Endoluminal Vacuum Therapy (EVAC) in Managing Esophagogastric Anastomosis Fistula / Terapia de vacío endoluminal (Endo-Vac) en el manejo de la fístula de anastomosis esofagogástrica

Abstract Endoluminal vacuum therapy (EVAC) is a promising alternative for the endoscopic management of gastrointestinal fistulas or perforations that do not respond to endoscopic procedures using clips and stents or are even refractory to surgical procedures. In this case report, we describe the successful endoscopic closure of an esophagogastric anastomotic fistula using EVAC, connected to a vacuum system through a probe in the cavity, which did not close with clip management given the friability and edema of the peri-wound tissue. In conclusion, it is a successful alternative to treat these complications, which are sometimes difficult to resolve.

Resumen La terapia de vacío endoluminal (Endo-Vac) es una alternativa promisoria en el manejo endoscópico de las fístulas o perforaciones gastrointestinales, que no responden a procedimientos endoscópicos cuando se utilizan técnicas como clips, stents o incluso refractarias a procedimientos quirúrgicos. En este reporte de caso describimos el cierre endoscópico exitoso de una fístula anastomótica esofagogástrica, utilizando la terapia Endo-Vac, conectada a un sistema de vacío mediante una sonda en la cavidad, que no presentó cierre inicial a manejo con clips, dada la friabilidad y el edema del tejido perilesional. Se concluye que esta es una alternativa exitosa en el cierre de estas complicaciones, que en ocasiones son de difícil resolución.

Clinical efficacy of off-midline closure techniques for treatment of chronic pilonidal sinus / 中华医学美学美容杂志

Objective:To evaluate the clinical efficacy of off-midline closure technique in the treatment of chronic pilonidal sinus.Methods:From July 2014 to July 2018, 59 patients suffered from chronic pilonidal sinus treated by off-midline closure were admitted to the Department of Proctology, Linyi Central Hospital, including 34 males and 25 females. According to the size and scope of the chronic pilonidal sinus, the off-midline flap was designed and sutured.Results:In this group of 59 patients, there were 52 cases of primary healing and 7 cases of incision complications, such as partial incision dehiscence and subcutaneous effusion. After follow-up for 2 years, no recurrence was observed. The scar was not obvious after wound healing. The patient was satisfied with the postoperative appearance.Conclusions:Using the off-midline closure technique to treat chronic pilonidal sinus can deviate from the midline to make the suture tension-free and the gluteal groove elevated. It not only effectively reduce the complication rate in patients, but also has high cure rate, low recurrence rate and does not affect appearance.

A novel and simplified closure method for defect closure after endoscopic full-thickness resection of gastric submucosal tumors: short-term outcomes of "Shao-Mai" closure method / 中华胃肠外科杂志

Objective@#To evaluate the feasibility and short-term efficacy of a novel and simplified closure method developed by our team for the defect closure after endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMT) in the gastric wall.@*Methods@#A prospective single-arm clinical study was used. Inclusion criteria: (1) the lesion was located in the fundus or the greater curvature of the stomach, and was confirmed to originate from the muscularis propria layer; (2) the diameter of the tumor was ≤3.5 cm, and the tumor had no extensive adhesion to the peritoneal tissues and organs in extraperitoneal cavity; (3) the tumor had no malignant features under ultrasound endoscopy; (4) the patient agreed to participate in the study; (5) patients with severe complications were excluded. Based on the above criteria, 20 patients with gastric SMT at the Endoscopy Center of Zhongshan Hospital of Fudan University from January 2015 to March 2018 were enrolled in this study, including 5 males and 15 females with mean age of 61.1 (38 to 70) years. Grasping forceps-assisted endo-loop snare ligation device which is called "Shao-Mai" method was used to close the defect site. All the patients underwent EFTR and "Shao-Mai" method to perform defect closure. After successful tumor resection by EFTR, an endo-loop was anchored onto the edge of the gastric defect with grasping forceps assistance and closed tightly. The observation indicators included tumor size, en bloc resection, operation time, postoperative complications and hospital stay. The follow-up indicators included tumor residual, local recurrence, and metachronous lesions.@*Results@#All the 20 lesions were located in the muscularis propria with a size of 0.5-3.5 (mean 1.4) cm. Three of them were located in the greater curvature of the mid-upper gastric body, 17 were located in the fundus. The endoscopic "Shao-Mai" closure was successfully performed after EFTR in all the 20 cases. Endoscope was used uniquely through the entire process, without laparoscopic assistance. The operative time was 20-100 (mean 43.8) minutes, while the "Shao-Mai" closure procedure took a range of 3-30 (mean 10.1) minutes. The en bloc resection rate was 100%. The pathological diagnosis included 17 gastrointestinal stromal tumors and 3 leiomyomas. No major complications occurred during or after surgery. All the patients were discharged 1-11 (mean 3.1) days after operation. The wounds of all the cases were healed completely six months after operation and only scar was observed without ulcer. No residual lesion, tumor recurrence or metastasis, leakage or fistula of digestive tract were found during the follow-up period of 15-54 (median 41) months.@*Conclusion@#The endoscopic "Shao-Mai" closure method is a simplified novel way, which is feasible, effective, and safe for closing the gastric defect after EFTR.

Clinical Trial on the Incidence of Wound Infection and Patient Satisfaction After Stoma Closure: Comparison of Two Skin Closure Techniques

PURPOSE: Surgical site infection (SSI) is one of the most common complications that can occur after stoma closure. Reports have described differences in the incidence of wound infection depending on the skin closure technique, but there is no consensus on the ideal closure technique for a stoma wound. The aim of this study was to compare the incidence of SSI and the patient satisfaction between a circumferential purse-string approximation (CPA) and a primary linear closure (PC) of a stoma wound. METHODS: This prospective nonrandomized trial enrolled 48 patients who underwent a stoma closure from February 2010 to October 2013. Patients were divided into two groups according to the stoma closing technique: the CPA group (n = 34) and the PC group (n = 14). The incidences of SSI for the two groups were compared, and the patients' satisfaction with the stoma closure was determined by using a questionnaire. RESULTS: SSI occurred in 3 of 48 patients (6.3%) and was more frequent in the PC group than in the CPA group (3/14 [21.4%] vs. 0/34 [0%], P = 0.021). Time to complete healing after stoma closure in the CPA group was 32 days (range, 14-61 days). Patients in the CPA group were more satisfied with the resulting wound scar (P = 0.043). CONCLUSION: After stoma closure, CPA was associated with a significantly lower incidence of wound infection and greater patient satisfaction compared to PC. However, with the CPA technique, the time to heal is longer than it is with PC.

Multidirectional Vector Excision Leads to Better Outcomes than Traditional Elliptical Excision of Facial Congenital Melanocytic Nevus

BACKGROUND: The elliptical excision is the standard method of removing benign skin lesions, such as congenital melanocytic nevi. This technique allows for primary closure, with little to no dog-ear deformity, but may sacrifice normal tissue adjacent to the lesion, resulting in scars which are unnecessarily long. This study was designed to compare the predicted results of elliptical excision with those resulting from our excision technique. METHODS: Eighty-two patients with congenital melanocytic nevus on the face were prospectively studied. Each lesion was examined and an optimal ellipse was designed and marked on the skin. After an incision on one side of the nevus margin, subcutaneous undermining was performed in the appropriate direction. The skin flap was pulled up and approximated along several vectors to minimize the occurrence of dog-ear deformity. RESULTS: Overall, the final wound length was 21.1% shorter than that achieved by elliptical excision. Only 8.5% of the patients required dog-ear repair. There was no significant distortion of critical facial structures. All of the scars were deemed aesthetically acceptable based on their Patient and Observer Scar Assessment Scale scores. CONCLUSIONS: When compared to elliptical excision, our technique appears to minimize dogear deformity and decrease the final wound length. This technique should be considered an alternative method for excision of facial nevi.

Application of Lumbar Artery Perforator Flap for Reconstruction of Back Ulcer: Clinical Study with Computed Tomographic Angiography

PURPOSE: Un-healing and centrally located defect on back area, it is sometimes a challenge for the reconstructive surgeon. Although skin grafts are considered as the first choice for reconstruction of large skin defect on the back region, it is not always helpful but vascularized flaps provide a superior functional and aesthetic outcome. The present study was designed to investigate the clinical anatomy of the lumbar artery perforator flap to reconstruct back ulcer. MATERIALS AND METHODS: Clinical anatomy study was undertaken using computed tomographic angiographic analysis. We identified the courses of lumbar arteries and its perforators, measured pedicle length by layers. The location of the perforator vessel was charted against anatomical landmarks. RESULTS: The pedicle lengths of the third and fourth lumbar artery perforator reached a mean of 27.8 mm and 37.1 mm respectively from superficial fascia to deep fascia. The fourth perforator was more laterally located than the third perforator and less than 1 cm above the iliac crest. A case in which the fourth lumbar artery perforator was used as flap pedicle is described. CONCLUSION: For the reconstruction of central defect on the back area, the lumbar artery perforator flap coverage may be a good alternative option. Computed tomographic angiography can easily identify the course and location of lumbar artery perforators and can be helpful to elevate the flap successfully.

Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series

OBJECTIVE: To compare the surgical outcomes of stapled and handsewn closures in loop ileostomies. METHODS: The data of 225 patients requiring loop ileostomies from 2002 to 2007 were retrospectively evaluated. The patients underwent partial small-bowel resections and either handsewn or stapled anastomoses for the ileostomy closures. They were followed up postoperatively with routine surgical examinations. RESULTS: The study group consisted of 124 men and 101 women with a mean age of 49.12 years. The ileostomy closure was performed with handsewn in 129 patients and with stapled in 96 patients. The mean time to the first postoperative flatus was 2.426 days in the handsewn group and 2.052 days in the stapled group (p <0.05). The mean time to the first postoperative defecation was 3.202 days in the handsewn group and 2.667 days in the stapled group (p <0.05). The mean duration of patient hospital stay was 8.581 days for the handsewn group and 6.063 days for the stapled group (p <0.05). CONCLUSIONS: Patients who underwent ileostomy closure with stapled recovered faster in the postoperative period and required shorter hospital stays than those whose closures were performed with handsewn. In our opinion, stapled should be considered the gold standard for loop ileostomy closures.

Role of suture material and technique of closure in wound outcome following laparotomy for peritonitis.

Background: There are no accepted guidelines for the closure of laparotomy incisions in patients of peritonitis. As these patients differ from the patients undergoing elective abdominal surgery, the same recommendations for closure may not be applicable in both groups. Aim: To compare wound outcome parameters following closure of the laparotomy incision with absorbable and non-absorbable suture material using the continuous and interrupted techniques in patients of peritonitis. Method: A single blinded randomised controlled trial using Polygalactin–910 and Polypropylene, number 1 sutures, to close midline vertical incisions, placed in continuous and interrupted manner, was performed on 174 patients. Patients were randomised into four groups: Group A (Polygalactin-910 continuous suturing, n=40), B (Polygalactin-910 interrupted suturing, n=47), C (Polypropylene continuous suturing, n=45) and D (Polypropylene interrupted suturing, n=42). The incidence of wound infection, dehiscence, suture sinus formation and incisional hernia was recorded. Patients were followed up for a period of four years. Statistical analysis involved the chi-square and Fisher’s exact tests. A ‘p’ value of <0.05 was considered significant. Results: The study included 139 male and 35 female patients between the ages of 10 and 75 years. The incidence of wound infection (p=0.656), dehiscence (p=0.997), and incisional hernia (p=0.930) at 3 months and four years (p= 0.910) was not statistically significant. There was no sinus formation in groups A and B, however 2 patients of group C and 6 patients of group D did develop suture sinus (p=0.003). Conclusion: Suture material and technique of closure does not influence wound outcome in patients of peritonitis except for a significantly lower incidence of sinus formation when non-absorbable sutures are used.

Application of modified abdominal closure technique by an all layer in ventro-pelvic part operation / 肿瘤研究与临床

Objective To investigate application of modified abdominal closure technique by an all layer in ventro-pelvic part operation and evaluate its value and significance. Methods 3200 cases with ventre-pelvic part operation between May 2002 and Aug 2007, were subjected to single layer closure with non absorbable suture material. The clinic data and some results of follow-up were retrospectively analyzed. Results Operative incisions of 1780 (55.6%) cases were in epigastric zone and their rate of primary healing was 98.5%, others (44.3%) in hypogastric zone (including pelvic cavity) and rate of primary healing was 98.2% (P>0.05). Rate of primary healing in older age-group was 97.9% and control group 98.8%, and primary healing of group diabetes 97.4%, control group 98.2% (P > 0.05). Average time of abdmenal closure was only 11±4 min. Primary complications included dehiscence of wound (0.5%), infection (1.4%) and incisional hernia (0.2%). Follow-up (66%) was performed at 30 days, 3 and 6 months, and at 1, 2 and 3 years. Conclusion It is concluded that closure of an abdominal incision can be effected by a multifilament interrupted absorbable sutures without an increased risk of wound dehiscence or incisional hernia, meanwhile economic and fast. It is the optimal method of abdominal closure and can be generalized.

Application of peritoneal non-closure technique in radical surgery of cervical carcinoma / 中国癌症杂志

Purpose:To assess the postoperative effects that maybe associated with the closure or non closure of peritoneum at transabdominal radical surgery of cervical carcinoma, and observe the feasibility of applying peritoneal non closure technique in gynaecological tumor operations.Methods:852 patients undergoing radical surgery in our hospital between August 1998 to August 2001 were divided randomly into two groups: peritoneum closed ( n = 407) or peritoneum open ( n = 445). Student u test and Chi square test were used for statistical analysis of the results: operative duration, bowel function restoration, febrile duration, antibiotics requirement, lymphadenocyst formation, pelvic infection and ileus and incision healing of the two groups.Results:As compared to the closure of peritoneum, the length of operation time and bowel function restoration were shorter, febrile duration was shorter, the morbidity of pelvic infection and lymphadenocyst formation were lower, antibiotics requirement was fewer, the incidence of ileus and wound infection was significantly less frequently seen in the non closure group( P