Nutrition and wound healing

Gastrointestinal Surgical Patient and Multidisciplinary Healthcare Provider Beliefs and Practices Around Perioperative Nutrition: A Mixed-Methods Study

INTRODUCTION

Nutrition is critical to gastrointestinal (GI) disease prevention and treatment, including operations, yet perioperative nutrition practices vary widely. We aimed to understand GI surgical patient and health care provider's perioperative nutrition beliefs and practices.

MATERIALS AND METHODS

We used a mixed-methods approach, including a patient survey (n = 19), provider survey (n = 26), and semistructured interviews with a subset of providers (n = 15). Providers included surgeons, gastroenterologists, medical oncologists, advanced practice providers, and dietitians. Provider interviews were transcribed, iteratively coded, and thematically analyzed. Quantitative and qualitative data were integrated.

RESULTS

94.7% of patients and 100% of providers surveyed believe that nutrition affects outcomes. Patients seek nutrition information from diverse resources (73.7% from websites or blogs, 42.1% from documentaries, and 36.8% from books or /magazines) and people (52.6% from family members, 42.1% from a significant other, partner, or spouse, and 36.8% from a dietitian or nutritionist). Providers cited a lack of quality information, misinformation, and inconsistency among health care providers as barriers to high-quality nutrition care. Both patients and providers noted that nutritional supplements have drawbacks, with 100% of patients and 96.2% of providers expressing interest in house- made plant-based protein smoothie or soup alternatives.

CONCLUSIONS

This study led to the development of a multidisciplinary task force, which has collaborated on multiple interventions to improve inpatient perioperative surgical nutrition (e.g., smoothie pilot and postoperative menu revisions).

Wound healing and pain sensitivity following caustic paste disbudding in dairy calves

Caustic paste disbudding is increasing in popularity on commercial dairy farms in the United States, but little research has explored the pain and welfare implications beyond the acute period of this procedure. In contrast, researchers have reported it takes 7 to 9 wk, on average, for hot-iron disbudding wounds to re-epithelialize in dairy calves. Our objective was to describe wound healing and sensitivity following caustic paste disbudding. Jersey and Holstein female calves were disbudded using caustic paste (H. W. Naylor Company Inc.) at 3 d of age (n = 18), and control calves received a sham procedure (n = 15). Before disbudding, calves received a local block and a nonsteroidal anti-inflammatory drug. Calves ≥34 kg and <34 kg at birth had 0.3 or 0.25 mL of paste applied per unshaved horn bud, respectively. Following disbudding, wounds were scored 2×/wk for the presence or absence of 8 tissue categories, including the final stages: new epithelium and fully healed. Control calves were removed from the experiment after 6 wk to be hot-iron disbudded. Mechanical nociceptive threshold (MNT) measures were collected weekly to evaluate wound sensitivity until calves were removed from the study or healed. Wounds were slow to re-epithelialize (16.2 ± 5.7 wk, mean ± SD; range: 6.2-32.5 wk) and contract to be considered fully healed (18.8 ± 6 wk, mean ± SD; range: 8.7-34.1 wk). Compared with non-disbudded controls, paste calves exhibited lower MNT values for all 6 wk (mean ± SE; control: 1.46 ± 0.16; paste: 1.18 ± 0.12 N). These data indicate that wounds from caustic paste disbudding are more sensitive than undamaged tissue for at least 6 wk and take twice as long to heal compared with cautery methods described in the literature. In conclusion, caustic paste disbudding wounds took 18.8 wk to fully heal and were more sensitive than intact horn buds for 6 wk. Future work should examine whether aspects of paste application (e.g., amount used, time rubbed in, calf age, pain mitigation) could improve healing time and sensitivity.

Changes in nutritional status of patients with jaw deformities due to orthognathic surgery

OBJECTIVE

In orthognathic surgery, it is important to carefully manage peri-operative nutrition because maxillomandibular fixation and problems such as swelling and pain after surgery may make it difficult to eat normally and may prevent adequate nutrition. This study investigated the changes in nutritional status of patients with jaw deformities due to orthognathic surgery.

STUDY DESIGN

The subjects were 155 jaw deformity patients, who underwent orthognathic surgery. The nutritional status was evaluated using anthropometry immediately before and 10 days after surgery and clinical laboratory results and the controlling nutritional status (CONUT) score before surgery and immediately, 1 week and >6 months after surgery. We investigated the relationship among the nutritional status, surgical procedures, and dietary intake in patients who underwent orthognathic surgery.

RESULTS

The surgical procedure time and amount of bleeding were significantly greater as the surgical procedure became more complex. All of the laboratory values and CONUT scores were significantly decreased immediately after surgery and then increased over time, recovering to the same level as before surgery except for serum albumin at >6 months after surgery.

CONCLUSIONS

Nutritional management is considered as one of the key factors for the better and faster recovery after the orthognathic surgery.

Hot spring bathing accelerates wound healing and enhances heat retention effect in guinea pigs

This study aimed to demonstrate the effects of hot springs on wound healing and heat retention by performing comparative experiments with tap water. The hot spring water used in this study was from an alkaline hot spring that was rich in sodium and chloride ions and exhibited high reducibility. Guinea pigs were divided into a hot spring bathing group and a tap water bathing group, and a bathing test was conducted for eight consecutive days. A comparison of the plasma amino acid composition between the two groups after the bathing test revealed differences in the concentrations of several amino acids associated with wound healing. Image analysis demonstrated that wounds made on the abdominal skin of guinea pigs were significantly contracted by hot spring bathing compared to that by tap water bathing, and histopathological findings showed that wound healing was accelerated. In the thermography test, changes in body surface temperature after bathing were investigated in both groups. The heat retention effect was not observed in the tap water bathing group after bathing, whereas it was enhanced in the hot spring bathing group until 30 min after bathing. In conclusion, this study demonstrated that hot spring bathing accelerates wound healing and has a more significant heat retention effect than tap water bathing.

Applications of Electrospun Drug-Eluting Nanofibers in Wound Healing: Current and Future Perspectives

Wounds are a consequence of disruption in the structure, integrity, or function of the skin or tissue. Once a wound is formed following mechanical or chemical damage, the process of wound healing is initiated, which involves a series of chemical signaling and cellular mechanisms that lead to regeneration and/or repair. Disruption in the healing process may result in complications; therefore, interventions to accelerate wound healing are essential. In addition to mechanical support provided by sutures and traditional wound dressings, therapeutic agents play a major role in accelerating wound healing. The medicines known to improve the rate and extent of wound healing include antibacterial, anti-inflammatory, and proliferation enhancing agents. Nonetheless, the development of these agents into eluting nanofibers presents the possibility of fabricating wound dressings and sutures that provide mechanical support with the added advantage of local delivery of therapeutic agents to the site of injury. Herein, the process of wound healing, complications of wound healing, and current practices in wound healing acceleration are highlighted. Furthermore, the potential role of drug-eluting nanofibers in wound management is discussed, and lastly, the economic implications of wounds as well as future perspectives in applying fiber electrospinning in the design of wound dressings and sutures are considered and reported.

Effect of plane of nutrition and analgesic drug treatment on wound healing and pain following cautery disbudding in preweaning dairy calves

The objective of this study was to determine the effect of a biologically normal plane of nutrition compared with a limited plane on the primary outcome wound healing, and one dose of nonsteroidal anti-inflammatory drug (NSAID) compared with 2 on the secondary outcomes: lying behavior, haptoglobin concentrations, and mechanical nociceptive threshold (MNT) in calves disbudded via cautery iron. Eighty female Holstein calves were enrolled at birth, individually housed, and fed via a Calf Rail system (Förster Technik). A 2 × 2 factorial design was used to assess the effect of plane of nutrition and an additional NSAID. Calves were randomly assigned to a biologically normal plane of nutrition (BN; offered up to 15 L/d) or a limited plane (LP; offered up to 6 L/d) and to receive one or 2 doses of meloxicam. All calves received a lidocaine cornual nerve block and a subcutaneous injection of meloxicam 15 min before cautery disbudding at 18 to 25 d of age, and half the calves received an additional injection of meloxicam (0.5 mg/kg) 3 d after disbudding. Tissue type present, wound diameter, and wound depth were evaluated 2 times per week for 7 to 8 wk as measures of wound healing, lying behavior was recorded beginning 1 to 2 wk before disbudding until 7 to 8 wk after as a behavioral indicator of pain, haptoglobin concentrations were measured once per day for 7 d after disbudding, and MNT was evaluated 2 times/wk for 3 wk. Survival analyses were analyzed using Cox regression models (wound healing) and continuous data were analyzed using mixed-effect linear regression models. Only 12% of horn buds were completely healed by 7 to 8 wk after disbudding and 54% had re-epithelized at this time. At any time, wounds from BN calves were more likely to have had re-epithelization occur compared with wounds from LP calves (hazard ratio: 1.93, 95% CI: 1.18-3.14). Wounds from calves that received only one dose of NSAID were more likely to have re-epithelization occur, compared with wounds from calves given 2 doses (hazard ratio: 1.87, 95% CI: 1.15-3.05). Wounds from BN calves had smaller diameters and depths over time beginning on wk 3 compared with LP calves. Wounds from calves that received an additional NSAID had larger diameters and depths over time beginning on wk 4 and 3 respectively, compared with calves that only received one dose of NSAID. Calves that received an extra NSAID tended to be less sensitive 7, 10, and 17 d after disbudding compared with calves that only received one dose and spent less time lying in the week after disbudding. Calves on the BN milk program were more active compared with LP calves with lower lying times, fewer lying bouts per day, and longer average lying bouts. Our results indicate that a BN milk feeding program for calves can result in faster healing times and more activity, and that providing an extra NSAID 3 d after disbudding appears to slow the healing process but may result in less pain experienced by the calf 1 to 2 wk after the procedure. This study is also among the first to demonstrate that after the complete removal of the horn bud, wounds can take more than 8 weeks to re-epithelize and fully heal.

IoT-Enabled Integrated Smart Wound Sensor for Multiplexed Monitoring of Inflammatory Biomarkers at the Wound Site

Chronic wounds that stall at the inflammatory phase of healing may create several life-threatening complications such as tissue damage, septicemia, and organ failures. In order to prevent these adverse clinical outcomes and accelerate the wound healing process, it is crucial to monitor the wound status in real-time so that immediate therapeutic interventions can be implemented. In addition, continuous monitoring of the wound status can prevent drug overdose at the wound site, leading to on-demand and personalized drug delivery. Inflammatory mediators, such as Interleukin-6 (IL-6) and Interleukin-10 (IL-10) are promising indicators for the progression of wound healing and predictors of disease severity. Toward this end, this work reports a flexible wound patch for multiplexed monitoring of IL-6 and IL-10 at the wound site in order to provide real-time feedback on the inflammation phase of the wound. An optimized composition of gold nanoparticles integrated multiwalled carbon nanotube was demonstrated to improve sensor performance substantially. The sensor also exhibited excellent repeatable, reversible, and drift characteristics. A miniaturized Internet-of-things (IoT)-enabled potentiostat was also developed and integrated with the flexible sensor to realize a wearable system. This IoT-enabled wearable device provides a smart and cost-effective solution to improving the existing wound care through continuous, real-time, and in-situ monitoring of multiple wound biomarkers.

Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach

BACKGROUND

This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population.

METHODS

Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center.

RESULTS

An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center.

CONCLUSIONS

Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.

A Systematic Review of Oral Nutritional Supplement and Wound Healing

OBJECTIVE

To explore the current literature for effects of oral nutritional supplement on wound healing rates in humans.

METHODS

A systematic review of the literature was performed using the Medline and PubMed database following PRISMA guidelines. The PubMed database was searched using terms relating to oral nutritional supplement and wound healing from 1837 to March 2020. Study inclusion criteria were: (i) design: randomized controlled trials, clinical studies, observational studies, clinical trials; (ii) population: adults; and (iii) intervention: oral nutritional supplement.

RESULTS

The search yielded 2433 studies, 313 of which were clinical trials or clinical studies. After abstract review, 28 studies qualified to be included in the review evaluating the following supplementation categories on wound healing: protein and amino acids (10), mineral, vitamin and antioxidants (9), probiotics (1), and mixed nutrients (8). Arginine and omega-3 supplement were shown to improve wound healing in head and neck cancer patients with surgical wounds by decreasing incidence of postoperative complications and reducing length of hospital stay. Mineral, vitamins, and antioxidants enriched supplements were more beneficial in increasing wound healing than non-enriched protein supplement for diabetic foot and pressure ulcers.

CONCLUSIONS

Supplementation of a variety of nutrients had variable effects on improving wound healing in different types of wounds. However, further research on the impact of nutritional supplements on surgical wound healing is necessary. The impact of multiple nutrient formulations may also need to be further evaluated for efficacy.

A Review of Recent Advances in Flexible Wearable Sensors for Wound Detection Based on Optical and Electrical Sensing

Chronic wounds that are difficult to heal can cause persistent physical pain and significant medical costs for millions of patients each year. However, traditional wound care methods based on passive bandages cannot accurately assess the wound and may cause secondary damage during frequent replacement. With advances in materials science and smart sensing technology, flexible wearable sensors for wound condition assessment have been developed that can accurately detect physiological markers in wounds and provide the necessary information for treatment decisions. The sensors can implement the sensing of biochemical markers and physical parameters that can reflect the infection and healing process of the wound, as well as transmit vital physiological information to the mobile device through optical or electrical signals. Most reviews focused on the applicability of flexible composites in the wound environment or drug delivery devices. This paper summarizes typical biochemical markers and physical parameters in wounds and their physiological significance, reviews recent advances in flexible wearable sensors for wound detection based on optical and electrical sensing principles in the last 5 years, and discusses the challenges faced and future development. This paper provides a comprehensive overview for researchers in the development of flexible wearable sensors for wound detection.

Nutrition and cutaneous wound healing

Wound healing is a complex and energy-demanding process. The relationship between nutrition and wound healing has been recognized for many centuries. Several studies have indicated that nutritional deficiencies are more prevalent among patients with chronic wounds. Malnutrition may alter the inflammatory response, collagen synthesis, and wound tensile strength, all of which are crucial for wound healing. Although the specific role of nutrition and supplementation in wound care remains uncertain, it is necessary to identify and correct nutritional imbalances to avoid any potential deterioration of the healing process. It is also important to recognize the differences in pathophysiology between acute and chronic wounds. A burn, surgical, or a traumatic wound is different from a diabetic foot ulcer, which is different from a pressure ulcer. Chronic wounds are more prevalent in the aging population, and patients often have underlying comorbidities, such as diabetes mellitus, peripheral vascular disease, connective tissue disease, or other systemic illnesses that may alter energy metabolism and contribute to impaired healing. Management approaches to acute wound care may not apply universally to chronic wounds. In this review, we discuss the available data and possible roles for nutrition in wound healing.

Wound healing in animals: a review of physiology and clinical evaluation

Wound healing is a complicated process consisting of overlapping phases directed and regulated by many mediators of healing produced locally at the wound. The end goal of wound healing is the production of tissue at the site of injury which has a similar structure and provides protection to the body. Any alterations in the normal healing process can lead to delayed healing or additional tissue damage. Factors that contribute to aberrant wound healing can be species-specific and include both intrinsic (systemic) factors and extrinsic (environmental) factors. Management of wounds and recognition of alterations can be optimised by adoption of a structured framework for wound assessment, such as the TIME principle (acronym referring to the following categories: tissue, inflammation or infection, moisture, and edge of wound or epithelial advancement). This review article provides an overview of the phases of wound healing, variation of healing among different species, factors reported to delay healing, and an introduction to the TIME principle as a structured approach to clinical evaluation of wounds.

A scoping review to inform a multi-disciplinary approach for nutrition therapy in critically ill children with pressure injuries

Nutrition status plays a critical role in pressure injury (PI) healing and yet the available literature, especially in pediatric patients, is limited. Critically ill pediatric patients are at an increased risk of skin integrity compromise and PI development. Adequate nutritional intake can often be challenging to achieve in this population and immobility and illness present additional obstacles to maintaining skin integrity in this vulnerable population. Despite the unique nutritional challenges and needs of this group, there is no standardized approach to macro- and micronutrient management and monitoring. Here, several key vitamins and minerals believed to play a role in PI healing are discussed and an approach to nutritional management and monitoring for PI healing in pediatric patients is proposed. Registered dietitians (RD) are essential to assess individual patient macro and micronutrient requirements, to identify gaps and make recommendations to optimize nutritional therapy that may exist and impact wound healing. We used a scoping review to focus on the interplay of nutrition and PI healing and inform a multidisciplinary approach to PI identification and management. Through this review, we propose a strategy for the nutritional management of pediatric patients <30 kg at risk for and who present with PI.

NOD1-Targeted Immunonutrition Approaches: On the Way from Disease to Health

Immunonutrition appears as a field with great potential in modern medicine. Since the immune system can trigger serious pathophysiological disorders, it is essential to study and implement a type of nutrition aimed at improving immune system functioning and reinforcing it individually for each patient. In this sense, the nucleotide-binding oligomerization domain-1 (NOD1), one of the members of the pattern recognition receptors (PRRs) family of innate immunity, has been related to numerous pathologies, such as cancer, diabetes, or cardiovascular diseases. NOD1, which is activated by bacterial-derived peptidoglycans, is known to be present in immune cells and to contribute to inflammation and other important pathways, such as fibrosis, upon recognition of its ligands. Since immunonutrition is a significant developing research area with much to discover, we propose NOD1 as a possible target to consider in this field. It is relevant to understand the cellular and molecular mechanisms that modulate the immune system and involve the activation of NOD1 in the context of immunonutrition and associated pathological conditions. Surgical or pharmacological treatments could clearly benefit from the synergy with specific and personalized nutrition that even considers the health status of each subject.

Body Weight Loss After Orthognathic Surgery: Comparison Between Postoperative Intermaxillary Fixation with Metal Wire and Elastic Traction, Factors Related to Body Weight Loss

INTRODUCTION

The aim of this study was to compare body weight loss between postoperative intermaxillary fixation with metal wire and elastic traction and to investigate factors related to body weight loss after orthognathic surgery.

MATERIALS AND METHODS

Subjects were 59 patients with dentofacial deformity, comprising 31 patients treated with intermaxillary fixation (IMF) and 28 patients treated with elastic traction without IMF (ELT) just after surgery. Body weight loss was measured at 1 week (T1) and 2 weeks (T2) after surgery. Body weight loss was compared between IMF and ELT, and factors related to body weight loss were statistically analyzed.

RESULTS

Body weight loss ratio was significantly increased in IMF (2.6%) rather than in ELT (1.4%) at T1, but only tended to be increased in both groups at T2, showing no statistical difference. Body weight loss ratio was significantly increased at T2 compared to T1 in both groups. Body weight loss was significantly greater at T2 than at T1.

CONCLUSION

Both IMF and ELT cause body weight loss after orthognathic surgery, but IMF causes body weight loss earlier than ELT and increased early body weight loss increases continuous body weight loss after orthognathic surgery.

Evidence-Based Perioperative Nutrition Recommendations: Optimizing Results and Minimizing Risks

Plastic surgery patients span the nutritional spectrum from generally healthy, nutritionally competent patients to inherently catabolic, nutritionally deficient, and chronic wound patients. Therefore, plastic and reconstructive surgery affords the opportunity to investigate the impact of nutrition across a heterogeneous patient population following a wide variety of procedures. Although patients may be nutritionally deficient in certain vitamins warranting perioperative repletion, other supplements have the potential to benefit all patients, regardless of nutritional status. Despite these putative benefits, there is a dearth of information regarding nutritional optimization, with the limited, available literature focusing mostly on herbal supplements and their potential side effects. A significant barrier to supplement use is the lack of education and available supporting information regarding the indications, contraindications, and physiology of these adjuncts. The goal of this article is to provide a comprehensive, evidence-based review of available nutritional supplements that can be considered for the plastic surgery patient in the perioperative period to optimize surgical outcomes while minimizing risk. Prospective, well-designed studies using validated, high-quality supplements will be critical in determining the significance that perioperative supplementation can have for surgical outcomes. Until well-done prospective studies are performed, the supplement, dose, and duration should be determined on an individual, patient-per-patient basis at the discretion of the operating surgeon.

Factors related to patients' nutritional state after orthognathic surgery

PURPOSE

The purpose of this study was to evaluate patients' nutritional state after orthognathic surgery.

METHODS

The subjects were 40 female patients with dentofacial deformity aged 17-33 years who were undergoing bilateral sagittal splitting ramus osteotomy. Twenty patients were treated with intermaxillary fixation, and 20 patients were treated without intermaxillary fixation. Age and body mass index (kg/m²) were assessed as physical factors, operation time, blood loss, and amount of mandibular movement with or without intermaxillary fixation were assessed as operation stress factors, and the following laboratory data, total protein, serum albumin, total cholesterol, total lymphocytes, and cholinesterase were assessed as nutritional state factors at 1 and 2 weeks after surgery. Statistical analysis was performed for body weight loss and relationship between body weight loss and examination factors.

RESULTS

Body weight significantly decreased 2.3% at 1 week and 3.9% at 2 weeks after surgery rather than preoperation. All laboratory data except total lymphocyte were decreased at 1 week after surgery and still remained significantly decreased at 2 weeks after surgery. There was a statistically significant relationship between body weight loss at 1 week after surgery and operation time.

CONCLUSIONS

These results indicate that long operation time caused body weight loss in orthognathic surgery.

Surgical Risk Assessment and Prevention in Elderly Spinal Deformity Patients

Introduction:

Prevalence of adult deformity surgery in the elderly individuals continues to increase. These patients have additional considerations for the spine surgeon during surgical planning. We perform an informative review of the spinal and geriatric literature to assess preoperative and intraoperative factors that impact surgical complication occurrences in this population.

Significance:

There is a need to understand surgical risk assessment and prevention in geriatric patients who undergo thoracolumbar adult deformity surgery in order to prevent complications.

Methods:

Searches of relevant biomedical databases were conducted by a medical librarian. Databases searched included MEDLINE, Web of Science, CINAHL, IPA, Cochrane, PQ Health and Medical, SocINDEX, and WHO’s Global Health Library. Search strategies utilized Medical Subject Headings plus text words for extensive coverage of scoliosis and surgical technique concepts.

Results:

Degenerative scoliosis affects 68% of the geriatric population, and the rate of surgical interventions for this pathology continues to increase. Complications following spinal deformity surgery in this patient population range from 37% to 62%. Factors that impact outcomes include age, comorbidities, blood loss, and bone quality. Using these data, we summarize multimodal risk prevention strategies that can be easily implemented by spine surgeons.

Conclusions:

After evaluation of the latest literature on the complications associated with adult deformity surgery in geriatric patients, comprehensive perioperative management is necessary for improved outcomes. Preoperative strategies include assessing physiological age via frailty score, nutritional status, bone quality, dementia/delirium risk, and social activity support. Intraoperative strategies include methods to reduce blood loss and procedural time. Postoperatively, development of a multidisciplinary team approach that encourages early ambulation, decreases opiate use, and ensures supportive discharge planning is imperative for better outcomes for this patient population.

Single-incision laparoscopic ileostomy is a safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection

Purpose

Currently, many operations are performed using the single-incision laparoscopic method. Although there have been recent reports on single-incision laparoscopic ileostomy, none have compared this method to conventional laparoscopic ileostomy. This study aimed to assess the safety and feasibility of single-incision laparoscopic ileostomy for anastomotic leakage following laparoscopic low anterior resections.

Methods

From April 2012 to April 2017, 38 patients underwent laparoscopic ileostomy (single-incision; 19 patients referred to as group A, conventional laparoscopy; 19 patients referred to as group B) for anastomotic leakage following laparoscopic low anterior resection. We analyzed surgical and clinical outcomes between the 2 groups. Patients in whom a protective ileostomy was carried out during the initial laparoscopic low anterior resection were excluded from this study.

Results

No significant differences were observed between the 2 groups in terms of patient demographics and initial operation details. Incisional surgical site infections occurred less in group A than in group B (2 of 19 vs. 9 of 19, P = 0.029). The median ileostomy operation time, amount of intraoperative bleeding, parastomal hernia ratio, hospital stay duration after ileostomy, postoperative pain score were not significantly different between the 2 groups.

Conclusion

Single-incision laparoscopic ileostomy is safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection.

Smart Bandages: The Future of Wound Care

Chronic non-healing wounds are major healthcare challenges that affect a noticeable number of people; they exert a severe financial burden and are the leading cause of limb amputation. Although chronic wounds are locked in a persisting inflamed state, they are dynamic and proper therapy requires identifying abnormalities, administering proper drugs and growth factors, and modulating the conditions of the environment. In this review article, we discuss technologies that have been developed to actively monitor the wound environment. We also highlight drug delivery tools that have been integrated with bandages to facilitate precise temporal and spatial control over drug release and review automated or semi-automated systems that can respond to the wound environment.

Factors Favoring and Impairing Healing of Tracheal Anastomosis

The factors governing successful healing of and impairing of tracheal and bronchial anastomosis are best understood by reviewing the normal histologic changes accompanying healing, governing factors, and biochemical advances made in the last 5 decades. Normal wound healing factors, also relevant to tracheal and bronchial reconstruction, rely on precise handling of tissues without interfering with tissue perfusion, careful selection and placement of sutures, and steps to minimize tension. Impairments of satisfactory healing are well recognized in gastrointestinal surgery and apply to tracheal and carinal resection, and sleeve bronchial resection.

Assessment and management of patients with intestinal failure: a multidisciplinary approach

Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.

The Effects of Local and Systemic Administration of Proline on Wound Healing in Rats

Purpose: Wound healing consists of a sequence of complex molecular and cellular events. Collagen is composed mainly of proline and hydroxyproline. Proline and hydroxyproline constitute 1/3 of the amino acids in collagen, which makes up approximately 30% of the proteins within the body. The hydroxylation of proline found in collagen determines the stability of the triple helical structure of collagen. In this study, we examined the effects of local and systemic administration of proline on wound healing. Materials and Methods: 24 female Sprague-Dawley rats were used in the study and divided into three groups. Group 1: The defect created in the backs of the subjects was left to secondary healing. Group 2: 200 µl proline per day was administered topically for 30 days on the defect in the backs of the subjects. Group 3: 200 µl per day was administered intraperitoneally for 30 days on the defect in the backs of the subjects. Results: On day 21, there was a statistically significant difference between the groups in terms of the mean re-epithelialization score. On days 7 and 14, there was a statistically significant difference between the groups in terms of the mean granulation score. On days 7, 14, and 21, there was a statistically significant difference between the groups in terms of the mean collagen accumulation score. On day 30, there was a statistically significant difference between Groups 1 and 3 in terms of the mean E-mode score on mechanical tensile test. Conclusion: Our study confirmed that proline has positive effects on wound healing. However, it revealed that systemic administration of proline is more effective than local administration of proline.

Scar management in burn injuries using drug delivery and molecular signaling: Current treatments and future directions

In recent decades, there have been tremendous improvements in burn care that have allowed patients to survive severe burn injuries that were once fatal. However, a major limitation of burn care currently is the development of hypertrophic scars in approximately 70% of patients. This significantly decreases the quality of life for patients due to the physical and psychosocial symptoms associated with scarring. Current approaches to manage scarring include surgical techniques and non-surgical methods such as laser therapy, steroid injections, and compression therapy. These treatments are limited in their effectiveness and regularly fail to manage symptoms. As a result, the development of novel treatments that aim to improve outcomes and quality of life is imperative. Drug delivery that targets the molecular cascades of wound healing to attenuate or prevent hypertrophic scarring is a promising approach that has therapeutic potential. In this review, we discuss current treatments for scar management after burn injury, and how drug delivery targeting molecular signaling can lead to new therapeutic strategies.

Evidence-Based Strategies to Reduce Postoperative Complications in Plastic Surgery

Reconstructive plastic surgery is vital in assisting patients with reintegration into society after events such as tumor extirpation, trauma, or infection have left them with a deficit of normal tissue. Apart from performing a technically sound operation, the plastic surgeon must stack the odds in the favor of the patient by optimizing them before and after surgery. The surgeon must look beyond the wound, at the entire patient, and apply fundamental principles of patient optimization. This article reviews the evidence behind the principles of patient optimization that are commonly used in reconstructive surgery patients.

Nutrients and Wound Healing: Still Searching for the Magic Bullet

Clinicians in nearly all practice areas are confronted with the challenges associated with delayed and impaired wound healing. Although nutrition plays a critical role in the healing process, controversy exists regarding the optimal nutrition regimen. This article reviews literature related to nutrition interventions that facilitate wound healing. The limitations of the research that forms the scientific basis of many nutrition recommendations are also examined. The limited availability of rigorously performed clinical studies to develop evidence-based guidelines for nutrition support in wound care emphasizes the need for further research and underscores the importance of individualizing the nutrition care plan for each patient.

The Effects of Dietary Macronutrient Balance on Skin Structure in Aging Male and Female Mice

Nutrition influences skin structure; however, a systematic investigation into how energy and macronutrients (protein, carbohydrate and fat) affects the skin has yet to be conducted. We evaluated the associations between macronutrients, energy intake and skin structure in mice fed 25 experimental diets and a control diet for 15 months using the Geometric Framework, a novel method of nutritional analysis. Skin structure was associated with the ratio of dietary macronutrients eaten, not energy intake, and the nature of the effect differed between the sexes. In males, skin structure was primarily associated with protein intake, whereas in females carbohydrate intake was the primary correlate. In both sexes, the dermis and subcutaneous fat thicknesses were inversely proportional. Subcutaneous fat thickness varied positively with fat intake, due to enlarged adipocytes rather than increased adipocyte number. We therefore demonstrated clear interactions between skin structure and macronutrient intakes, with the associations being sex-specific and dependent on dietary macronutrient balance.

Complications in body contouring stratified according to weight loss method

Background

Body contouring procedures following massive weight loss have become increasingly common and, unfortunately, continue to be associated with a high complication rate.

Objective

To evaluate how weight loss method affects complications following abdominally based body contouring procedures.

Methods

Patients undergoing abdominally based contouring procedures were retrospectively evaluated over an 11-year period and stratified into two groups based on method of weight loss: diet and exercise; or bariatric surgery. Complications, including seroma, wound dehiscence, skin necrosis, infection, hematoma and venous thromboembolism, were included if they required intervention. An adjusted logistic model was used to examine the effect of weight loss method on aggregate complication rates.

Results

A total of 307 patients were included: 77 (25%) lost weight through diet and exercise; and 230 (75%) through bariatric surgery. Results from the logistic model showed no difference in complication rates between weight loss methods (OR 1.01 [95% CI 0.51 to 2.02]). However, there was a strong correlation between body mass index at the time of surgery and complication rates (OR 1.05 [95% CI 1.02 to 1.08]; P<0.01).

Conclusions

The findings reveal no difference in complication rates following abdominal body contouring procedures attributable to method of weight loss. Rather, there was a proportional rise in complication rates in patients with a higher body mass index at the time of surgery. Surgeons and patients should be aware of this trend, and it should be part of any discussion of abdominal body contouring procedures and informing patients of their risk profile.

Complications in body contouring stratified according to weight loss method

BACKGROUND

Body contouring procedures following massive weight loss have become increasingly common and, unfortunately, continue to be associated with a high complication rate.

OBJECTIVE

To evaluate how weight loss method affects complications following abdominally based body contouring procedures.

METHODS

Patients undergoing abdominally based contouring procedures were retrospectively evaluated over an 11-year period and stratified into two groups based on method of weight loss: diet and exercise; or bariatric surgery. Complications, including seroma, wound dehiscence, skin necrosis, infection, hematoma and venous thromboembolism, were included if they required intervention. An adjusted logistic model was used to examine the effect of weight loss method on aggregate complication rates.

RESULTS

A total of 307 patients were included: 77 (25%) lost weight through diet and exercise; and 230 (75%) through bariatric surgery. Results from the logistic model showed no difference in complication rates between weight loss methods (OR 1.01 [95% CI 0.51 to 2.02]). However, there was a strong correlation between body mass index at the time of surgery and complication rates (OR 1.05 [95% CI 1.02 to 1.08]; P<0.01).

CONCLUSIONS

The findings reveal no difference in complication rates following abdominal body contouring procedures attributable to method of weight loss. Rather, there was a proportional rise in complication rates in patients with a higher body mass index at the time of surgery. Surgeons and patients should be aware of this trend, and it should be part of any discussion of abdominal body contouring procedures and informing patients of their risk profile.

Role of nutrition in oral and maxillofacial surgery patients

Diet, nutrition, and dental health are closely related and have multidirectional impacts. Any oral diseases, may it be congenital, infective, traumatic, inflammatory, or neoplastic, affect routine functions of the oral cavity and even after corrective surgeries done to improve may adversely affect the food and fluid intake and further compromises nutritional status. Unlike other general surgeries, the surgeries done in oral and maxillofacial region impairs normal food intake, especially by mouth which is the preferred commonly used route. This oral cavity being harbored by multiple organisms makes it prone to further infection which again hampers the healing. Oral surgeries include the dentoalveolar region for the treatment of fracture or prosthetic reasons, for maxillofacial trauma, orthognathic surgeries, tumors, cleft lip and palate correction, etc., Nutrition plays a major role in the postoperative recovery and healing. Malnutrition in the Oral and Maxillofacial Surgery (OMFS) patients increases the postoperative morbidity and mortality rate. Nutrition in jaw fractures treated with intermaxillary fixation is more compromised. Healing is impaired in malnourished, critically ill, elderly, and patients with prolonged stay in hospital and hence nutrition in the form of enteral, parenteral, and oral sip feeding plays a major role in providing nutritional care. Preoperative nutrition and perioperative nutrition influence the postoperative outcome and hence metabolic and nutritional care is important for the uneventful healing. This article provides a basic review of the role of nutrition in the postoperative outcome of OMFS patients based on the search through articles in journal and internet.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Adrenal sensitivity to stress is maintained despite variation in baseline glucocorticoids in moulting seals

Stressful disturbances activate the hypothalamic-pituitary-adrenal (HPA) axis and result in the release of glucocorticoid (GC) hormones. This characteristic stress response supports immediate energetic demands and subsequent recovery from disturbance. Increased baseline GC concentrations may indicate chronic stress and can impair HPA axis function during exposure to additional stressors. Levels of GCs, however, vary seasonally and with life-history stage, potentially confounding their interpretation. Our objective was to evaluate HPA axis function across variations in baseline GC levels. Northern elephant seals show substantial baseline variation in GC levels during their annual moulting period. We therefore conducted measurements early, in the middle and at the end of moulting; we simulated an acute stressor by administering adrenocorticotrophic hormone and evaluated the changes in circulating hormones and metabolites over the following 2 h. The stress response was characterized by increases in both cortisol and aldosterone (F 7,105 = 153 and 25.3, respectively; P < 0.001). These hormones increased in parallel and the slopes of their relationship varied by study group, suggesting they are regulated in a co--ordinated manner during acute stress in this species. There was no detectable difference in the total release of cortisol or aldosterone among study groups, indicating that the HPA axis remained sensitive to stimulation by adrenocorticotrophic hormone despite varying baseline levels of GCs. Acute stress influenced carbohydrate and fat metabolism in all study groups, but protein catabolism was affected to a far lesser degree. These findings suggest that elephant seals, and potentially other pinniped species, are resilient to moderate variations in baseline GC levels and remain capable of mounting a response to additional stressors.

Wound Healing: Biologics, Skin Substitutes, Biomembranes and Scaffolds

This review will explore the latest advancements spanning several facets of wound healing, including biologics, skin substitutes, biomembranes and scaffolds.

Obesity and surgical wound healing: a current review

Objective. The correlation between obesity and deficient wound healing has long been established. This review examines the current literature on the mechanisms involved in obesity-related perioperative morbidity. Methods. A literature search was performed using Medline, PubMed, Cochrane Library, and Internet searches. Keywords used include obesity, wound healing, adipose healing, and bariatric and surgical complications. Results. Substantial evidence exists demonstrating that obesity is associated with a number of postoperative complications. Specifically in relation to wound healing, explanations include inherent anatomic features of adipose tissue, vascular insufficiencies, cellular and composition modifications, oxidative stress, alterations in immune mediators, and nutritional deficiencies. Most recently, advances made in the field of gene array have allowed researchers to determine a few plausible alterations and deficiencies in obese individuals that contribute to their increased risk of morbidity and mortality, especially wound complications. Conclusion. While the literature discusses how obesity may negatively affect health on various of medical fronts, there is yet to be a comprehensive study detailing all the mechanisms involved in obesity-related morbidities in their entirety. Improved knowledge and understanding of obesity-induced physiological, cellular, molecular, and chemical changes will facilitate better assessments of surgical risks and outcomes and create efficient treatment protocols for improved patient care of the obese patient population.

Granzyme B degrades extracellular matrix and contributes to delayed wound closure in apolipoprotein E knockout mice

Chronic inflammation and excessive protease activity have a major role in the persistence of non-healing wounds. Granzyme B (GzmB) is a serine protease expressed during chronic inflammation that, in conjunction with perforin, has a well-established role in initiating apoptotic cell death. GzmB is also capable of acting extracellularly, independent of perforin and can degrade several extracellular matrix (ECM) proteins that are critical during wound healing. We used apolipoprotein E (ApoE) knockout (AKO) mice as a novel model of chronic inflammation and impaired wound healing to investigate the role of GzmB in chronic wounds. Wild-type and AKO mice were grown to 7 weeks (young) or 37 weeks (old) of age on a regular chow or high-fat diet (HFD), given a 1-cm diameter full thickness wound on their mid dorsum and allowed to heal for 16 days. Old AKO mice fed a HFD exhibited reduced wound closure, delayed contraction, chronic inflammation and altered ECM remodeling. Conversely, GzmB/ApoE double knockout mice displayed improved wound closure and contraction rates. In addition, murine GzmB was found to degrade both fibronectin and vitronectin derived from healthy mouse granulation tissue. In addition, GzmB-mediated degradation of fibronectin generated a fragment similar in size to that observed in non-healing mouse wounds. These results provide the first direct evidence that GzmB contributes to chronic wound healing in part through degradation of ECM.

Single-incision laparoscopic stoma creation: experience with 31 consecutive cases

INTRODUCTION

Fecal diversion may be performed using various techniques. Each technique has advantages that affect patient selection. In this report, we report our experience with 31 patients who underwent single-incision laparoscopic stoma creation using only a pre-selected stoma site as the point of port access.

METHODS

A 2.5-cm skin incision was made at a previously marked stoma site, and two 5-mm trocars were placed into the abdomen through the stoma site. An optional third trocar was inserted at the stoma site only if the bowel needed to be mobilized or if adhesions needed to be divided. After full intra-abdominal exploration, a selected intestinal loop was brought up to the stoma site, and the ostomy was then matured using standard techniques.

RESULTS

Between April 2009 and March 2012, 31 patients (19 men) with a mean age of 68 years (range, 46-87 years) underwent single-incision laparoscopic stoma creation. Fecal diversion included ileostomy (n = 18) and colostomy (n = 13). There were no intraoperative complications. Two patients (6.5%) required additional port placement in the midline suprapubic area. Conversion to open laparotomy was required in two patients (6.5%) because of the presence of extensive adhesions. Postoperative complications were observed in two patients and included peristomal ileus and dehydration due to high ileostomy output.

CONCLUSIONS

Single-incision laparoscopic stoma creation is an effective technique that allows full intra-abdominal visualization and bowel mobilization, while reducing the need for additional skin incisions beyond that of the stoma site.

A prospective evaluation of the risk factors for development of wound dehiscence and incisional hernia

OBJECTIVE

Post-laparotomy wound dehiscence, evantration and evisceration are important complications leading to an increase in both morbidity and mortality. Incisional hernias are frequently observed following abdominal surgeries and their occurrence is related to various local and systemic factors. This study aims to analyze the factors affecting wound healing by investigating the parameters that may cause wound dehiscence, incisional hernia, sinus formation and chronic incisional pain.

MATERIAL AND METHODS

The records of 265 patients who underwent major abdominal surgery were analyzed. The data on patient characteristics, medication, surgical procedure type, type of suture and surgical instruments used and complications were recorded. The patients were followed up with respect to sinus formation, incisional hernia occurrence and presence of chronic incision pain. Statistical analysis was performed using SPSS 10.00 program. The groups were compared via chi-square tests. Significance was determined as p<0.05. Multi-variate analysis was done by forward logistic regression analysis.

RESULTS

115 (43.4%) patients were female and 150 (56.6%) were male. Ninety-four (35.5%) patients were under 50 years old and 171 (64.5%) were older than 50 years. The median follow-up period was 28 months (0-48). Factors affecting wound dehiscence were found to be; creation of an ostomy (p=0.002), postoperative pulmonary problems (p=0.001) and wound infection (p=0.001). Factors leading to incisional hernia were; incision type (p=0.002), formation of an ostomy (p=0.002), postoperative bowel obstruction (p=0.027), postoperative pulmonary problems (p=0.017) and wound infection (p=0.011).

CONCLUSION

Awareness of the factors causing wound dehiscence and incisional hernia in abdominal surgery, means of intervention to the risk factors and taking relevant measures may prevent complications. Surgical complications that occur in the postoperative period are especially related to wound healing problems.

Obesity and burns

The population of overweight patients presenting to burn facilities is expected to increase significantly over the next decades due to the global epidemic of obesity. Excess adiposity mediates alterations to key physiological responses and poses challenges to the optimal management of burns. The purpose of this study is to document the general epidemiological aspects of thermal injuries in the obese population, outline relevant physiological aspects associated with obesity, and draw attention to topics relating to the management, rehabilitation, and prognosis of burns in this emerging subpopulation of patients.

A 3-year follow-up study of inpatients with lower limb ulcers: evidence of an obesity paradox?

Objectives

To determine whether body composition is related to long-term outcomes amongst vascular inpatients with lower limb ulcers.

Design

Prospective study with 3 years follow-up.

Materials and methods

Body mass index (BMI), fat, and fat-free mass were measured and associations with readmission to hospital (number, cause, length of stay) and all-cause mortality were explored.

Results

Thirty patients (22 men, 8 women) participated in the study. Ten patients (33%) had a BMI ≥ 30 kg/m². 18/20 (90%) patients with a BMI < 30 kg/m² and 9/10 (90%) patients with a BMI ≥ 30 kg/m² were admitted to hospital in the 3 years of follow-up. Patients with a BMI < 30 kg/m² were admitted more frequently, earlier and for longer compared to those with BMI ≥ 30 kg/m² but these did not reach statistical significance. The 3 year mortality rate for patients with BMI ≥ 30 kg/m² was 20% (n = 2/10) compared to 70% (n = 14/20) with a BMI < 30 kg/m², P = 0.019.

Conclusion

This preliminary study suggests that higher BMI may have a protective effect against mortality in vascular patients with lower limb ulcers. These findings contradict the universal acceptance that obesity leads to poor health outcomes. Further work is required to confirm these findings and explore some of the potential mechanisms for this effect.

Single-port laparoscopic diverting sigmoid colostomy

BACKGROUND

Single-port laparoscopic surgery has been described for various colorectal conditions. Here, we report the first 4 single-port laparoscopic sigmoid colostomies for fecal diversion.

METHODS

A 1.5-cm-round incision was made on the skin at a previously marked colostomy site. A wound retractor was inserted and an access platform with four 5-mm trocars was attached to the wound retractor. The sigmoid colon was mobilized using electrocautery, laparoscopic scissors, or an advanced bipolar device. A standard Brooke colostomy was created through the initial skin incision.

RESULTS

Four elective single-port laparoscopic diverting colostomies were performed. Indications included obstructing colon and rectal cancers and intractable Crohn's proctitis. The average operative time was 73 minutes (range, 53-105), and blood loss was minimal (<50 mL). There were no intraoperative complications. Three of 4 patients received oral analgesia, and one patient received patient-controlled intravenous analgesia postoperatively. The average time to passage of flatus was 1 day. Diet was advanced either on the day of surgery or on postoperative day 1. The length of hospital stay ranged from 0 to 15 days.

CONCLUSION

Single-port laparoscopic sigmoid colostomy is an effective technique that allows full intra-abdominal visualization and colonic mobilization while eliminating the need for additional skin incisions other than the colostomy site itself.

Complications in postbariatric body contouring: strategies for assessment and prevention

Massive weight loss patients present specific challenges to the plastic surgeon. Review of these issues may be valuable for the surgeon who does not specialize in this area. Obtaining excellent results involves a comprehensive perioperative approach, beginning with proper patient selection and appropriate expectations. Operative considerations such as hypothermia prevention and thromboembolic prophylaxis can play a role in improving outcomes and reducing morbidity. Appropriately focused postoperative care completes the surgical plan, leading to satisfying results for both patient and surgeon.

The influence of iron status and genetic polymorphisms in the HFE gene on the risk for postoperative complications after bariatric surgery: a prospective cohort study in 1,064 patients

BACKGROUND

Gastric bypass surgery is a highly effective therapy for long-term weight loss in severely obese patients, but carries significant perioperative risks including infection, wound dehiscence, and leaks from staple breakdown. Iron status can affect immune function and wound healing, thus may influence peri-operative complications. Common mutations in the HFE gene, the gene responsible for the iron overload disorder hereditary hemochromatosis, may impact iron status.

METHODS

We analyzed 1064 extremely obese Caucasian individuals who underwent open and laparoscopic Roux-n-Y gastric bypass surgery at the Geisinger Clinic. Serum iron, ferritin, transferrin, and iron binding capacity were measured pre-operatively. All patients had intra-operative liver biopsies and were genotyped for the C282Y and H63D mutations in the HFE gene. Associations between surgical complications and serum iron measures, HFE gene status, and liver iron histology were determined.

RESULTS

We found that increased serum iron and transferrin saturation were present in patients with any post-operative complication, and that increased serum ferritin was also increased in patients with major complications. Increased serum transferrin saturation was also associated with wound complications in open RYGB, and transferrin saturation and ferritin with prolonged lengths of stay. The presence of 2 or more HFE mutations was associated with overall complications as well as wound complications in open RYGB. No differences were found in complication rates between those with stainable liver iron and those without.

CONCLUSION

Serum iron status and HFE genotype may be associated with complications following RYGB surgery in the extremely obese.