A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer.

BACKGROUND: The aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer. METHODS: Patients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016-2021) were compared to a multicentre cohort of primary closure (2000-2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis. RESULTS: Twenty-five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734-6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184). CONCLUSIONS: The uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

Combined use of a petal flap and V-Y advancement flap for reconstruction of presacral defects following rectal resection.

BACKGROUND: The aim of this study was to evaluate the efficacy of a combination of flaps for the reconstruction of presacral defects following abdominoperineal resections: a paramedian vertically oriented caudally based lotus petal flap for presacral defects combined with a horizontal V-Y advancement flap for closure of the superficial donor site defect. METHODS: A retrospective study was conducted on patients with a residual defect following an abdominoperineal resection between 2010 and 2017 in the Noordwest Ziekenhuisgroep. The primary endpoint was complications related to the reconstruction. RESULTS: Twelve patients were included, all reconstructions healed well. Three patients had a grade I or II complication (Clavien Dindo classification). CONCLUSIONS: Use of a petal flap and V-Y advancement flap for reconstruction of presacral defects was found to be safe and simple, and should, therefore, be considered in the management of such problems.

Long-term outcomes after contaminated complex abdominal wall reconstruction.

PURPOSE: Complex abdominal wall repair (CAWR) in a contaminated operative field is a challenge. Available literature regarding long-term outcomes of CAWR comprises studies that often have small numbers and heterogeneous patient populations. This study aims to assess long-term outcomes of modified-ventral hernia working group (VHWG) grade 3 repairs. Because the relevance of hernia recurrence (HR) as the primary outcome for this patient group is contentious, the need for further hernia surgery (FHS) was also assessed in relation to long-term survival. METHODS: A retrospective cohort study with a single prospective follow-up time-point nested in a consecutive series of patients undergoing CAWR in two European national intestinal failure centers. RESULTS: In long-term analysis, 266 modified VHWG grade 3 procedures were included. The overall HR rate was 32.3%. The HR rates for non-crosslinked biologic meshes and synthetic meshes when fascial closure was achieved were 20.3% and 30.6%, respectively. The rates of FHS were 7.2% and 16.7%, and occurred only within the first 3 years. Bridged repairs showed poorer results (fascial closure 22.9% hernia recurrence vs bridged 57.1% recurrence). Overall survival was relatively good with 80% en 70% of the patients still alive after 5 and 10 years, respectively. In total 86.6% of the patients remained free of FHS. CONCLUSIONS: In this study of contaminated CAWR, non-crosslinked biologic mesh shows better results than synthetic mesh. Bridging repairs with no posterior and/or anterior fascial closure have a higher recurrence rate. The overall survival was good and the majority of patients remained free of additional hernia surgery.

The development and validation of risk-stratification models for short-term outcomes following contaminated complex abdominal wall reconstruction.

BACKGROUND: Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien-Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR. METHODS: A consecutive cohort of patients who underwent CCAWR in two European national intestinal failure centers, from January 2004 to December 2015, was identified. Data were collected retrospectively for short-term outcomes and used to develop risk models using logistic regression. A further cohort, from January 2016 to December 2017, was used to validate the models. RESULTS: The development cohort consisted of 272 procedures performed in 254 patients. The validation cohort consisted of 114 patients. The cohorts were comparable in baseline demographics (mean age 58.0 vs 58.1; sex 58.8% male vs 54.4%, respectively). A multi-variate model including the presence of intestinal failure (p < 0.01) and operative time (p < 0.01) demonstrated good discrimination and calibration on validation. Models for wound and intra-abdominal complications were also developed, including pre-operative immunosuppression (p = 0.05), intestinal failure (p = 0.02), increasing operative time (p = 0.04), increasing number of anastomoses (p = 0.01) and the number of previous abdominal operations (p = 0.02). While these models showed reasonable ability to discriminate patients on internal assessment, they were not found to be accurate on external validation. CONCLUSION: Acceptable short-term outcomes after CCAWR are demonstrated. A robust model for the prediction of CD ≥ grade 3 complications has been developed and validated. This model is available online at www.smbari.co.uk/smjconv2.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer.

BACKGROUND: Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. METHODS: Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. RESULTS: Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days). CONCLUSIONS: The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.

A squamous cell carcinoma in a young woman with Lynch syndrome.

Lynch syndrome (LS) is an autosomal-dominant inherited disorder characterized by a predisposition to colorectal cancer and extracolonic cancers (particularly endometrium, ovary, stomach, small bowel, hepatobiliary tract, pancreas, urothelial tract, brain, and skin). Muir-Torre syndrome (MTS) is considered a phenotypical variant of LS, where patients develop sebaceous neoplasms and keratoacanthomas. Currently, only few studies and case reports suggest an association between LS and other skin cancers, such as Bowens' disease, melanoma and squamous cell carcinoma (SCC). In this case-report we describe the case of a 33-year-old woman with LS and a proven MSH2 germline mutation, presenting with a SCC on the right cheek. Immunohistochemistry lacked MSH2 and MSH6 protein staining. The tumor showed a discordance between immunohistochemistry and micro-satellite instability status, for which a clear explanation cannot be provided yet. To conclude whether this pattern is indicative for SCC occurring in LS patients, further analyses of other LS patients presenting with SCC should be carried out. Our patient's young age and skin type (Fitzpatrick phototype VI) suggest a possible link between LS and cutaneous SCC.

Inter- and intrarater reliability of Hurley staging for hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, inflammatory and recurrent skin disease. Different staging instruments have been suggested, but none has achieved universal acceptance. Despite the fact that Hurley staging is one of the most widely applied HS disease severity staging instruments, it has not been validated. OBJECTIVES: To determine the inter- and intrarater reliability of the Hurley staging system. METHODS: Fifteen raters (five plastic surgeons, five general surgeons and five dermatologists) independently staged 30 photos of patients with HS according to Hurley staging at two time points. Reliability was assessed using kappa (&kgr;) statistics, and multivariable logistic regressions were used to determine independent risk factors for photos with discordant staging. RESULTS: Inter-rater reliability was moderate for the three stages of HS [κ = 0·59, 95% confidence interval (CI) 0·48-0·70]. It was moderate for Hurley stage I (κ = 0·45, 95% CI 0·32-0·55) and stage II (κ = 0·51, 95% CI 0·31-0·71) and it was almost perfect for stage III (κ = 0·81, 95% CI 0·62-1·00). The intrarater reliability was substantial for all stages and all raters (κ = 0·65, 95% CI 0·58-0·72). For stage I it was moderate (κ = 0·50, 95% CI 0·38-0·62), for stage II it was substantial (κ = 0·62, 95% CI 0·51-0·73) and for stage III it was almost perfect (κ = 0·82, 95% CI 0·77-0·87). Hurley stages II and III were less likely to result in discordant staging than Hurley stage I (odds ratios 0·47, 95% CI 0·29-0·77 and 0·21, 95% CI 0·12-0·38, respectively). The mean time spent on staging a photo was 14 s. CONCLUSIONS: Hurley staging is reliable for rapid severity assessment of HS, with moderate inter-rater and substantial intrarater reliability for all stages. It is best for assessing Hurley stage III HS, which is an indication for surgery.

[Multidisciplinary approach of facial injuries]. / Multidisciplinaire aanpak bij aangezichtsletsel.

BACKGROUND: Approximately one quarter of polytrauma patients has facial injuries, which usually lead to loss of form and function. Several specialties are involved in the acute and reconstructive phases of facial injuries, such as oral and maxillofacial surgery, otorhinolaryngology, plastic surgery, ophthalmology and dentistry. CASE DESCRIPTION: A 25-year-old man with severe facial injuries was brought to the shock room after sustaining high-energy trauma. He had a panfacial fracture that required reconstruction. This was done with two surgeries, with an interval of 4 days. The patient recovered successfully after this. CONCLUSION: Because of the complexity of facial trauma, many factors are involved in acute care and treatment. It is therefore important to designate one coordinating specialty to guide this process. The oral and maxillofacial surgeon plays a vital role in this.

Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair.

PURPOSE: To evaluate if incisional prophylactic negative pressure wound therapy (pNPWT) reduces wound infections and other wound complications in high-risk patients undergoing major complex ventral abdominal wall repair. METHODS: Retrospective before-after comparison nested in a consecutive series of patients undergoing elective major complex abdominal wall repair. Starting January 2014, pNPWT was applied on the closed incisional wound for a minimum of 5 days. To minimize selection bias, we compared two periods of 14 months before and after January 2014. Wound infections according to the Centre for Disease Control Surgical Site Infection classification as well as other wound complications were recorded. RESULTS: Thirty-two patients were included in the pNPWT group and 34 in the control group. The study group involved clean-contaminated and contaminated operations due to enterocutaneous fistula, enterostomies or infected mesh. Median duration of pNPWT was 5 days (IQR 5-7). Overall wound infection rate was 35%. pNPWT was associated with a significant decrease in postoperative wound infection rate (24 versus 51%; p = 0.029, OR 0.30 (95% CI 0.10-0.90)). Incisional wound infection rates dropped from 48 to 7% (p < 0.01, OR 0.08 (95% CI 0.16-0.39), whereas the number of subcutaneous abscesses was comparable in both groups. Moreover, less interventions were needed in the pNPWT group (p < 0.001). CONCLUSIONS: Closed incision pNPWT seems a promising solution to reduce the incidence of wound infections in complex abdominal wall surgery. Randomized controlled trials are needed to estimate more precisely the value and cost-effectiveness of pNPWT in this high-risk setting.

Postoperative single-dose interstitial high-dose-rate brachytherapy in therapy-resistant keloids.

PURPOSE: Patients with keloids complain of the cosmetic aspect, pain, and pruritus. Many different therapies are being used for keloids. The aim of this study was to evaluate the recurrence rate and outcome after resection followed by a single-dose brachytherapy. METHODS AND MATERIALS: Patients treated by resection of the keloid plus a single dose of 13 Gy high-dose-rate brachytherapy were evaluated at least 1 year after treatment. Clinical response and cosmesis were assessed by a plastic surgeon and by the patients using the Patient and Observer Scar Assessment Scale. RESULTS: Only 24 of the 61 invited patients responded to participate with the study; 29 keloids were evaluated. The recurrence rate was 24.1% after a median followup of 53 months (19-95 months). Patients scored on average 24.3 for their total Patient and Observer Scar Assessment Scale score (range 6-52), whereas the observer scored on average 14.6 (range 6-42). CONCLUSIONS: This treatment has a higher recurrence rate than that reported in most other studies. This may be explained by differences in recurrence definition, differences in followup time among studies, and selection bias because of not contributing to the study. The cosmetic outcome for evaluated patients is relatively good. This treatment policy has the advantage that patients are treated in a single day.

Is there a place for a biological mesh in perineal hernia repair?

PURPOSE: This study aimed to determine the outcome of perineal hernia repair with a biological mesh after abdominoperineal resection (APR). METHOD: All consecutive patients who underwent perineal hernia repair with a porcine acellular dermal mesh between 2010 and 2014 were included. Follow-up was performed by clinical examination and MRI. RESULTS: Fifteen patients underwent perineal hernia repair after a median of 25 months from APR. Four patients had a concomitant contaminated perineal defect, for which a gluteal fasciocutaneous flap was added in three patients. Wound infection occurred in three patients. After a median follow-up of 17 months (IQR 12-24), a clinically recurrent perineal hernia developed in 7 patients (47 %): 6 of 11 patients after a non-cross-linked mesh and 1 of 4 patients after a cross-linked mesh (p = 0.57). Routine MRI at a median of 17 months revealed a recurrent perineal hernia in 7 of 10 evaluable patients, with clinical confirmation of recurrence in 5 of these 7 patients. No recurrent hernia was observed in the three patients with combined flap reconstruction for contaminated perineal defects. CONCLUSION: A high recurrence rate was observed after biological mesh repair of a perineal hernia following APR.

Surgery for complex perineal fistula following rectal cancer treatment using biological mesh combined with gluteal perforator flap.

Three patients with complex perineal fistula after extensive pelvic surgery and radiotherapy underwent surgical treatment combining a biological mesh for pelvic floor reconstruction and a unilateral superior gluteal artery perforator (SGAP) flap for filling of the perineal defect. All patients had both fecal and urinary diversion. Two fistulas originated from the small bowel, necessitating parenteral feeding, and one from the bladder. Symptoms included severe sacral pain and skin maceration. After laparotomy with complete debridement of the pelvic cavity, the pelvic floor was reconstructed by stitching a biological mesh at the level of the pelvic outlet. Subsequently, patients were turned to prone position, and perineal reconstruction was completed by rotating a SGAP flap into the defect between the biomesh and the perineal skin. Operating time ranged from 10 to 12.5 h, and hospital stay lasted from 9 to 23 days. The postoperative course was uneventful in all three patients. Reconstruction of large pelvic defects with a combination of biological mesh and SGAP flap is a viable alternative to a rectus abdominis musculocutaneous flap and may be preferable after extensive pelvic surgery with ostomy.

Surgical management of gynecomastia: 20 years' experience.

BACKGROUND: Gynecomastia, breast hypertrophy in men, is a common finding. The diagnosis is clinical, and ancillary tests may be performed; however, there is no unanimity in the literature about their use or utility. The mainstay of management is conservative, with a minority of patients being operated on. The surgical treatment of gynecomastia is not restricted to one discipline and is performed by plastic, general, and pediatric surgeons. The aim of this study was to assess the experience treating gynecomastia in a university hospital and the practices of the different surgical disciplines in the diagnosis and surgical treatment of gynecomastia; this knowledge could be used for the formulation of guidelines and the allocation of health-care resources. SETTING: a university medical center. DESIGN: A retrospective cohort study in which all records of patients operated on for gynecomastia over a 20-year period were retrieved. Data were obtained concerning patient demographics, responsible surgical discipline, the workup and etiology found, the surgical technique used, the occurrence of reoperations and revisions, and the use of pathological examination and its results. RESULTS: A total of 179 patients were treated. There was a difference between the patient groups operated on by the different disciplines regarding the indication, the workup, as well as in the operative techniques used. Plastic surgeons performed more bilateral operations than the other disciplines. Surgeons used more radiology and cytology testing. CONCLUSION: These results most probably represent differences in the population and pathologies treated. This is possibly due to a bias in the referrals by primary care physicians.

Different models of training and certification in plastic surgery.

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Meningomyelocele reconstruction with bilobed flaps.

A new method for the repair of meningomyeloceles is described. After neurosurgical repair and closure of the placode, the soft-tissue deficit is closed using a bilobed flap. The flap is based superiorly and laterally to the area to be covered. The first lobe crosses the midline above the defect, and the second lobe goes up the midline perpendicular to the first lobe. Once in place, the flap provides a tension-free repair; no suture lines overlie the cord closure.

Congenital epulis.

Epulis is a rare tumor of the newborn, also known as granular cell tumor of the newborn or Neumann's tumor. This tumor arises from the mucosa of the gingiva, most commonly from the anterior part of the maxillary alveolar ridge, and is typically seen as a mass protruding out of the newborn child's mouth, which may interfere with respiration or feeding. Epulis is seen only in the newborn and is a different entity from other granular cell tumors. The tumor has a marked female preponderance of 8:1. The recommended treatment is prompt surgical resection. Recurrences of the tumor and damage to future dentition have not been reported, suggesting that radical excision is not warranted. A newborn female with such a mass is described. The tumor was resected using a carbon dioxide laser; the postoperative course was uneventful. On histologic examination, it was composed of diffuse sheets and clusters of polygonal cells containing small round to oval nuclei and abundant coarsely granular cytoplasm. The tumor cells stained positive for vimentin, and negative for S100-protein, actin, desmin, laminin, keratin, estrogen, and progesterone receptors. Electron microscopic examination showed granular cells containing heterogeneous electron-dense granules, lysosomes, and cytoplasmic lipid droplets. The clinical and microscopic features of such tumors are reviewed.

An improved design for vacuum tube drains.

Mini vacuum drains can be helpful in reconstructive surgery. The drains may be assembled using a scalp needle and a vacuum tube. The addition of the adapter that is used with the vacuum tubes for blood sampling improves the ease of use and practicality of these drains and increases their safety.