used to limit the quantity of air able to enter into the heart, avoiding air embolisms when the heart is restarted. This surgical technique has been evaluated as a method of limiting the number of skin particles able to enter into the wound, using computational fluid dynamics (CFD) simulations and experimental testing. Spherical particles of 5.0 and 13.5 μm in diameter were used to simulate skin particles falling above a wound, travelling in air ventilation velocities of either 0.2 or 0.4 m/s, and with or without CO₂ insufflation. The CFD simulations with CO₂ included a diffuser placed in the wound and supplied with CO₂ at a rate of 10 L/min. Experimental testing was completed under similar conditions. The results of CFD simulations and experimental testing showed CO₂ insufflation can significantly limit the number of particles able to enter into the wound.

Randomised controlled feasibility trial of standard wound management versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for hip fractures

INTRODUCTION

Deep wound infection is a catastrophic complication after hip fracture surgery. However, current understanding of infection rates in this population is limited. Many technologies such as incisional negative-pressure wound therapy (NPWT) show promise in reducing the rate of infection. This trial is a feasibility study looking to establish a value estimated with a greater precision of the rate of deep infection after hip fracture treatment in patients treated with NPWT versus standard dressing following hip fracture surgery.

METHODS AND ANALYSIS

A randomised controlled trial of 464 patients will be run across multiple centres. It is embedded in the World Hip Trauma Evaluation cohort study. Any patient over the age of 65 years having surgery for hip fracture is eligible unless they are being treated with percutaneous screw fixation. A web-based randomisation sequence will stratify patients by centre. Patients will be allocated to either NPWT or standard care on a 1:1 basis. The primary outcome measure is the Centre for Disease Control definition of deep infection at 30 days. Follow-up at 4 months will also assess deep infection and the core outcome dataset for hip fractures. This includes health-related quality of life (EQ-5D-5L), mobility, mortality and late complications such as further surgery. The primary analysis will be intention to treat.

ETHICS AND DISSEMINATION

Oxford C Research Ethics Committee granted ethical approval on 28/04/2017, 17/SC/0207. The results of this study will be reported in a peer-reviewed publication and inform the design of a future full-scale trial.

TRIAL REGISTRATION NUMBER

ISRCTN55305726.

Proposed treatment pathway for the management of incisions

Assessment of patients and their surgical risk is at the discretion of the clinician. There may be patients who present with two or less risk factors, such as a lower BMI, but are still suitable for NPWT incision management.

Hyperbaric oxygen therapy as adjuvant for treating wound complications after extensive resection for vulvar malignancy

INTRODUCTION

Necrosis, wound breakdown, and infection represent major complications associated with radical vulvectomy. We aimed to analyze the feasibility of hyperbaric oxygen (HBO₂) therapy as an adjunctive treatment for such complications.

METHODS

We performed a retrospective analysis of the medical records, clinical charts, and operative records of vulvar cancer patients who underwent hyperbaric oxygen therapy after extensive surgical resection in our institute between 2012 and 2016, with a comparison of the clinical outcomes of patients with similar surgical procedures andsevere wound complications who did not undergo HBO₂.

RESULTS

A total of 16 patients were included in the study. In the subgroup treated with HBO₂, seven patients were identified. Two patients had primary surgery, while five had recurrent surgery (of these, two had previously undergone radiation therapy). Six patients received reconstructive flaps (five myocutaneous and onefasciocutaneous), while one patient had primary suture. Dehiscence, ischemia and necrosis were estimated to cover 30%-80% of the surgical surface area. Surgical debridement was performed in six patients. Daily 90-minute sessions in the hyperbaric chamber were performed at a pressure of 2.2 atmospheres absolute, with partial oxygen pressure of 1672 mbar. Infection control and satisfactory healing were achieved using 10-61 sessions. All patients in the subgroup who did not receive HBO₂ required surgical debridement due to partial or near-total flap necrosis, with two reconstructive interventions required.

CONCLUSIONS

Hyperbaric oxygen therapy was an efficient adjuvant for wound healing and infection control in managing wound complications after extensive vulvar resections.

Negative pressure treatment for improvement of surgical wounds after circumferential thigh lift

BACKGROUND

The circumferential thigh lift (CTL) with vertical scar is a more extensive and effective procedure compared to the traditional lift, but the scar is not aequally concealed. Negative pressure treatment (NPT) is considered to have a beneficial effect on the physiological process of wound healing and early scar formation. A comparison study was therefore carried out in order to evaluate the effect of NPT on scar quality.

METHODS

All postobese patients consecutively treated for thigh laxity in the period January 2012 to April 2013 were recruited in a prospective cohort study. All patients underwent CTL. In group A, NPT was applied on the sutured wound in the immediate postoperative phase for a period of one week. In Group B traditional dressings were used. The quality of scars was evaluated by means of the Stony Brook Scar Evaluation Scale (SBSES) at 7, 15, 30 and 365 days postoperatively.

RESULTS

91 patients were included in the period defined, of whom 48 in group A and 43 in group B. In group A, the mean SBSES score was 4.4 at 7 days, 4 at 15 days, 4.6 at 30 days and 4.8 at 365 days. In group B the SBSES score was 3.2 at 7 days, 3 at 15 days, 3 at 30 and 365 days. At all postoperative stages the quality of the scar showed to be significantly improved by the use of NPT (p<0.05).

CONCLUSIONS

NPT is a useful adjunct to the postoperative wound healing after circumferential thigh lift, when compared to a hostile cohort of patients whose wounds are not treated with NPT.

KEY WORDS

Thigh lift, Negative Pressure Therapy.

Developing outcome measures assessing wound management and patient experience: a mixed methods study

OBJECTIVES

To develop outcome measures to assess practical management of primary surgical wounds and patient experience.

DESIGN

Mixed methods, including qualitative interviews and data extraction from published randomised controlled trials (RCTs).

SETTING

Two university-teaching NHS hospitals and three district NHS hospitals in the South West and Midlands regions of England.

PARTICIPANTS

Sixty-four patients and 15 healthcare professionals from abdominal general surgical specialities and obstetrics (caesarean section).

METHODS

Measures were developed according to standard guidelines to identify issues relevant to patients' experiences of surgical wounds and dressings, including analysis of existing RCT outcomes and semi-structured interviews. These were written into provisional questionnaire items for a single outcome measure. Cognitive interviews with patients and healthcare professionals assessed face validity, acceptability and relevance. Findings from interviews were regularly shared with the study team who suggested amendments to modify and reword items to improve understanding before further iterative testing with patients and healthcare professionals.

RESULTS

Analyses of existing RCT outcomes and interviews produced a total of 69 issues. Pretesting and iterative revision established the need for two separate measures. One measure addresses healthcare professionals' experience of wound management in two key areas: exudate and its impact, and allergic reactions to the dressing. The other measure addresses patients' experience of wounds in seven key areas: wound comfort, dressing removal, dressings to protect the wound, impact on daily activities, ease of movement, anxiety about the wound and satisfaction with dressing. Each measure took less than five min to complete and both were understood and acceptable to patients and healthcare professionals.

CONCLUSION

This in-depth study has developed two measures to assess practical management of primary surgical wounds and patient experience. Further work to test their validity, reliability and application to other settings is now required.

TRIAL REGISTRATION NUMBER

HTA - 12/200/04; Pre-results.

Skin graft donor site: a procedure for a faster healing

BACKGROUND

The authors want to evaluate the efficacy of fibrillary tabotamp dressing in skin graft-donor site. A comparison was made with Vaseline gauzes. Tabotamp is an absorbable haemostatic product of Ethicon (Johnson and Johnson) obtained by sterile and oxidized regenerated cellulose (Rayon). It is used for mild to moderate bleeding.

MATERIALS AND METHODS

276 patients were subject to skin graft and divided into two group: Group A and Group B. The donor site of patients in Group A was medicated with fibrillary tabotamp, while the patients of Group B were medicated only with Vaseline gauze. We recorded infection, timing of healing, number of dressing change, the pain felt during and after the dressing change with visual analog scale (VAS) and a questionnaire.

RESULTS

Patients allocated in Group A healed faster than the Group B. Questionnaires and VAS analysis showed lower pain felt, lower intake of pain drugs and lower infection rate in the Group A than the Group B. Analysis of coast showed lower dressing change in Group A than the Group B.

CONCLUSION

We believe that the use of tabotamp is a very viable alternative to improve healing.

Tumor potential in rat wounds after short- and long-term administration of platelet-rich plasma

Platelet-rich plasma (PRP) has been recognized as an effective strategy for tissue regeneration, how-ever, the safety of PRP in wound healing in terms of tumorigenicity has not yet been addressed. Therefore, the aim of this study was to examine the impact of PRP administration on the expression of the inflammatory marker, tenascin-C (TnC) and the myofibroblast markers, α-smooth muscle actin (α-SMA) and vimentin. The immune suppressive response was examined by determining the level of forkhead box protein 3 (Foxp3). PRP was administered for both long-term (two times weekly for four weeks) and short-term (for the fourth week only) post-wounding. Collagen I (col1) and lysyl oxidase (LOX) were used to indicate complete healing, after which any increase in the myofibroblast or in the inflammatory markers would suggest tumor potential. Collagen III (col3), a marker for granulation tissue, was used to remark non-healing. Quantitative real-time reverse transcriptase polymerase chain reaction (QRT-PCR) and Western blot showed that after long-term administration of PRP, the expression of TnC, α-SMA and vimentin was barely detected, while being markedly expressed in the wounded non-treated group and in the short-term administration group. Moreover, the active expression of α-SMA in the two groups was associated positively with the expression of col3 and negatively with the expression of col1. The low expression of Foxp3 after short-term administration relative to the control group indicated active immunity against tumor development. In conclusion, these findings indicate that PRP can be safely used in short- and long-term administration without tumorigenesis concern.

A mixed-methods feasibility and external pilot study to inform a large pragmatic randomised controlled trial of the effects of surgical wound dressing strategies on surgical site infections (Bluebelle Phase B): study protocol for a randomised controlled trial

BACKGROUND

Surgical site infections (SSIs) are common, occurring in up to 25% of > 4 million operations performed in England each year. Previous trials of the effect of wound dressings on the risk of developing a SSI are of poor quality and underpowered.

METHODS/DESIGN

This study is a feasibility and pilot trial to examine the feasibility of a full trial that will compare simple dressings, no dressing and tissue-glue as a dressing. It is examining the overall acceptability of trial participation, identifying opportunities for refinement, testing the feasibility of and validating new outcome tools to assess SSI, wound management issues and patients' wound symptom experiences. It is also exploring methods for avoiding performance bias and blinding outcome assessors by testing the feasibility of collecting wound photographs taken in theatre immediately after wound closure and, at 4-8 weeks after surgery, taken by participants themselves or their carers. Finally, it is identifying the main cost drivers for an economic evaluation of dressing types. Integrated qualitative research is exploring acceptability and reasons for non-adherence to allocation. Adults undergoing primary elective or unplanned abdominal general surgery or Caesarean section are eligible. The main exclusion criteria are abdominal or other major surgery less than three months before the index operation or contraindication to dressing allocation. The trial is scheduled to recruit for nine months. The findings will be used to inform the design of a main trial.

DISCUSSION

This pilot trial is the first pragmatic study to randomise participants to no dressing or tissue-glue as a dressing versus a simple dressing. Early evidence from the ongoing pilot shows that recruitment is proceeding well and that the interventions are acceptable to participants. Combined with the qualitative findings, the findings will inform whether a main, large trial is feasible and, if so, how it should be designed.

TRIAL REGISTRATION

ISRCTN49328913 . Registered on 20 October 2015.

[Effects of Electroacupuncture on Activities of Satellite Glial Cells of Dorsal Root Ganglia in Rats with Neck Incision Pain]

OBJECTIVE

To observe the effect of electroacupuncture (EA) stimulation of "Futu"(LI 18), etc. on activities of satellite glial cells (SGCs) in the dorsal root ganglia (DRG) in rats with neck-incision pain so as to explore its mechanism underlying reduction of post-surgical pain of thyroidectomy.

METHODS

Male SD rats were randomly divided into control, model, EA-Futu (LI 18), EA-Hegu (LI 4)-Neiguan (PC 6), and EA-Zusanli (ST 36)-Yanglingquan (GB 34) groups, with 20 rats in each group. The neck-incision pain model was established by making a longitudinal incision and repeated mechanical stimulation. In the EA-LI 18, EA-LI 4-PC 6 and EA-ST 36-GB 34 groups, EA stimulation was administrated for 30 min, once a day,continuously for 3 days. The thermal pain threshold (PT) of the neck-incision region was detected. The immunoactivity of glial fibrillary acidic protein (GFAP,a specific marker for SGCs) and connexin 43 (Cx 43) of DRGs (C 2-C 6) was determined by fluorescent immunohistochemistry. The expression levels of GFAP, IL-1 β, IL-6, and TNF-α mRNAs were determined by quantitative Real-time PCR, and the contents of IL-1 β,IL-6,TNF-α assayed by enzyme linked immunosorbent assay (ELISA) and the expression of Cx 43 protein was detected by Western blot.

RESULTS

After EA intervention at LI 18 and LI 4-PC 6 (but not ST 36-GB 34), neck incision-induced reduction of the thermal PT was obviously prolonged in comparison with the model group (P<0.05),suggesting a pain relief. The expression levels of GFAP, IL-1 β, IL-6 and TNF-α mRNAs and Cx 43 protein, and the contents of IL-1 β, IL-6 and TNF-α in C 2-C 6 DRGs were all significantly up-regulated in the model group relevant to those of the control group (P<0.05). Following EA, modeling induced dramatic increase of expression of GFAP, IL-1 β, IL-6 and TNF-α mRNAs and Cx 43 protein in both EA-LI 18 and EA-LI 4-PC 6 groups, and the contents of IL-1 β and TNF-α in the EA-LI 18 group, IL-6 in the EA-LI 4-PC 6 group was considerably down-regulated (P<0.05). In comparison with the model group, no significant changes were found in all the abovementioned indexes of EA-ST 36 -GB 34 group except the down-regulated IL-1 β and TNF-α mRNAs, in the contents of IL-1 β and TNF-α of the EA-LI 4-PC 6 group, and in the IL-6 content of the EA-LI 18 group (P>0.05).

CONCLUSIONS

EA stimulation of LI 18 and LI 4-PC 6 can significantly suppress pain reaction of neck incision in the rat, which is closely associated with its effects in down-regulating the activity of SGCs, decreasing the release of pro-inflammatory cytokines and in weakening the expression of Cx 43 in the cervical DRGs.

[Application of multimodal analgesia in radical gastrectomy for gastric cancer patients: a prospective nonrandomized controlled study]

OBJECTIVE

To compare the postoperative analgesia efficacy, rehabilitation parameters and complication between multimodal analgesia and traditional analgesia after radical gastrectomy for gastric cancer patients.

METHODS

Patients with gastric cancer who underwent surgery in our hospital from October 2016 to December 2016 were enrolled in this prospective study. According to the non-randomized method, patients were assigned to multimodal analgesia group(n=32) and traditional analgesia group(n=33) in gastric cancer treatment team A and B in Department of Gastrointestinal Surgery, West China Hospital, Sichuan University. The treatment measures of group A were as follows: (1) The ratio of 1/1 diluted ropivacaine (100 mg, 10 ml) was infiltrated around the incision before abdomen closure, with incision sutured layer by layer. (2) Parecoxib sodium (40 mg) was injected intravenously every 12 hours after operation for 5 days. (3) Oxycodone-acetaminophen tablet was given orally on the first day or the second day after operation, 50 mg twice a day. (4) Patient-controlled analgesia was not used after operation. Patients in group B received direct suture of incision and patient-controlled analgesia. The pain score, postoperative rehabilitation and 30-day postoperative complications were collected and analyzed.

RESULTS

Multimodal analgesia group had lower pain scores at 1 d (4.8±0.9), 2 d (4.3±1.0), 3 d (2.9±0.8), 4 d (2.4±0.7) and 5 d (1.7±0.7) after surgery, as compared to traditional analgesia group (5.9±0.9, P=0.000), (5.1±0.7, P=0.001), (3.9±0.8, P=0.000), (3.0±0.6, P=0.000), (2.6±0.7, P=0.000), with significant difference. Postoperative hospital stay [(8.2±1.6) days vs. (10.6±2.2) days, P=0.000], time to ambulation [(47.5±13.8) days vs. (66.2±16.8) days, P=0.000], time to first flatus [(76.4±25.2) days vs. (120.0±29.9) days, P=0.000], time to first defecate [(117.3±42.2) days vs. (159.7±30.7) days, P=0.000] and time to first fluid diet [(83.8±21.6) days vs. (141.9±33.9) days, P=0.000] in the multimodal analgesia group were significantly shorter than those in the traditional analgesia group. There was no significant difference between the two groups with respect to 30-day postoperative complication rate(9.4% vs. 9.1%, P=1.000).

CONCLUSIONS

Multimodal analgesia can significantly reduce the postoperative pain and is beneficial to rehabilitation, meanwhile it does not increase the risk of postoperative complications. Multimodal analgesia is safe and effective for gastric cancer patients undergoing radical gastrectomy.

Comparison of nanoparticular hydroxyapatite pastes of different particle content and size in a novel scapula defect model

Nanocrystalline hydroxyapatite (HA) has good biocompatibility and the potential to support bone formation. It represents a promising alternative to autologous bone grafting, which is considered the current gold standard for the treatment of low weight bearing bone defects. The purpose of this study was to compare three bone substitute pastes of different HA content and particle size with autologous bone and empty defects, at two time points (6 and 12 months) in an ovine scapula drillhole model using micro-CT, histology and histomorphometry evaluation. The nHA-LC (38% HA content) paste supported bone formation with a high defect bridging-rate. Compared to nHA-LC, Ostim® (35% HA content) showed less and smaller particle agglomerates but also a reduced defect bridging-rate due to its fast degradation The highly concentrated nHA-HC paste (48% HA content) formed oversized particle agglomerates which supported the defect bridging but left little space for bone formation in the defect site. Interestingly, the gold standard treatment of the defect site with autologous bone tissue did not improve bone formation or defect bridging compared to the empty control. We concluded that the material resorption and bone formation was highly impacted by the particle-specific agglomeration behaviour in this study.

Dressing Wear Time after Breast Reconstruction: A Randomized Clinical Trial

Background

The evidence to support dressing standards for breast surgery wounds is empiric and scarce.

Objective

This two-arm randomized clinical trial was designed to assess the effect of dressing wear time on surgical site infection (SSI) rates, skin colonization and patient perceptions.

Methods

A total of 200 breast cancer patients undergoing breast reconstruction were prospectively enrolled. Patients were randomly allocated to group I (dressing removed on the first postoperative day, n = 100) or group II (dressing removed on the sixth postoperative day, n = 100). SSIs were defined and classified according to criteria from the Centers for Disease Control and Prevention. Samples collected before placing the dressing and after 1 day (group I) and 6 days (both groups) were cultured for skin colonization assessments. Patients preferences and perceptions with regard to safety, comfort and convenience were recorded and analyzed.

Results

A total of 186 patients completed the follow-up. The global SSI rate was 4.5%. Six patients in group I and three in group II had SSI (p = 0.497). Before dressing, the groups were similar with regard to skin colonization. At the sixth day, there was a higher colonization by coagulase-negative staphylococci in group I (p<0.0001). Patients preferred to keep dressing for six days (p<0.0001), and considered this a safer choice (p<0.05).

Conclusions

Despite group I had a higher skin colonization by coagulase-negative staphylococci on the sixth postoperative day, there was no difference in SSI rates. Patients preferred keeping dressing for six days and considered it a safer choice.

Trial Registration

ClinicalTrials.gov NCT01148823

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

[Effect of Electroacupuncture Intervention on β-endorphin Levels of Hypothalamus and Spinal Cord Tissues in Rats with Pelmatic Incisional Pain]

OBJECTIVE

To observe the effect of electroacupuncture (EA) intervention on pain thresholds (PT) and contents of β-endorphin (EP) in the hypothalamus and spinal cord, and the expression of 5-HT in the dorsal raphe nucleus(DRN)in rats with pelmatic incisional pain, so as to investigate the underlying mechanisms of acupuncture in reducing post-operative pain.

METHODS

Wistar rats were randomized into normal control, model, EA and non-acupoint groups (n=8/group). The pelmatic pain model was induced by making an incision (about 1 cm in length, to the fascia and muscle layers) from the heel towards the toes. EA (2 Hz, 1.5-2 V) was applied to "Zusanli" (ST 36) and "Kunlun" (BL 60) or non-acupoint (about 3 mm beside the ST 36 and BL 60) on the affected side for 20 min, once daily for three days. The thermal PT and mechanical PT were measured before and after operation and after EA. The contents of β-EP in hypothalamus and L₃-S₄ spinal cord were detected using enzyme linked immunosorbent assay (ELISA) and the expressions of β-EP in hypothalamus and 5-HT in DRN were measured with immunohistochemistry.

RESULTS

After EA intervention, the markedly decreased mechanical and thermal pain thresholds on day 1 and 3 after paw incision were significantly increased in the EA group (P<0.05), but not in the non-acupoint group (P>0.05). The hypothalamic β-EP content was significantly higher in the model group than in the normal group (P<0.05), and further up-regulated in the EA group (not the non-acupoint group) than in the model group (P<0.05). In addition, the hypothalamic β-EP immunoreactive (IR)-positive cell number and 5-HT immunoactivity level in DRN were also considerably up-regulated in the EA group (P<0.05) but not in the non-acupoint group (P>0.05). No significant changes were found in the lumbar spinal β-EP contents in the model, EA and non-acupoint groups (P>0.05).

CONCLUSIONS

EA stimulation of "Zusanli"(ST 36) and "Kunlun" (BL 60) has an analgesic effect in pelmatic incision pain rats, which may be related to its effects in raising the level of hypothalamic β-EP and the expression of 5-HT in DRN.

Management of nipple-areolar complex complications in skin-sparing mastectomy with prosthetic reconstruction A case report

INTRODUCTION AND OBJECCTIVES

Venous congestion of the NAC (Nipple-Areola Complex) is not an uncommon complication of Skin-Reducing Mastectomy (SRM). The correct and prompt evaluation of the NAC's vitality in the first hours after surgery is important for the survival of the same, in fact the possibility of early intervention allows avoiding the use of invasive and radicals techniques to the advantage of simpler rapid procedures.

MATERIALS AND METHODS

DM, 57yr, multiple invasive ductal carcinoma of the right breast, underwent a SRM and immediate reconstruction with implant in August 2014 In the immediate post-operative appeared a venous stasis of the NAC. Treatment started with Negative Pressure Wound Therapy (NWPT) through VAC-Systems to 75 mmHg.

RESULTS

The use of the VAC-Therapy was in total 12 days and allowed the partial rescue of the NAC (85%). the vacuum pump is put into a portable bag so the patient's mobility is not limited.

DISCUSSION

NWPT permitted a rapid resolution of NAC's complication in SRM in order to guarantee an optimal timing for the start of adjuvant chemotherapy. The VAC-Therapy is a cost effective and simple to use in cases of suffering venous NAC in patients undergoing breast surgery.

KEY WORDS

NAC, NWPT, Skin-Reducing Mastectomy, VAC-Therapy.

[POSSIBILITIES OF THE AUTOLIPOTRANSPLANTS APPLICATION IN REGENERATION OF DEFECTS OF CARTILAGE TISSUES AND ITS PRELAMINATION]

Possibilities of stimulation of the cartilage tissue regenerative properties in damage, using autolipofilling, were studied.The experimental investigations data witnesses efficacy of cartilage restoration while application of the method proposed. The data obtained are forcing for further investigation on possibilities of the cartilage tissue regeneration, using autolipotransplants.