Negative pressure wound closure system for giant thoracic defect closure in a patient with completely visible pericardium: A case report.

Negative pressure wound closure system facilitates wound closure via wound contraction. In this article, we report a successful application of thoracic negative pressure wound closure system to fill the thoracic defect, control infection, and expand the lung in a 35-year-old male patient with threerib defect, lung parenchyma injury, empyema, left complete pneumothorax, and visible pericardium after gunshot injury. The excellent result obtained in our patient demonstrates that negative pressure wound closure system is a good choice for treating high-energy thoracic injuries by reducing wound infection and enabling early wound closure.

An uncommon cause of acute abdomen in an acromegalic patient: colonic volvulus.

Acromegaly is a chronic endocrine disease, typically caused by a pituitary adenoma leading to increased circulating GH levels and increased IGF-I secretion by peripheral tissues. Gastrointestinal diseases related acromegaly such as colon cancers, adenomatous polyps, and dolichocolon are much less known. We aimed to present a case of complete colonic volvulus in a patient with acromegaly. A 60-year-old male patient presented with the complaints of inability to pass gas or stool, worsening distension, and pain for one week. The clinical exam showed significant tenderness and distended abdomen as well as a typical appearance of acromegaly. In his past medical history, he underwent an operation of pituitary adenoma with the diagnosis of acromegaly. He also underwent a sigmoid colon resection due to dolichocolon detected by abdominal computerized tomography (CT) and colonoscopy. Upright abdominal X-ray was compatible with volvulus, so endoscopic distortion was tried but failed. At exploration, entire colon was extremely dilated and had a necrotic appearance, and observed to be twisted 360 degrees around its mesenteric axis. The patient underwent total colectomy and end ileostomy. Pathology result was reported as necrotic and hemorrhagic colon with 150 cm in length and 20 cm in width. The patient was discharged on the 14th postoperative day without complications. GH and IGF-1 have an irreversible effect on colonic collagen synthesis in acromegaly and has been proposed to be correlated with the presence of dolichocolon. Dolichocolon often can lead to an abnormal rotation, volvulus, and development of Chilaiditi syndrome. The occurrence of volvulus including the whole colon, although the pituitary adenoma was treated and partial colectomy was done, refers to predisposing factor being the irreversible effect of acromegaly on the colon. KEY WORDS: Acromegaly, Emergency, Volvulus.

Comparison of modified Limberg flap transposition and lateral advancement flap transposition with Burow's triangle in the treatment of pilonidal sinus disease.

BACKGROUND: Although many options exist for surgical treatment of pilonidal sinus disease (PSD), consensus has not yet been achieved, as all surgical methods have various rates of complications, postoperative infection, and recurrence. METHODS: This study was a prospective, randomized, clinical trial, and was conducted with consecutive 100 patients admitted to Ankara Military Hospital General Surgery Service for treatment of PSD from May 2013 to August 2013. This study compared two surgical treatments for PSD: modified Limberg flap transposition and lateral advancement flap transposition with Burow's triangle. The patients received surgical treatment with either modified Limberg flap transposition (n = 50) or lateral advancement flap transposition with Burow's triangle (n = 50). Clinical healing period, length of hospital stay, operative time, postoperative complications including recurrence, wound dehiscence, and surgical site infection, as noted during postoperative follow-up period; Visual Analog Scale scores for pain. RESULTS: The mean follow-up period was 12 months. No significant differences were observed between the 2 groups in length of hospital stay (P = .515), operative time (P = .175), wound dehiscence (P = .645), and Visual Analog Scale pain scores (P = .112). The mean operative times were 42.5 minutes in the modified Limberg group and 40.0 minutes in the lateral advancement group. CONCLUSIONS: Although lateral advancement flap transposition with Burow's triangle is used less often than modified Limberg flap transposition, we could not determine a parameter that was statistically different such as operative time, postoperative complication, or the length of hospital stay. Hence, the lateral advancement flap is as viable an option as other more preferable techniques in the treatment of PSD, which particularly settled on the upper segment without a deep natal cleft.

Body mass index and ghrelin levels after laparoscopic Nissen fundoplication.

PURPOSE: The study aims to evaluate the changes between body mass index (BMI) and ghrelin levels after laparoscopic Nissen fundoplication (LNF). METHODS: Twenty-four consecutive patients with gastroesophageal reflux disease who were scheduled for LNF consented to participate in the study. The participants' age, sex, preoperative (phase 0), postoperative 1st week (phase 1) and postoperative 4th week (phase 2) dysphagia scores, plasma ghrelin levels, and BMI were recorded. RESULTS: Compared to the preoperative level (phase 0), ghrelin was decreased in both phase 1 and phase 2. A strong correlation in the changes in the ghrelin values and BMI between phase 0 and phase 2 was detected. There was a strong, statistically significant difference in the changes in the BMI values between phase 1 and phase 2. CONCLUSIONS: Total plication of the fundus impairs its ghrelin-secreting functions for up to 4 weeks and is accompanied by weight loss.

A simple novel technique for enteroatmospheric fistulae: silicone fistula plug.

Enteroatmospheric fistulae (EAFs), a rare condition that develops in patients treated with an open abdomen, present serious problems for the surgeon. There are no fixed algorithms for treatment of EAF, and treatment options are determined based on the experience of the surgeon and status of the patient. We developed a 'suspended silicone fistula plug' for treating a patient who developed an EAF after undergoing multiple operations in a short period of time. Used in conjunction with negative pressure wound therapy, application of this novel therapy resulted in EAF closure and patient discharge.

Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report.

Blast injuries, caused by explosions accompanied by high-pressure waves, produce tissue damage in the acute period, followed in the later period by circulatory disorders due to vascular endothelial damage and related tissue necrosis. Blunt rectal perforation is rare and difficult to diagnose. In the acute period following blast pelvic injuries, the main objectives are to stop bleeding, minimise contamination and preserve the patient's life. The patient in this report had major vascular injuries, severe pelvic injury and, in the later period, rectal perforation because of vascular endothelial damage caused by the blast effect. Our aim was to treat the patient conservatively because of his poor general condition. We placed a self-expanding covered stent (SECS) into the rectum and then applied negative pressure wound therapy (NPWT; V.A.C.® Therapy, KCI) to the pelvic region and perirectal area. At the end of the treatment, the rectal perforation was closed, and the patient was discharged with healing. In this article, we discuss the novel use of an SECS with NPWT and review related literature.

Effectiveness of N-butyl cyanoacrylate-based microbial skin sealant on the prevention of surgical site infections.

BACKGROUND: Surgical site infections (SSIs) are a serious concern in health care, and wound contamination by endogenous skin flora is a major factor in the development of SSIs. Despite preventive tactics in pre-operative skin care, antibiotic prophylaxis, surgical technique, and post-operative incision care, complete sterilization of the skin is not possible. Recently developed microbial skin sealant forms a continuous but breathable barrier that prevents migration of endogenous skin flora into the incision. The skin sealant closes dermal microabrasions, preventing re-colonization of potential pathogens at the incision. The purpose of this study was to determine the effect of an N-butyl cyanoacrylate-based microbial skin sealant in reducing the occurrence of SSIs in an experimental rodent model. METHODS: This was a randomized, controlled animal trial. Forty-eight Wistar albino rats were divided into six groups of eight rats each. Three groups received application of sealant against specific bacteria, and three matched control groups received only the bacteria without the sealant. Group one underwent pre-operative hair removal, followed by application of skin sealant, then abdominal incision and closure. Group two (control) simply underwent hair removal, followed by incision and closure, with no skin sealant applied. Group three received an application of cage swabs (containing a mixture of urine, stool and sawdust from the animals' cages) before application of skin sealant, and group four (control) received cage swabs without subsequent skin sealant. Group five received methicillin-resistant Staphylococcus aureus (MRSA) followed by skin sealant, and group six (control) received MRSA without skin sealant. Seven days after surgery, the animals were sacrificed. Samples were taken from the abdomen of each rat and placed in culture medium. Proliferation of the following bacteria were observed: Coagulase-negative staphylococci (CoNS), gram-positive bacilli (GPB), Pseudomonas aeruginosa, and MRSA. RESULTS: There was a statistically significant difference between the median number of GPB in the group that received cage swabs+sealant and the group that received cage swabs without sealant (median, GPB count 29,430 colony-forming units [CFU]/g vs 359,100 colony-forming units [CFU]/g; p<0.05). The study results showed that microbial skin sealant was not as effective in preventing CoNS or MRSA contamination as it was in preventing GPB contamination. CONCLUSIONS: Use of a microbial skin sealant before surgery can lower the rate of SSIs by reducing the migration of some specific bacterial agents. Additional data are needed to validate its use in clinical practice.

Rectus abdominus fascial sheath usage for crural reinforcement during surgical management of GERD: preliminary report of a prospective randomized clinical trial.

PURPOSE: Many materials are currently being used to reinforce the crural repair. Perforation, intensive fibrosis, and price are limiting the usage of these materials. Our purpose was to seek an alternative, cheap, always available, and inert material to use for cruroplasty reinforcement. METHODS: Twenty-four patients participated and were randomly divided into 2 groups (graft+laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication alone) with 12 patients in each group. Total operation time, postoperative dysphagia rate, dysphagia improvement time, postoperative pain, recurrence, and incisional hernia rate were compared. RESULTS: There was no difference in terms of study parameters between both groups except for the mean operation time. CONCLUSIONS: Autograft hiatoplasty seems to be a good alternative for crural reinforcement. It provides safe reinforcement, has the same dysphagia rates as meshless hiatoplasty, and avoids potential complications of redo surgery by minimizing extensive fibrosis. Furthermore, the rectus abdominus sheath is always available and inexpensive.

Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study.

This prospective randomized study compared single-incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to estimated blood loss, operative time, postoperative pain levels, and complications. Thirty-four study patients were divided into 2 groups: 17 patients underwent SILC and 17 underwent LC. Operative time was longer for SILC than for LC, and the difference was statistically significant (P<0.001). There was no statistically significant difference in the relationship of body mass index with operative time between SILC and LC (P=0.613, P=0.983, respectively). The 2 groups had no statistically significant differences with respect to visual analog scale scores, estimated blood loss, shoulder pain, or complications (P>0.05). SILC can be the treatment of choice for gallbladder disease. Although the surgeon's first several attempts at SILC require a longer operative time compared with LC, there are no differences in hospital length of stay, blood loss, complication rates, or pain scores between SILC and LC.

The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia.

BACKGROUND: Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use. METHODS: All patients who had biologic mesh placed at the hiatus and who had been followed for at least 1 year were included. Perioperative data were reviewed, and a questionnaire was administered, designed to identify symptoms of gastroesophageal reflux, other symptoms such as dysphagia, and all other operative or endoscopic interventions that occurred after mesh implantation. In addition, postoperative radiologic and endoscopic studies were reviewed to assess signs of complications related to use of mesh. RESULTS: There were 126 patients eligible for the study. We were able to contact 73 of these patients, at median follow-up of 45 months. No mesh-related complications were found. The frequency and severity of heartburn, regurgitation, and dysphagia improved significantly compared with preoperative values, and 89% of the patients reported good to excellent results in terms of overall satisfaction. Six patients recorded worsening of dysphagia postoperatively, but after careful work-up and review of each individual case, no case seemed to be directly related to the mesh. No erosions, strictures, or other complications directly related to use of mesh were found. One patient required reoperation due to hiatal hernia recurrence with gastroesophageal reflux disease (GERD) symptoms. CONCLUSIONS: Use of biologic mesh for laparoscopic repair of large, complicated hiatal hernias appears safe. There were no major complications related to the mesh, and overall satisfaction with the operation was very good.

Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases.

Our study reviewed nine patients who were treated with the VAC™ Abdominal Dressing System after suffering pelvic fractures and soft tissue loss after high-energy pelvic trauma. Between March 2008 and August 2009, our clinic treated nine patients with complicated perineal injuries from high-energy pelvic trauma with multiple irrigation and debridement procedures and broad-spectrum antibiotics. Protective ostomies were created for all nine patients. Required interventions were made for associated injuries, and VAC™ application was started. All patients were male, with an average age of 24·3 (range 21-32) years, and a mean injury severity score of 36·4 (range 16-59). Wound diameters ranged from 15 to 30 cm, and wound depths ranged from 5 to 25 cm. The injuries included one traumatic bilateral hemipelvectomy, and three unilateral and two bilateral lower extremity amputations. Intensive care unit length of stay averaged 12 (6-19) days, and average hospital length of stay was 44·12 (31-64) days. Beginning at an average of day 17 (±5·9 days) post-injury, wound cultures detected no bacterial colonisation. One patient died on the sixth day after injury from septic complications. Two patients' wounds were closed by primary closure, and six patients' wounds were closed by split thickness grafts after an average of 31·4 (17-50) days. Optimal treatment of high-energy perineal injuries requires early and extensive debridement and rich irrigation. The application of the VAC™ system as temporary coverage of large complex wounds in the pelvic region enhances wound healing and facilitates an early grafting process.

Assessment of a simple, novel endoluminal method for gastrotomy closure in NOTES.

BACKGROUND: A reliable method for gastrotomy closure in NOTES will be essential for NOTES to become viable clinically. However, methods using existing and widely available endoscopic accessories have been ineffective. The objective of this study was to evaluate the feasibility and safety of a new simple method for gastric closure (retracted clip-assisted loop closure) that uses existing endoscopic accessories with minor modifications. METHODS: The retracted clip-assisted loop closure technique involves deploying 3-4 Resolution(®) clips (modified by attaching a 90-cm length of suture to the end of each clip) along the margin of the gastrotomy with one jaw on the serosal surface and the other jaw on the mucosal surface. The suture strings are threaded through an endoloop. Traction is then applied to the strings causing the gastric wall to tent. The endoloop is secured below the tip of the clips, completing a full-thickness gastrotomy closure. The main outcome measures were feasibility, efficacy, and safety of the new retracted clip-assisted loop closure technique for NOTES gastrotomy closure. RESULTS: An air-tight seal was achieved in 100% (n = 9) of stomachs. The mean leak pressure was 116.3 (±19.4) mmHg. CONCLUSIONS: The retracted clip-assisted loop closure technique can be used to perform NOTES gastrotomy closure by using existing endoscopic accessories with minor modifications.

Improvement of respiratory symptoms following Heller myotomy for achalasia.

INTRODUCTION: Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms. METHODS: We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms. RESULTS: All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy. CONCLUSIONS: A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

The effects of hyperbaric oxygen therapy on colonic anastomosis in rats with peritonitis.

The aim of this study is to investigate the healing effect of hyperbaric oxygen (HBO) on colonic anastomoses in the presence of experimentally induced peritonitis. Thirty-two rats were allocated randomly into short-term anastomosis (STA), short-term anastomosis + HBO treatment (STA+HBO), long-term anastomosis (LTA), and long-term anastomosis + HBO (LTA+HBO) treatment groups. The STA and LTA groups were administered fluid resuscitation and antibiotics for 3 and 7 days, respectively, whereas the HBO treatment groups received additional HBO therapy for 3 and 7 days, respectively. The rats were reoperated on the third and the seventh days of anostomoses for evaluation. The bursting pressures in STA+HBO and LTA+HBO therapy groups were significantly higher than those in groups with anastomoses alone (p < .001 and p < .01). HBO therapy did not affect the fibrotic index neither in STA nor in LTA groups (p > .05 for both); however, it was significantly higher in LTA+HBO group than that in STA+HBO group (p < .05). The hydroxyproline level was significantly higher in LTA group than in STA group (p < .05), yet HBO therapy did not affect the hydroxyproline levels in STA or LTA groups (p > .05 for both). It is concluded that hyperbaric oxygen treatment has positive effects on colonic anastomotic healing in case of peritonitis.