Preoperative CT imaging as a tool to predict incisional hernia outcomes following abdominal wall reconstruction: A retrospective cohort analysis

INTRODUCTION

Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR.

METHODS

A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests.

RESULTS

The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection.

CONCLUSIONS

Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Incision planning in complex abdominal wall reconstruction

Background

Complex abdominal wall reconstruction (CAWR) has evolved dramatically over the last 10 years and has become a speciality in its own right. Usually surgery is carried out by a General Surgeon, sometimes alone and sometimes in combination with a Plastic Surgeon. Patients frequently have multiple incisions over the abdomen, soft tissue excess and skin redundancy and planning the incisions to allow for a comprehensive abdominal wall reconstruction can be a challenge.In order to help simplify incision planning we examined our personal series of 150 cases to formulate a classification system for the incision and provide a simple algorithm.

Methods

Over an 8 year period from 2007 to 2015, 150 patients underwent complex abdominal wall reconstruction, patient demographics, outcome and complications were recorded. Preoperative photographs of the planned incisions were reviewed by the senior author and classified into 4 groups.

Results

All patients fell into one of four groups. Type 1, using existing incisions (28%). Type 2, using an abdominoplasty approach (26%). Type 3, a fleur-de-lys approach (43%). Type 4, a free style group where the incisions are so complex that the above three categories are not suitable (3%).

Conclusion

Soft tissue management in CAWR can be challenging with the primary objective to achieve uncomplicated primary wound healing while optimising the aesthetic outcome. We present a simple classification system and associated algorithm, which can help surgical planning and identify cases that may benefit from a joint procedure with a Plastic Surgeon.

Management of severe Dupuytren's contracture of the proximal interphalangeal joint with use of a central slip facilitation device

Thirty-eight fingers in 27 patients with Dupuytren's contracture of the proximal interphalangeal joint (PIPJ) in excess of 70° were treated using a staged technique. The first stage involved applying a mini external fixator across the PIPJ for continuous extension over 6 weeks with intensive hand therapy to maintain mobility of the joint and help correct the deformity. Twice weekly during hand therapy sessions the tension of the elastic band across the mini ex-fix was increased, allowing that full active flexion of the PIPJ against the elastic band could still be achieved. The second stage, 4 weeks after the external fixator was applied, involved an open palm technique of fasciectomy for the contracted cords restricting metacarpophalangeal joint movement and dermofasciectomy with full-thickness skin grafting over the proximal phalanx for bands restricting PIPJ movement. The external fixator was used to maintain active extension force until the graft healed. It was generally removed in the outpatient clinic under ring block 2 weeks after the second stage procedure. The patients were followed for a mean of 20.6 (6-48) months. The mean preoperative PIPJ deformity improved from 75° to 37° postoperatively. Overall, 69% of results were rated as good to excellent. Only one patient reported any on-going functional problems. There were eight cases of pin site infections and one case each of loose pins, osteoarthritics at the PIPJ, reflex sympathetic dystrophy, and disease recurrence needing PIPJ fusion. We conclude that our simple staged procedure is a valid alternative in the management of severe Dupuytren's PIPJ contracture.

Sitting on a gold mine: optimal autologous reconstruction of a significant cosmetic contour defect of the buttock using a deep inferior epigastric artery perforator free flap

The options for reconstruction of soft tissue defects of the buttock include custom prosthetic implants and autologous tissue transfer: fat transfer, local flaps, pedicled flaps and free flaps. Optimal reconstruction involves replacement of like-with-like tissue, sufficient padding and adequate contouring. We report a case of a female patient presenting with a significant cosmetic contour defect of her left buttock following previous excision of a malignant fibrous histiocytoma. The patient had autologous buttock reconstruction using a deep inferior epigastric artery perforator free flap with an excellent result. To our knowledge a deep inferior epigastric artery perforator free flap has not previously been described to reconstruct the buttock.

Tibial stress fracture as a complication of free-fibula vascularised graft for mandibular reconstruction

The free vascularised fibula graft is used for a variety of reconstructive procedures and is frequently associated with donor site morbidity. Non-traumatic stress fracture to the tibia following a vascularised free-fibula graft is an uncommon but important complication. The diagnosis may be missed if radiological "stress views" of a possible fracture site are not performed, which may result in its underreporting. The authors report a case in which the aetiology, diagnosis and management recommendations are presented for discussion.

Use of the 'nutriceutical', bovine colostrum, for the treatment of distal colitis: results from an initial study

BACKGROUND

Bovine colostrum is a rich source of nutrients, antibodies and growth factors.

AIM

To examine the efficacy of colostrum enemas in the treatment of distal colitis using a randomized, double-blind, controlled protocol.

METHODS

Fourteen patients (eight female), with a mean age of 45 years (range, 16-75 years) and mild to moderately severe distal colitis (Powell-Tuck scoring system), received colostrum enema (100 mL of 10% solution) or placebo (albumin solution) b.d. for 4 weeks. Both groups also received mesalazine (1.6 g/day) or, if already taking it, had a dose increment of 1.6 g/day. Disease activity was documented at 0, 2 and 4 weeks.

RESULTS

After 4 weeks, the colostrum group showed a mean reduction in symptom score of - 2.9 (95% confidence interval (CI), - 5.4 to - 0.3), whereas the placebo group showed a mean response of + 0.5 (95% CI, - 2.4 to +3.4). The histological score improved in five of the eight patients in the colostrum group (mean response, - 0.9; 95% CI, - 1.69 to - 0.03), whereas the histological scores only improved in two of the six patients in the placebo group (mean response, 0.2; 95% CI, - 2.4 to +2.6).

CONCLUSIONS

Bovine colostrum enema shows potential as a novel therapy for left-sided colitis with additional benefits over using mesalazine alone. Further studies appear to be warranted.

The Soho nail bomb: the UCH experience. University College Hospital

This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.

A case-control study of Yersinia enterocolitica infections in Auckland

OBJECTIVE

To identify major risk factors for Yersinia enterocolitica (YE) and identify measures to reduce YE infections.

METHODS

A prospective case control study, group age matched, using 186 cases of YE identified by community pathology laboratories and 379 randomly selected controls. Conducted between April 1995 and June 1996 in Auckland, New Zealand. Face-to-face interviews used a standardised questionnaire examining exposures to factors potentially associated with YE infections including untreated water, unreticulated sewerage, consumption of selected foods, selected food handling practices and socio-demographic factors. Multivariate logistic regression was used to calculate adjusted odds ratios for the potential risk factors. Population attributable risk (PAR) was calculated for significant exposures.

RESULTS

Having more than two people living in the home was more common among cases than controls (OR = 2.2). Town supply water (OR = 0.2), reticulated sewerage (OR = 0.34) and looking after a young child (OR = 0.51) were significantly less common. Of the meats, only pork (OR = 1.34) had a higher consumption rate, while bacon (OR = 0.75) and smallgoods (OR = 0.73) were consumed less frequently by cases than controls. Eating food from a sandwich bar was more frequent among cases (OR = 1.18). Fruit and vegetable consumption was marginally less (OR = 0.98). The population attributable risk of these factors was 0.89, implying that 89% of YE would be eliminated if adverse exposures were removed.

CONCLUSIONS

The risk of YE illness is increased by contact with untreated water, unreticulated sewerage and consumption of pork. Investigation of non-town water supply, informal sewerage systems and methods of preparation and consumption of pork are recommended to determine how YE enters the human food chain.

Behavior of a cell line derived from normal human hepatocytes on non-physiological and physiological-type substrates: evidence for enhancement of secretion of liver-specific proteins by a three-dimensional growth pattern

The behavior of a recently described cell line, HH25, derived from normal human hepatocytes, has been investigated on several different substrates--tissue-culture plastic, glass, a thin layer of rat-tail collagen I, and thin layers or thick gels of extracellular matrix derived from the Engelbreth-Holm-Swarm murine sarcoma (EHS matrix). Cellular morphology, proliferation, and secretion of three hepatocyte-specific proteins (albumin, alpha1 acid glycoprotein, and alpha1 antitrypsin) have been examined. There were no differences in morphology, proliferation, or differentiated function in the cells on either plastic, glass, collagen, I, or a thin layer of EHS matrix, but on a thick EHS matrix gel the cells altered their morphology (forming three-dimensional colonies with canalicular-like structures) and their production of albumin and alpha1 acid glycoprotein was enhanced. This suggests that the enhanced differentiated function is associated with the morphological change (occurring only on the thick EHS gel) rather than with receptor-mediated cell-matrix interactions (which can also occur on the thin layer of EHS matrix). This cell line is therefore a good in vitro cellular model for the investigation of the roles of morphological changes and of cell-cell and cell-matrix interactions in the control of human hepatocyte behavior without the need for an extensive source of primary tissue.

Intracranial cavernous angioma initially presenting in pregnancy with new-onset seizures

A case of an intracranial cavernous angioma, which presented with headaches and seizures in a pregnant patient, is described. Diagnosis was established with magnetic resonance imaging. A computer-assisted literature search uncovered no previously reported case of intracranial cavernous angioma initially presenting during pregnancy.

Howard Mold Count of Fruit Nectars, Purees, and Pastes: Collaborative Study

The various mold count methods for nectars, purees, and pastes make no adjustment for concentration of the pulped liquid. Thus, mold counts of different forms of the same product (e.g., guava nectar, puree, or paste) or of the same product from different manufacturers cannot be compared. A method was developed in which the product is centrifuged under standardized conditions, then diluted to a standard pellet-to-final-volume ratio. Because variations in the concentration of fruit or vegetable tissue are corrected, comparisons of mold counts are possible. The method was adopted official first action.

Determination of Geotrichum Mold in Comminuted Fruits and Vegetables: Collaborative Study

The official AOAC method for determination of Geotrichum mold in canned fruits and vegetables (44.079) requires a series of 3 sieves, Nos. 8, 16, and 230, to separate the packing liquid from the product and the mold from the packing liquid. Although this method has been successful for whole or coarsely chopped products (e.g., green beans, potatoes, carrots, and beets), finely divided products such as fruit purees and tomato products tend to clog the sieves. A method was developed in which the product is centrifuged, diluted by volume, stained with crystal violet, and counted with the sieving steps eliminated. The proposed method was adopted official first action.

Particle size and concentration adjustments of tomato products for Howard mold count

The present AOAC method for mold counts of tomato products (44.096) provides no inter-product standardization of concentration among juice, sauce, paste, puree, and catsup; no intra-product standardization of concentration for juice, sauce, and catsup; and no adjustment for degree of comminution. Use of the official method, therefore, could result in an artificially increased mold count for products which have undergone extreme comminution. A new method was developed to adjust all products to the same concentration and grind them to a uniform particle size, thereby ensuring comparable mold counts on products produced by different processes. Collaborative study results showed equal repeatability for both the official and the proposed methods and a lower coefficient of variation for the proposed method.

Particle Size and Concentration Adjustments of Tomato Products for Howard Mold Count

The present AOAC method for mold counts of tomato products (44.096) provides no inter-product standardization of concentration among juice, sauce, paste, puree, and catsup; no intra-product standardization of concentration for juice, sauce, and catsup; and no adjustment for degree of comminution. Use of the official method, therefore, could result in an artificially increased mold count for products which have undergone extreme comminution. A new method was developed to adjust all products to the same concentration and grind them to a uniform particle size, thereby ensuring comparable mold counts on products produced by different processes. Collaborative study results showed equal repeatability for both the official and the proposed methods and a lower coefficient of variation for the proposed method.

Extraction of Thrips and Other Whole or Equivalent Insects from Frozen Blackberries and Raspberries: Collaborative Study

A method was developed for the extraction of thrips and other whole or equivalent insects from frozen blackberries and raspberries. The method consisted of a thawing and drained weight step, followed by acid maceration. Berries were wet-sieved over a No. 25 sieve nested in a No. 80 sieve. The berry tissue retained on the No. 80 sieve was dehydrated with isopropanol and then treated with chloroform. The chloroform was stripped from the residue with isopropanol. The berry residue was extracted with light mineral oil from a 40% isopropanol-Tween 80- Na4EDTA mixture. The collaborative study was successfully completed with 83.3% average recoveries of thrips and a 19.2% coefficient of variation. The method has been adopted official first action.