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Background : Risk factors for surgical site infection (SSI) are thought to include poorly controlled diabetes mellitus, dialysis, and a long operating time, but patients without risk factors can also develop infection. Therefore, it is possible that SSI could be prevented by routinely using the precautions against SSI developed for high-risk patients. We investigated the route and pathogenetic mechanism of mediastinitis, which is the most frequent SSI after cardiac surgery. We hypothesized that mediastinitis occurred when the deep sternal marrow was contaminated by skin bacteria. Based on this hypothesis, we investigated the efficacy of various intraoperative prophylactic methods for preventing mediastinitis. Methods : We evaluated 658 patients undergoing cardiac surgery at our institution between April 2011 and July 2016. They were classified into two groups. Group C comprised 406 patients who received standard insertion of a sternal retractor after sternotomy. Group S was 252 patients in whom a retractor was inserted after covering the sternal marrow with oxidized cellulose hemostats and belt-like thin towels, with surplus parts of the towels being used to fill subcutaneous dead space at the superior and inferior margins of the midline wound. We investigated the following 10 risk factors for mediastinitis: diabetes (HbA1c≥7.5), renal failure (Cr≥2), smoking, obesity (BMI≥30), reoperation, urgent/emergency operation, intubation in the preoperative period, long operating time (≥8 h), reopening the chest for hemostasis, and coronary artery bypass grafting (CABG). Factors associated with mediastinitis were determined using univariate modeling analysis followed by multi-variate logistic regression analysis. Results : Mediastinitis occurred in 13 patients (2.0%). The significant risk factor for mediastinitis were urgent/emergency operation and CABG, but 1 patient had no risk factors. A univariate analysis showed statistical significance in CABG, presence of maneuver covering the sternal marrow, JapanSCORE-II in mortality and deep sternum infection (DSI). Reopening the chest for hemostasis, CABG, aortic aneurysm, plural risk factors, and JapanSCORE-II in DSI were identified as a risk factor by multiple logistic regression, not all factors showed a significant difference. Mediastinitis only occurred in group C, and it was significantly less frequent in group S with additional precautions against infection including propensity score matching analysis (p<0.05). Conclusion : When the bone marrow of the transected sternum was covered tightly to protect it from contamination by skin bacteria during cardiac surgery, the frequency of postoperative mediastinitis was significantly reduced.
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Objective To evaluate the application value of absorbable hemostat textile as submucosal injection of endoscopic submucosal dissection(ESD). Methods Twelve New Zealand rabbits were injected with absorbable hemostat textile solution,glycerol fructose and normal saline. The uplift effect was measured after injection. Simulated ESD was performed in the rabbit stomach and bleeding amount was measured. The injection site was pathologically examined at 30 minutes after the soluble hemostat textile and normal saline were injected. Fifteen pigs were injected with absorbable hemostat textile at two locations of 20-30 cm from the anus,and injected normal saline at another two locations of 20-30 cm from the anus.One site was performed simulated ESD and the other was not. Fifteen simulated ESD were performed in the soluble hemostatic group and the normal saline group, respectively. Operation time was recorded and difference in wound healing was compared between the two groups. Results In the uplift experiment, the absorbable hemostat textile group had higher uplift height(4.3±1.4 mm,4.1±1.9 mm,3.8±0.7 mm, 3.3±0.9 mm, respectively)at 0 min,10 min,20 min,30 min than that of the glycerol fructose group(4.3±2.2 mm,4.1± 2.0 mm,3.6±1.4 mm, 3.2±0.8 mm, respectively, P<0.05), and the glycerol fructose group was higher than that of the normal saline group(3.8±1.6 mm,2.6±1.4 mm,1.9±1.9 mm,1.1±0.7 mm, P<0.05). There was no significant difference in uplift height between the absorbable hemostat textile group and the glycerol fructose group(P>0.05). In the bleeding experiment, the bleeding amount of absorbable hemostat textile group was significantly less than that of the glycerol fructose group(0.36±0.07 mL VS 0.42±0.06 mL, P<0.05);the bleeding amount of glycerol fructose group was significantly lower than that of the normal saline group(0.42±0.06 mL VS 0.55±0.07 mL,P<0.05). There was no obvious tissue necrosis and other adverse complications in the absorbable hemostat textile group and the normal saline group. In simulated ESD experiment,complete resection rate of the absorbable hemostat textile group was higher than that of the normal saline group[86.7%(13/15)VS 46.7%(7/15), P<0.05], and mean operation time of the absorbable hemostat textile group was less than that of the normal saline group(3.2± 0.3 min VS 3.8± 0.5 min, P<0.05). No hemorrhage, perforations or other related adverse events occurred in non-ESD lesions. Conclusion Absorbable hemostat textile is safe and effective as submucosal injection of ESD.
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El trabajo repasa la evolución histórica en el entendimiento y en el manejo de la cirugía tiroidea. Describe los orígenes de esta cirugía y su ejecución, mucho antes de que se entendiera el funcionamiento de la glándula. Enumera los personajes más trascendentes de esta historia y cómo otras técnicas aplicadas en la cirugía oncológica general se adaptaron a la cirugía de cabeza y cuello. Se mencionan las innovaciones tecnológicas en cirugía tiroidea.
This work reviews the historical evolution of thyroid surgery, its understanding and management. It mentions the origins of this surgical procedure and its execution well before the understanding of the glandular function. The leading persons in this historical field are enumerated; and a review is made of how other techniques applied in surgical oncology were adapted in head and neck surgery. Technological innovations in thyroid surgery are enumerated.