Implementation of AIRVO™ System for Postoperative Tracheostomy Care in Head and Neck Free Flaps

OBJECTIVE

Effective postoperative tracheostomy management after free flap surgery is critical but can offer challenges including difficulty with humidification delivery and contraindications toward neck instrumentation. The purpose of this project was to establish a multidisciplinary team and implement the AIRVO™ tracheostomy humidification system for those undergoing free flap surgery and determine its effect on respiratory secretions and related events.

METHODS

A retrospective cohort study of head and neck free flap surgery patients prior to implementation of AIRVO™ (Jan 2021-May 2021) and after (August 2021-December 2021) were analyzed with a 2 month (June 2021-July 2021) implementation phase. Main variables analyzed included excessive tracheal secretions, necessity of supplemental oxygen above baseline for a day or greater, respiratory rapid response calls, elevation to intensive care units (ICU), and length of hospital stay.

RESULTS

A total of 82 patients (40 pre-AIRVO™ and 42 with AIRVO™) met criteria for the study. A significant reduction in excessive tracheal secretions (40% pre-AIRVO™, 11.9% with AIRVO™, P = .01) and necessity of supplemental oxygen above baseline (25% pre-AIRVO™, 7.1% with AIRVO™, P = .04) were observed. No significant difference in hospital length of stay (P = .63) was observed. No respiratory rapid responses or elevation to ICU care were seen in either groups.

CONCLUSION

The AIRVO™ system provided an efficient, portable, free of neck instrumentation, and easy to use device that resulted in a reduction in excessive tracheal secretion events and necessity of supplemental oxygenation needs in free flap tracheostomy patients.

A transient, closed-loop network of wireless, body-integrated devices for autonomous electrotherapy

Temporary postoperative cardiac pacing requires devices with percutaneous leads and external wired power and control systems. This hardware introduces risks for infection, limitations on patient mobility, and requirements for surgical extraction procedures. Bioresorbable pacemakers mitigate some of these disadvantages, but they demand pairing with external, wired systems and secondary mechanisms for control. We present a transient closed-loop system that combines a time-synchronized, wireless network of skin-integrated devices with an advanced bioresorbable pacemaker to control cardiac rhythms, track cardiopulmonary status, provide multihaptic feedback, and enable transient operation with minimal patient burden. The result provides a range of autonomous, rate-adaptive cardiac pacing capabilities, as demonstrated in rat, canine, and human heart studies. This work establishes an engineering framework for closed-loop temporary electrotherapy using wirelessly linked, body-integrated bioelectronic devices.

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care

OBJECTIVE

To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients.

METHODS

A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed.

RESULTS

Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy.

CONCLUSIONS

In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

Patient-Directed Home Drain Removal in Head and Neck Surgery

OBJECTIVES/HYPOTHESIS

The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients.

METHODS

The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes.

RESULTS

One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved.

CONCLUSIONS

The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Efficacy of commercial nasal bridle use in reducing feeding tube dislodgements in pediatric patients following double stage laryngotracheoplasty

INTRODUCTION

Maintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements.

METHODS

Medical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements.

RESULTS

A total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group.

CONCLUSION

The commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

Telehealth Delivery of Outpatient Pediatric Surgical Care in Hawai'i: An Opportunity Analysis

In the state of Hawai'i, nearly all pediatric surgical care is delivered on the main island of O'ahu at the state's primary tertiary children's hospital. Outpatient clinic visits require patients and families to travel to O'ahu. The direct and opportunity costs of this can be significant. The objective of this study was to characterize potential telehealth candidates to estimate the opportunity for telehealth delivery of outpatient pediatric surgical care. A retrospective chart review including all patients transported from neighbor islands for outpatient consultation with a pediatric surgeon on O'ahu over a 4-year period was performed. Each patient visit was examined to determine if the visit was eligible for telehealth services using stringent criteria. Direct, insurance-based costs of the travel necessary were then determined. Demographic data was used to characterize the patients potentially affected. A total of 1081 neighbor island patients were seen in the pediatric surgery clinic over 4 years. Thirty-one percent of these patients met criteria as candidates for telehealth visits. The majority of patients came from Hawai'i and Maui. Most patients were identified as Native Hawaiian or Asian. The average cost per trip was $112.53 per person, leading to a potential direct cost savings of $37,697 over 4 years. Over 30% of outpatient pediatric surgical encounters met stringent criteria as candidates for telehealth delivery of care. Given the significant number of patients that met our criteria, we believe there is an opportunity for direct, travel-based cost savings with the implementation of telehealth delivery of outpatient pediatric surgical care in Hawai'i.

Wireless implantable and biodegradable sensors for postsurgery monitoring: current status and future perspectives

In in vivo postsurgery monitoring, the use of wireless biodegradable implantable sensors has gained and is gaining a lot of interest, particularly in cases of monitoring for a short period of time. The employment of biodegradable materials allows the circumvention of secondary surgery for device removal. Additionally, the use of wireless communication for data elaboration avoids the need for transcutaneous wires. As such, it is possible to prevent possible inflammation and infections associated with long-term implants which are not wireless. It is expected that microfabricated biodegradable sensors will have a strong impact in acute or transient biomedical applications. However, the design of such high-performing electronic systems, both fully biodegradable and wireless, is very complex, particularly at small scales. The associated technologies are still in their infancy and should be more deeply and extensively investigated in animal models and, successively, in humans, before being clinically implemented. In this context, the present review aims to provide a complete overview of wireless biodegradable implantable sensors, covering the vital signs to be monitored, the wireless technologies involved, and the biodegradable materials used for the production of the devices, as well as designed devices and their applications. In particular, both their advantages and drawbacks are highlighted, and the key challenges faced, mainly associated with fabrication techniques, and control over degradation kinetics and biocompatibility of the device, are reported and discussed.

Rigid dressings versus soft dressings for transtibial amputations

BACKGROUND

Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump.

OBJECTIVES

To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations.

SEARCH METHODS

In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments.

MAIN RESULTS

We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I² = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I² = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost.

AUTHORS' CONCLUSIONS

We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).

Use of Prolonged Prophylactic Antibiotics with Closed Suction Drains in Ventral Abdominal Hernia Repair

Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090-0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.

Efficacy of Enteral Nutrition by Double Elementary Diet Tube after Pylorus-Preserving Pancreatoduodenectomy

Nutritional support after pylorus-preserving pancreaticoduodenectomy (PpPD) is still controversial. This study aimed to evaluate the efficacy of enteral nutrition (EN) via the double elementary diet (W-ED) tube after PpPD. One hundred two patients who received EN by the W-ED tube were compared with 52 patients who received total parental nutrition (TPN) previously. Clinicopathological and postoperative features were analyzed among the two groups. Patients with EN by the W-ED tube after PpPD had a lower incidence of postoperative pancreatic fistula than those with TPN. The total protein and albumin levels on discharge in the EN group were significantly higher than those in the TPN group. In the case without complication, decreasing rate of the third lumbar vertebra skeletal muscle area was significantly lower in the EN group. In the cases of soft pancreas, drainage volume by the W-ED tube until four postoperative day was significantly larger in the case without postoperative pancreatic fistula. The W-ED tube offers the advantages of reducing gastrointestinal pressure and enabling reduction of complications after PpPD surgery.

Mobile health applications enhance weight loss efficacy following bariatric surgery

INTRODUCTION

With the epidemic of obesity numerous mobile health (mHealth) applications have been designed with the goal of facilitating weight loss. This technology has the potential to focus behavioral modification in a manner that's effective for weight loss. We examined the use of this mHealth technology in our bariatric surgery population to evaluate effects on weight loss following surgery.

METHODS

Single institution prospective randomized control trial performed at an academic center. 56 patients who recently underwent a laparoscopic sleeve gastrectomy (LSG) were enrolled into a control group with standard post-operative monitoring and a mHealth application group provided with iPad© minis with the MyFitnessPal© mHealth application. Participants were followed for 24 months. The primary outcomes were effect on weight loss as determined by excess body weight loss (%EWL) and excess BMI loss (%EBL).

RESULTS

Statistically significant differences in weight loss outcomes between the groups were present throughout the duration of the study. At 12 months, %EWL was 74.41% (control) vs 81.41% (mHealth) p value 0.047 and at 24 months, it was 59.10% (control) vs 71.47% (mHealth) p value 0.0078. %EBL findings at 12 months was 28.02% (control) vs 32.15% (mHealth) p value 0.0007 and at 24 months, it was 25.39% (control) vs 27.87% (mHealth) p value 0.048.

CONCLUSION

Our results demonstrate mHealth applications are a useful adjunct to improve and maintain weight loss following bariatric surgery. We suggest mHealth applications should be utilized following bariatric surgery for improved outcomes.

Association of Wearable Activity Monitors With Assessment of Daily Ambulation and Length of Stay Among Patients Undergoing Major Surgery

IMPORTANCE

Early postoperative ambulation is vital to minimizing length of stay (LOS), but few hospitals objectively measure ambulation to predict outcomes. Wearable activity monitors have the potential to transform assessment of postoperative ambulation, but key implementation data, including whether digitally monitored step count can identify patients at risk for poor efficiency outcomes, are lacking.

OBJECTIVES

To define the distribution of digitally measured daily step counts after major inpatient surgical procedures, to assess the accuracy of physician assessment and ordering of ambulation, and to quantify the association of digitally measured step count with LOS.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study at Cedars-Sinai Medical Center, an urban tertiary referral center. Participants were patients undergoing 8 inpatient operations (lung lobectomy, gastric bypass, hip replacement, robotic cystectomy, open colectomy, abdominal hysterectomy, sleeve gastrectomy, and laparoscopic colectomy) from July 11, 2016, to August 30, 2017.

INTERVENTIONS

Use of activity monitors to measure daily postoperative step count.

MAIN OUTCOMES AND MEASURES

Operation-specific daily step count, daily step count by physician orders and assessment, and a prolonged LOS (>70th percentile for each operation).

RESULTS

Among 100 patients (53% female), the mean (SD) age was 53 (18) years, and the median LOS was 4 days (interquartile range, 3-6 days). There was a statistically significant increase in daily step count with successive postoperative days in aggregate (r = 0.55; 95% bootstrapped CI, 0.47-0.62; P < .001) and across individual operations. Ninety-five percent (356 of 373) of daily ambulation orders were "ambulate with assistance," although daily step counts ranged from 0 to 7698 steps (0-5.5 km) under this order. Physician estimation of ambulation was predictive of the median step count (r = 0.66; 95% bootstrapped CI, 0.59-0.72; P < .001), although there was substantial variation within each assessment category. For example, daily step counts ranged from 0 to 1803 steps (0-1.3 km) in the "out of bed to chair" category. Higher step count on postoperative day 1 was associated with lower odds of prolonged LOS from 0 to 1000 steps (odds ratio [OR], 0.63; 95% CI, 0.45-0.84; P = .003), with no further decrease in odds after 1000 steps (OR, 0.99; 95% CI, 0.75-1.30; P = .80).

CONCLUSIONS AND RELEVANCE

In this study, digitally measured step count up to 1000 steps on postoperative day 1 was associated with lower probability of a prolonged LOS. Wearable activity monitors improved the accuracy of assessment of daily step count over the current standard of care, providing an opportunity to identify patients at risk for poor efficiency outcomes.

The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care

OBJECTIVE

Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery.

METHODS

This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups.

RESULTS

The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013).

CONCLUSIONS

This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.

High flow nasal oxygen after bariatric surgery (OXYBAR), prophylactic post-operative high flow nasal oxygen versus conventional oxygen therapy in obese patients undergoing bariatric surgery: study protocol for a randomised controlled pilot trial

BACKGROUND

The incidence of obesity is increasing worldwide. In selected individuals, bariatric surgery may offer a means of achieving long-term weight loss, improved health, and healthcare cost reduction. Physiological changes that occur because of obesity and general anaesthesia predispose to respiratory complications following bariatric surgery. The aim of this study is to determine whether post-operative high flow nasal oxygen therapy (HFNO2) improves respiratory function and reduces the incidence of post-operative pulmonary complications (PPCs) in comparison to conventional oxygen therapy in these patients.

METHOD

The OXYBAR study is a prospective, un-blinded, single centre, randomised, controlled pilot study. Patients with body mass index (BMI) > 30 kg/m2, undergoing laparoscopic bariatric surgery, will be randomised to receive either standard low flow oxygen therapy or HFNO2 in the post-operative period. The primary outcome measure is the change in end expiratory lung impedance (∆EELI) as measured by electrical impedance tomography (EIT). Secondary outcome measures include change in tidal volume (∆Vt), partial arterial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, incidence of PPCs, hospital length of stay and measures of patient comfort.

DISCUSSION

We hypothesise that the post-operative administration of HFNO2 will increase EELI and therefore end expiratory lung volume (EELV) in obese patients. To our knowledge this is the first trial designed to assess the effects of HFNO2 on EELV in this population. We anticipate that data collected during this pilot study will inform a larger multicentre trial.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617000694314 . Registered on 15 May 2017.

Efficacy of the SENSIMED Triggerfish® in the postoperative follow-up of PHACO-ExPRESS combined surgery

OBJECTIVE

To determine the usefulness of the SENSIMED Triggerfish^® system in the postoperative control of combined phacoemulsification and ExPRESS implant (PHACO-ExPRESS) surgery in patients with cataract and chronic open angle glaucoma (COAG) during a 2 months follow-up.

METHODS

A prospective study conducted on 15 eyes that were subjected to PHACO-ExPRESS combined surgery. Using the SENSIMED Triggerfish^® system, two records of the circadian patterns of intraocular pressure (IOP) were performed, one before and one after surgery. A record was made of the best corrected visual acuity (BCVA), comorbidities, previous IOP, and 7-30-60 days after surgery, as well as any hypotensive drugs and complications.

RESULTS

The final sample was 12 eyes. The mean pre-operative BCVA (log MAR chart) before surgery was 0.5±0.2, and after surgery 0.14±0.1 (P=.02). The previous IOP was 18.7±3.8mmHg with 2.9±0.7 drugs. The mean IOP at 7, 30, and 60 days after surgery decreased to 13±4.1mmHg (P=.002), 13.5±2mmHg (P=.001), and 13.9±2.5mmHg (P=.001), respectively. The amplitudes of the circadian curves changed significantly after surgery (P=.007). The mean values between daytime and night-time periods decreased significantly from 146.8±80.9 mVeq and 61.2±92.mVeq before surgery to 36.4±36 mVeq (P=.000), and -23,2±47.6mVeq (P=.014) after surgery, respectively. There were complications in one patient.

CONCLUSIONS

The SENSIMED Triggerfish^® monitoring system showed changes in the curves of the circadian patterns, as well as decreased mean amplitudes after the combined PHACO-ExPRESS technique, suggesting that it may become a useful tool for postoperative follow-up of COAG.

Telemedicine with mobile devices and augmented reality for early postoperative care

Advanced features are being added to telemedicine paradigms to enhance usability and usefulness. Virtual Interactive Presence (VIP) is a technology that allows a surgeon and patient to interact in a "merged reality" space, to facilitate both verbal, visual, and manual interaction. In this clinical study, a mobile VIP iOS application was introduced into routine post-operative orthopedic and neurosurgical care. Survey responses endorse the usefulness of this tool, as it relates to The virtual interaction provides needed virtual follow-up in instances where in-person follow-up may be limited, and enhances the subjective patient experience.

Management of Chest Drains After Thoracic Resections

Immediately after lung resection, air tends to collect in the retrosternal part of the chest wall (in supine position), and fluids in its lower part (costodiaphragmatic sinus). Several general thoracic surgery textbooks currently recommend the placement of 2 chest tubes after major pulmonary resections, one anteriorly, to remove air, and another into the posterior and basilar region, to drain fluids. Recently, several authors advocated the placement of a single chest tube. In terms of air and fluid drainage, this technique demonstrated to be as effective as the conventional one after wedge resection or uncomplicated lobectomy.

Postoperative Mechanical Circulatory Support with Biomedicus Centrifugal Pump

Despite advances in surgical techniques, myocardial protection, and management protocols, approximately 1% of patients undergoing open heart operations still need mechanical circulatory support for severe cardiac dysfunction. The Biomedicus centrifugal pump, available in most cardiovascular centers, is a highly effective and relatively inexpensive system compared to other more sophisticated devices for the same purpose. Of 10 patients aged 5 to 61 years who were supported for 22 to 168 hours with a Biomedicus centrifugal pump, 7 (70%) were weaned from support, there was one hospital death, and 6 patients were discharged from hospital. Two sudden deaths occurred in the first 8 months after discharge. Four patients (40%) were still alive after follow-up of 11–55 months, with no restriction in their daily activities. The centrifugal pump is a very cost-effective support system with survival rates comparable to those of more sophisticated devices in short-term ventricular assistance.

Prospective evaluation of routine early computed tomography scanner in laparoscopic sleeve gastrectomy

BACKGROUND

Prompt management of laparoscopic sleeve gastrectomy (LSG) complications is essential in avoiding prolonged hospital stay and associated mortality. The value of routine computed tomography (CT) scan examination in early diagnosis of postoperative complications after LSG has not been studied.

OBJECTIVES

To prospectively assess the impact of postoperative day (POD) 2 CT scan after LSG.

SETTING

Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France.

METHODS

Data were prospectively gathered for 1000 patients undergoing single-incision LSG and POD 2 CT scan. Complications were identified and treatment modalities decided according to the severity of complications. Sensitivity, specificity, and positive and negative predictive values were calculated for the diagnosis of surgical complications on POD 2 CT scan.

RESULTS

Mean age was 40.1 years and median BMI 42.6 kg/m². Early postoperative surgical complications occurred in 66 patients (6.6%). Intraabdominal bleeding/hematoma occurred in 38 patients, with 3 requiring emergent reoperation on POD 1. POD 2 CT scan detected this complication in 32 patients (sensitivity: 91.4%). Twenty-four (63.1%) patients were treated with relaparoscopy and drainage while 14 (36.9%) received conservative management. Postoperative transfusion was required in 7 patients. Twenty-eight patients suffered a gastric staple line leak, 13 (sensitivity: 46.4%) detected on POD 2 CT scan. Three patients (10.7%) received pure surgical treatment, 16 (57.1%) combined relaparoscopy and endoscopic treatment, and 9 (32.2%) had pure endoscopic treatment.

CONCLUSION

POD 2 abdominal CT scan is an efficient diagnostic tool for detecting active bleeding/hematoma, but shows less impressive results with gastric staple line leak detection. A combination of clinical surveillance and early imaging allowed prompt management of complicated cases, avoiding further morbidity.

Suction on chest drains following lung resection: evidence and practice are not aligned

OBJECTIVES

A best evidence topic in Interactive CardioVascular and Thoracic Surgery (2006) looked at application of suction to chest drains following pulmonary lobectomy. After screening 391 papers, the authors analysed six studies (five randomized controlled trials [RCTs]) and found no evidence in favour of postoperative suction in terms of air leak duration, time to chest drain removal or length of stay. Indeed, suction was found to be detrimental in four studies. We sought to determine whether clinical practice is consistent with published evidence by surveying thoracic units nationally and performing a meta-analysis of current best evidence.

METHODS

We systematically searched MEDLINE, EMBASE and CENTRAL for RCTs, comparing outcomes with and without application of suction to chest drains after lung surgery. A meta-analysis was performed using RevMan(©) software. A questionnaire concerning chest drain management and suction use was emailed to a clinical representative in every thoracic unit.

RESULTS

Eight RCTs, published 2001-13, with 31-500 participants, were suitable for meta-analysis. Suction prolonged length of stay (weighted mean difference [WMD] 1.74 days; 95% confidence interval [CI] 1.17-2.30), chest tube duration (WMD 1.77 days; 95% CI 1.47-2.07) and air leak duration (WMD 1.47 days; 95% CI 1.45-2.03). There was no difference in occurrence of prolonged air leak. Suction was associated with fewer instances of postoperative pneumothorax. Twenty-five of 39 thoracic units responded to the national survey. Suction is routinely used by all surgeons in 11 units, not by any surgeon in 5 and by some surgeons in 9. Of the 91 surgeons represented, 62 (68%) routinely used suction. Electronic drains are used in 15 units, 10 of which use them routinely.

CONCLUSIONS

Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence.

Heat retention head wrap for rewarming infants undergoing cardiopulmonary bypass surgery

BACKGROUND

A major postoperative problem for infants undergoing cardiopulmonary bypass surgery is hypothermia.

OBJECTIVE

To determine the safety and feasibility of a newly designed Heat Retention Head Wrap on infants during the rewarming period of cardiopulmonary bypass surgery.

METHODS

A sample of 10 infants was recruited into this descriptive pilot study. The health care providers completed ease-of-use questionnaires to describe the feasibility of the head wrap. Interval body temperatures were recorded to characterize temperature progression from onset of rewarming to arrival in the cardiac intensive care unit (ICU) and were compared with the temperature progression of a similar group of nonparticipants. Adverse events were recorded on the basis of perioperative body temperatures and skin assessments.

RESULTS

The head wrap was easily applied to the infant's head and was removed without difficulty. A steady increase in median body temperature from (1) the onset of rewarming (28°C), to (2) removal of bypass cannulas (28.9°C), to (3) removal of the rectal temperature probe before transfer from the operating room to the cardiac ICU (34.5°C), and (4) upon arrival in the cardiac ICU (36.0°C) was observed. No skin lesions or temperature-related adverse events were observed.

CONCLUSIONS

The newly designed Heat Retention Head Wrap was associated with a gradual normalization of temperature during rewarming and did not interfere with routine perioperative care of infants undergoing bypass surgery. This pilot study indicates that the head wrap is both safe and feasible for use in infants undergoing cardiopulmonary bypass surgery.

Biodegradable nasal packings for endoscopic sinonasal surgery: a systematic review and meta-analysis

OBJECTIVES

To assess biodegradable nasal packing effectiveness for improving postoperative symptoms and mucosal healing after endoscopic sinonasal surgery as compared with conventional/non-packing groups.

METHODS

Relevant articles were searched on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials (RCTs) that compared biodegradable packings with conventional packings or no packing, reporting postoperative symptoms and/or mucosal healing outcomes.

RESULTS

This review included 19 studies, of which 11 compared biodegradable packings with conventional packings. Meta-analysis found that biodegradable packings significantly improved postoperative symptoms: bleeding at removal, pain at removal, pain in situ, and nasal blockage. Mucosal healing outcomes were inconsistent within studies, with no data could be pooled. Eight studies compared biodegradable packings with non-packing group. Postoperative symptom data in this comparison could not be pooled: A protective or equal effect on postoperative bleeding was reported in different studies; no difference was reported in pain status and nasal blockage. As for mucosal healing, meta-analysis showed that two arms of comparison had similar effect on synechiae, edema, infection and granulation at each time point.

CONCLUSION

The limiting evidence suggests that biodegradable nasal packings are statistically better than conventional packings in postoperative symptoms, and probably comparable to non-packing group, as in this comparison we could not carry out meta-analysis. No beneficial or detrimental effect on postoperative mucosal healing could be determined based on existing evidence.

Autologous re-transfusion drain compared with no drain in total knee arthroplasty: a randomised controlled trial

BACKGROUND

Post-operative anaemia following total knee arthroplasty is reported to impede functional mobility in the early period following surgery, whereas allogeneic blood transfusions, used to correct low post-operative haemoglobin levels, have concomitant disadvantages. The use of a post-operative autologous blood re-transfusion drainage system as well as no drainage system following total knee arthroplasty have been shown to reduce peri-operative blood loss and allogeneic blood transfusions, compared to the regularly used closed-suction drains. No randomised studies have been performed, to the best of our knowledge, that indicate the superiority of either method.

MATERIALS AND METHODS

An open, randomised controlled study was conducted in 115 patients undergoing total knee arthroplasty who were randomly allocated to an autotransfusion drain or no drainage system. The primary end-point was haemoglobin level on the first post-operative day.

RESULTS

In the autotransfusion group 515 mL (0-1,500 mL) of drained blood was re-transfused within the first 6 hours after surgery. Haemoglobin levels on the first (11.6 vs 11.0 g/dL), second (11.0 vs 10.3 g/dL) and third (10.5 vs 9.8 g/dL) days after surgery were significantly higher in the autotransfusion group. Total peri-operative net blood loss (1,576 mL vs 1,837 mL; -P=0.03) and allogeneic transfusion rates (10.2% vs 19.6%; P=0.15) were lower in the autotransfusion group. There were no differences in pain scores, range of motion or adverse events during hospital stay and the first 3 months after surgery.

DISCUSSION

Compared with no drainage, the use of a post-operative autologous blood re-transfusion drainage system following total knee arthroplasty results in higher post-operative haemoglobin levels and less total blood loss.

[Results of scanning of internal carotid arteries using the system of proximal cerebral protection in the immediate postoperative period]

AIM

to analyse the outcomes of stenting of internal carotid arteries (ICA) using the system of proximal cerebral protection in the immediate (in-hospital) postoperative period.

MATERIAL AND METHODS

we analysed the outcomes of a total of 330 stenting procedures on the cervical segment of the ICA using the proximal cerebral protection MoMa Ultra system in the immediate postoperative period, which were consecutively performed at the Regional Vascular Centre of the Rostov Regional Clinical Hospital over 2010-2013 in a total of 283 patients. Of these, 209 (73.9%) were men. The patients' mean age amounted to 67.4 ± 9.7 years. A total of 194 (68.6%) patients had symptomatic lesions of the ICA. Emergency ICA stenting within 6 hours from the moment of the onset of neurological deficit was performed in eleven (3.9%) patients presenting with acute ischaemic stroke. Recanalization and stenting of ICA chronic occlusion was performed in 5.2% of cases. The outcomes of endovascular interventions were assessed by the technical success of the stenting procedure, presence or absence of new-onset neurological symptomatology, acute coronary events, and lethal outcomes during hospital stay.

RESULTS

technical success of the intervention amounted to 100%. Resulting from intervention, only two (0.6%) patients endured minor ischaemic stroke with complete regression of neurological symptomatology during the hospital stay. Three (0.9%) patients on the background of hypotension developed acute coronary syndrome rapidly relieved by stenting of the symptom-dependent coronary arteries. The composite index "stroke, infarction, death" over the hospital stay amounted to 0.6%.

CONCLUSION

ICA stenting with the use of proximal cerebral protection systems is characterized by a low incidence rate of stroke, infarction and death in the immediate period. All patients with atherosclerotic lesions of ICA should obligatory undergo coronarography. The use of proximal protection systems in clinical practice makes it possible to successfully perform the whole spectrum of endovascular interventions on carotid arteries.

[An implantable micro-device using wireless power transmission for measuring aortic aneurysm sac pressure]

In order to detect endoleaks after endovascular aneurysm repair (EVAR), we developed an implantable micro-device based on wireless power transmission to measure aortic aneurysm sac pressure. The implantable micro-device is composed of a miniature wireless pressure sensor, an energy transmitting coil, a data recorder and a data processing platform. Power transmission without interconnecting wires is performed by a transmitting coil and a receiving coil. The coupling efficiency of wireless power transmission depends on the coupling coefficient between the transmitting coil and the receiving coil. With theoretical analysis and experimental study, we optimized the geometry of the receiving coil to increase the coupling coefficient. In order to keep efficiency balance and satisfy the maximizing conditions, we designed a closed loop power transmission circuit, including a receiving voltage feedback module based on wireless communication. The closed loop improved the stability and reliability of transmission energy. The prototype of the micro-device has been developed and the experiment has been performed. The experiments showed that the micro-device was feasible and valid. For normal operation, the distance between the transmitting coil and the receiving coil is smaller than 8cm. Besides, the distance between the micro-device and the data recorder is within 50cm.

Development of a flexible implantable sensor for postoperative monitoring of blood flow

We have developed a blood flow measurement system using Doppler ultrasound flow sensors fabricated of thin and flexible piezoelectric-polymer films. These flow sensors can be wrapped around a blood vessel and accurately measure flow. The innovation that makes this flow sensor possible is the diffraction-grating transducer. A conventional transducer produces a sound beam perpendicular to its face; therefore, when placed on the wall of a blood vessel, the Doppler shift in the backscattered ultrasound from blood theoretically would be 0. The diffraction-grating transducer produces a beam at a known angle to its face; therefore, backscattered ultrasound from the vessel will contain a Doppler signal. Flow sensors were fabricated by spin coating a poly(vinylidene fluoride-trifluoroethylene) copolymer film onto a flexible substrate with patterned gold electrodes. Custom-designed battery-operated continuous wave Doppler electronics along with a laptop computer completed the system. A prototype flow sensor was evaluated experimentally by measuring blood flow in a flow phantom and the infrarenal aorta of an adult New Zealand White rabbit. The flow phantom experiment demonstrated that the error in average velocity and volume blood flow was less than 6% for 30 measurements taken over a 2.5-hour period. The peak blood velocity through the rabbit infrarenal aorta measured by the flow sensor was 118 cm/s, within 1.7% of the measurement obtained using a duplex ultrasound system. The flow sensor and electronics operated continuously during the course of the 5-hour experiment after the incision on the animal was closed.

Postoperative noninvasive ventilation

General anesthesia and surgery are associated with changes in the shape of the chest that result in atelectasis, a major factor in the development of postoperative respiratory failure. Postoperative noninvasive positive pressure ventilation (NIPPV) has been shown to improve oxygenation and ventilation for high-risk patients. NIPPV has been used as rescue therapy for patients developing acute respiratory distress postoperatively, and appears to be most frequently successful in patients whose problem is atelectasis or obesity. Failure to respond to NIPPV after 20 minutes is usually an indication of intubation, mechanical ventilation, and transfer to the intensive care unit.

[Optical introscopy is a new diagnostic technique in reproductive medicine]

The WHO classification's concept "infertility of unclear genesis" is due to a number of circumstances. On the one hand, this is a preponderance of the subtle forms of diseases, which are a cause of female infertility, including the subclinical forms of small pelvic inflammatory diseases (SPID). On the other hand, this is an imperfection of existing diagnostic methods. Laparoscopy considered to be the gold standard demonstrates a not very high efficiency in diagnosing SPID because of its low sensitivity. In practice, laparoscopic diagnosis of SPID is combined with ultrasound study, computed tomography, and magnetic resonance tomography. This paper proposes to use optical coherent tomography (OCT) in addition to laparoscopy. OCT makes it possible to noninvasively in real time obtain information on the internal structure of biological tissues with a resolution of 10-15 pm at a depth of at least 2 mm. Removable endoscopic probes make OCT compatible with standard endoscopic studies. The use of OCT during laparoscopy yielded optical images of the internal structure of the fallopian tube wall in different conditions: unaltered fallopian tubes; an acute inflammatory process with pronounced changes; minimal manifestations of fallopian tube inflammatory changes. Based on the comparative analysis of OCT data and histological findings, the authors elaborated OCT criteria for health and disease. A blind test indicated the high diagnostic efficacy of the technique. The additional processing of images makes it possible to objectify the data and to automate the optical introscopic technique proposed by the authors.

Accuracy of respiratory rate monitoring using a non-invasive acoustic method after general anaesthesia

BACKGROUND

Respiratory rate should be monitored continuously in the post-anaesthesia care unit (PACU) to avoid any delay in the detection of respiratory depression. Capnometry is the standard of care but in extubated patients requires a nasal cannula or a face mask that may be poorly tolerated or can be dislodged, leading to errors in data acquisition and false alarms. The value of a new non-invasive acoustic monitor in this setting has not been fully investigated.

METHODS

Adult patients admitted to the PACU after general anaesthesia were included. After tracheal extubation, an adhesive sensor with an integrated acoustic transducer (RRa™) was placed on the patient's throat and connected to its monitor while the patient breathed through a face mask with a carbon dioxide sampling port (Capnomask™) connected to a capnometer. Both the acoustic monitor and the capnometer were connected to a computer to record one pair of data per second for up to 60 min.

RESULTS

Fifty-two patients, mean (range) age 54 (22-84) yr and BMI 26 (19-39) kg m(-2), were studied. Compared with capnometry, the bias and limits of agreement of the acoustic method were 0 (-1.4-1.4) bpm. The acoustic sensor was well tolerated while the face mask was removed by eight patients, leading to study discontinuation in two patients.

CONCLUSIONS

In extubated patients, continuous assessment of respiration rate with an acoustic monitor correlated well with capnometry.

Evaluation of a smart alarm for intensive care using clinical data

We describe and report the results of an evaluation of a smart alarm algorithm for post coronary artery bypass graft (CABG) patients. The algorithm (CABG-SA) was applied to vital sign data streams recorded in a surgical intensive care unit (SICU) at a hospital in the University of Pennsylvania Health System. In order to determine the specificity of CABG-SA, the alarms generated by CABG-SA were compared against the actual interventions performed by the staff of the critical care unit. Overall, CABG-SA alarmed for 55% of the time relative to traditional alarms while still generating alarms for 12 of the 13 recorded interventions.

[Electronic system for correct head position control after some vitreoretinal surgeries]

Team of authors consisting of vitreoretinal surgeons and biomedical engineers developed and tested an electronic system helping the patients after some vitreoretinal surgeries to keep the recommended head position. The authors describe the principle of this system and its use in clinical practice.

Effect of strontium-containing hydroxyapatite bone cement on bone remodeling following hip replacement

It is uncertain whether the use of bioactive bone cement has any beneficial effect on local bone adaptation following hip replacement. In this study, twelve goats underwent cemented hip hemiarthroplasty unilaterally, with either PMMA bone cement or strontium-containing hydroxyapatite (Sr-HA) bioactive bone cement. Nine months later, the femoral cortical bones at different levels were analyzed by microhardness testing and micro-CT scanning. Extensive bone remodeling was found at proximal and mid-levels in both PMMA and Sr-HA groups. However, with regard to the differences of bone mineral density, cortical bone area and bone hardness between implanted and non-implanted femur, less decreases were found in Sr-HA group than PMMA group at proximal and mid-levels, and significant differences were shown for bone area and hardness at proximal level. The results suggested that the use of Sr-HA cement might alleviate femoral bone remodeling after hip replacement.

[Use of alternating magnetic field with the frequency of spontaneous local vessels oscillation for rehabilitation of patients after dental implantation]

New software-hardware system for diagnostic and treatment (RF patents: number 75294, 2008 and number 75314, 2008) allowing to use the technique of microcirculatory bed regional pulse vessels control (RF patent number 2383369, 2008) for optimization of patients' rehabilitation process after dental implantation operation. It was shown the normalizing action of alternating magnetic field with the frequency of spontaneous local vessels oscillation by comparison of regional blood flow indices.

[Post operatory blood recuperators; bibliographical review]

The authors presented this report at the Apheresis Workshop at the Mexican Congress on Transfusions. VI Annual Congress AMMTAC in Monterrey, Nuevo León district. The use of post operatory recuperators, especially in orthopedic surgery is a habitual practice nowadays. Nurses play a special role in their handling and use; therefore, the authors comment on the reasons why these devices should be used. The authors also state different scientific evidence, based on a bibliographical review regarding the effectiveness of these systems, their utility, their product quality, their cost benefit, and the absence of undesirable effects. The authors conclude that there is a determined patient profile for when a patient benefits from the use of these devices. After some years of high use, at present times, there has been a reduction in using these devices due to, firstly the pre-surgical use of hematin agents, and secondly due to the development of certain less invasive surgical techniques. In spite of this, this procedure has proven to be cost effective. Nurses have an important role in the handling and use of these instruments which, combined with other measures such as the use of hemoglobin analysis devices at the head of a patient's bed, can contribute to an improved management of transfusion requirements.

[Electrical infusion pumps for postoperative epidural analgesia]

Two types of new electrical infusion pumps (pump) scheduled to be introduced to the Japanese market in this autumn, were featured focusing on patient controlled analgesia (PCA). For the successful introduction of PCA pumps into clinical practice, initial investments including both finance and manpower may be required. The clinical application of these PCA pumps should benefit both patients and medical staffs and gain more than the initial investment eventually.

A miniature and mobile intermittent pneumatic compression device for the prevention of deep-vein thrombosis after joint replacement

The WizAir-DVT is a miniature, lightweight (690 g), battery-operated and mobile intermittent pneumatic compression device (ICD), which enables continuous intraoperative use and immediate patient mobilization postoperatively. We compared its efficacy with a commonly used ICD, the Kendall SCD. Peak femoral vein flow velocity was measured in 20 apparently healthy volunteers at rest and with each device: we found no significant differences between them. A second prospective, randomized, clinical trial was used to compare the efficiency of the device in preventing deep venous thrombosis (DVT) after joint replacement in 50 patients (n=25/group). None developed DVT. Doppler ultrasonography revealed no significant differences. The WizAir-DVT antithrombotic compression device is as safe and effective as the Kendall SCD.

Stomal mucocutaneous dehiscence as a complication of topical negative pressure used to treat an open abdomen: a case series

Although mucocutaneous dehiscence in cases of laparostomies is rare, this complication occurred in three patients in The Netherlands (all men, 53 to 65 years old) who received topical negative pressure (TNP) therapy in the management of open abdomens. Two patients experienced anastomotic failure following colonic resection and one had iatrogenic suturing of the small bowel to the fascia. TNP therapy was initiated and stomal dehiscence occurred after 2 to 3 days, contaminating the area. All patients developed sepsis and one died. Two required numerous additional surgeries and antibiotic treatments for 6 and 8 months, respectively. The complication was believed to have occurred as a result of tension on the proximal bowel of the stoma (the bowel inside the abdomen) not due to tension on the sutures or the small part of the bowel outside the abdomen. A modified TNP procedure, consisting of careful placement of the primary dressing around the stoma using separate primary dressing flaps, has since been used without complications in one patient. With implementation of TNP increasing and because of concerns regarding its use, additional research and innovative, simple solutions to manage complex wounds such as the one presented here are needed.

[Nursing procedures and techniques: permanent pleural drainage devices for use after thoracic surgery]

After various years of not having any innovations in the structure and manageability of pleural or thoracic drainage systems, at present time medical personnel are utilizing some known as permanent pleural drainage devices. These mechanisms are carried by patients who suffer from empyema or persistent pleural drainage, usually as a consequence of oncologic lung procedures. Current closed thoracic drainage systems are disposable and guarantee optimal, safe use by patients. To know the principal basic techniques for their correct utilization will allow medical personnel to maintain an efficient and effective drainage system as well as follow-up control of patients as their treatment evolves. In this article, the authors refer to the technical and the physiological aspects of this procedure so one fully understands how these devices function; they deal with the care necessary until these devices are finally removed. The authors describe nursing treatment and guides which provide recommendations focused on patient release from hospital care.