Effects of topical negative pressure therapy on perfusion and microcirculation of human skin.

BACKGROUND: Topical negative pressure wound therapy (TNPWT) is one of the most frequently used techniques in wound treatment. But some of the underlying mechanisms still remain unclear. One possible explanation is an improved microcirculation by TNPWT. OBJECTIVE: This study investigated the influence of TNPWT on microcirculation on intact skin in real-time. METHODS: In healthy individuals, we performed a combined tissue - laser/photo - spectrometry technique to monitor changes of 4 different microcirculation parameters in real-time: The local blood flow, the capillary-venous oxygen saturation, the blood flow velocity and the relative amount of hemoglobin. We compared these parameters using two different protocols: a continuously (VAC ON 60/OFF 60) and discontinuously (VAC ON 30/OFF 60/ON 5) application. RESULTS: Our results demonstrate a significant increase of all four measured parameters during the active TNPWT and the pressure free period. The comparison of two different protocols shows an advantage of the examined parameters using a discontinuous TNPWT application. CONCLUSIONS: Our study demonstrated the changes of the microvascular tissue perfusion in intact human skin under the conditions of negative pressure and may thereby offer a broader understanding of mechanisms underlying the TNPWT.

Avoidance of leakage and strictures when creating an invisible conduit for antegrade colonic enemas.

BACKGROUND: Antegrade enemas have been proven to minimize problems with stool control for many incontinent patients; however, foreign bodies are unsightly, and native tissues have been shown to leak or stricture. METHODS: Using a limited laparotomy incision, the appendix or a rolled cecal tube was sutured to the apex of the everted umbilical skin using a V-shaped incision. The skin then was inverted to hide the mucosa. The cecum was plicated around the base of the appendix or cecal tube and then tested by filling the cecum with saline to a pressure of 30 cm H2O. RESULTS: Twenty patients (aged 4.8 to 41 years) with fecal incontinence caused by imperforate anus (17 cases) and other causes underwent this procedure. Two patients had minor strictures that resolved with home dilatations, and one cecal tube necrosed, and the patient has refused reoperation. One patient had minor prolapse and underwent revision. None of the conduits leak. Two patients achieved continence and stopped cannulating their stomas. With adjustment and customization of each enema regimen, stool accidents are infrequent. Follow-up is 22 +/- 14 (mean +/- SD) months. CONCLUSION: A catheterizeable colocutaneous conduit has been developed that allows for an invisible, leak-proof, and relatively stricture-free means through which antegrade enemas can be given.

Successful repair of ectopia cordis using alloplastic materials.

Ectopia cordis is a very rare congenital anomaly associated with a high mortality rate. A successful repair of ectopia cordis with complete absence of sternum was achieved in a two-stage procedure. Initial management consisted of coverage of skin over the malpositioned heart using bilateral pectoral skin flaps. A second more definitive repair was undertaken at age 14 months. Four methyl methacrylate struts were used to reconstruct the anterior chest wall and were then covered with bilateral pectoralis major muscle flaps. At the 2.5-year follow-up there is no evidence of cardiopulmonary compromise and the development of the thorax appears normal. We advise that use of alloplastic materials is a valid option in managing this difficult congenital anomaly.

The treatment of complicated appendicitis in children using peritoneal drainage: results from a public hospital.

During the 2-year period from January 1, 1987 to December 31, 1988, 656 emergency appendectomies were performed on the Pediatric Surgery Service at the Los Angeles County-USC Medical Center. Of these, 398 patients were 12 years of age or less, and 227 appendices (57%) were perforated or gangrenous. The records of 167 of those patients with perforated or gangrenous appendices, treated by a standardized protocol are summarized. The protocol included perioperative antibiotics of gentamicin and clindamycin, appendectomy through a muscle-splitting incision, irrigation of the peritoneal cavity with saline, and peritoneal drainage through the lateral aspect of the wound with skin closure. There was no mortality, and the major complication rate was 8%, with 3% developing intraabdominal abscesses and 5% with bowel obstructions. The minor complication rate was 11%, and included prolonged ileus and prolonged fever, with no wound infections. The average hospital stay was 8.7 days. Our experience suggests that the adopted protocol is reliable for preventing wound infections without increasing the rate of intraabdominal abscesses in an innercity population with particularly advanced stages of appendicitis.

Infectious diseases in day care: parallels between psychologically and physically healthy care.

A review of day care practices in the United States indicates a substantial increase since 1977 in out-of-home care for infants and toddlers, with a preponderance of care in unlicensed family day care homes. The effects of group care on infants and toddlers depend largely on the facility's success at meeting certain criteria for group size, staff-to-child ratio, and staff training. Parallels exist between providing psychologically healthy day care and minimizing the spread of infectious disease in day care facilities. Many of the same factors involved in providing psychologically safe day care are also involved in providing disease-free care. Financial and regulatory obstacles to high-quality care are considerable; however, supplementary child care for working parents is essential, and efforts to address such problems as infectious diseases must keep this perspective.

The role and safety of early postoperative feeding in the pediatric surgical patient.

The authors report their experience with early postoperative feedings in a variety of pediatric surgical patients utilizing a needle catheter jejunostomy. A small caliber catheter, similar to that used for antecubital central venous cannulation, is inserted in the antimesenteric border of the jejunum providing a subserosal tunnel. A purse-string suture is placed around the catheter and then it is secured to the abdominal wall, and the catheter is brought out through the abdominal wall via a needle puncture wound. Our experience with 27 insertions in 25 patients ranging in age from 1 day to 17 yr, has demonstrated the ease of placement and feasibility of immediate postoperative feeding. Patients were generally started on a dilute elemental diet through the jejunostomy within 12 hr of the operative procedure. Patients were administered between one and 3.5 g of protein kg/day and between 45 and 100 cal/kg/day depending on age and weight. Duration of treatment with enteral nutrition ranged from 10 to 150 days. There was no catheter-related complications utilizing the technique described. Technical details of catheter placement and protocol for administration of early postoperative feedings are discussed. The ability to provide nutritional support via the gut has obviated the need for total parenteral nutrition in the majority of these patients.