Prophylactic mesh placement to prevent parastomal hernia, early results of a prospective multicentre randomized trial.

PURPOSE: Parastomal hernia (PSH) is a common complication after colostomy formation. Recent studies indicate that mesh implantation during formation of a colostomy might prevent a PSH. To determine if placement of a retromuscular mesh at the colostomy site is a feasible, safe and effective procedure in preventing a parastomal hernia, we performed a multicentre randomized controlled trial in 11 large teaching hospitals and three university centres in The Netherlands. METHODS: Augmentation of the abdominal wall with a retromuscular light-weight polypropylene mesh (Parietene Light™, Covidien) around the trephine was compared with traditional colostomy formation. Patients undergoing elective open formation of a permanent end-colostomy were eligible. 150 patients were randomized between 2010 and 2012. Primary endpoint of the PREVENT trial is the incidence of parastomal hernia. Secondary endpoints are morbidity, pain, quality of life, mortality and cost-effectiveness. This article focussed on the early results of the PREVENT trial and, therefore, operation time, postoperative morbidity, pain, and quality of life were measured. RESULTS: Outcomes represent results after 3 months of follow-up. A total of 150 patients were randomized. Mean operation time of the mesh group (N = 72) was significantly longer than in the control group (N = 78) (182.6 vs. 156.8 min; P = 0.018). Four (2.7 %) peristomal infections occurred of which one (1.4 %) in the mesh group. No infection of the mesh occurred. Most of the other infections were infections of the perineal wound, equally distributed over both groups. No statistical differences were discovered in stoma or mesh-related complications, fistula or stricture formation, pain, or quality of life. CONCLUSIONS: During open and elective formation of an end-colostomy, primary placement of a retromuscular light-weight polypropylene mesh for prevention of a parastomal hernia is a safe and feasible procedure. The PREVENT trial is registered at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2018 .

A case of intrathoracic stomach and spleen after aortic repair: an unusual complication.

UNLABELLED: A patient is described who presented with an intrathoracic stomach and spleen two weeks after aortic repair for an aortoduodenal fistula. At an urgent laparotomy the stomach was repositioned and the spleen removed. The patient recovered fully. The possible mechanism of this severe complication is discussed and relevant literature reviewed. KEYWORDS: Aortoduodenal fistula; Complication; Intrathoracic stomach; Intrathoracic spleen.

Circumferential application of VAC on a large degloving injury on the lower extremity.

Full healing was achieved following the circumferential application of VAC therapy to prepare a large lower-extremity wound involving both soft-tissue injury and femoral fractures for grafting. No complications were reported.

Coping Strategies Used By Patients With Chronic and/or Complex Wounds .

UNLABELLED: Objective. The aim of this study was to investigate coping strategies used by patients with chronic and/or complex wounds treated in an outpatient wound clinic. METHODS: Coping strategies were assessed using the Utrecht Coping List (UCL). The Mini-Mental State Examination (MMSE) was used to assess the patient's cognitive functioning. Fifty patients were selected for this study. The wound etiologies studied were: diabetic foot ulcers, lower extremity ulcers, surgical wounds, trauma wounds, and pressure ulcers. RESULTS: Scores on the coping measure for men and women differed significantly from the control groups. It was also found that each wound etiology showed a preference toward different coping strategies. Furthermore, 28% of the studied group had a lowered score on the MMSE, indicating possible cognitive impairments. CONCLUSION: There might be an association between wound etiology and the coping strategy that is preferred; this knowledge could be used to guide treatment strategies used by clinicians. Further research could focus on the effects of coping strategies on wound healing rates .

Maggot debridement therapy: serious bleeding can occur: report of a case.

Maggot debridement therapy is generally a safe therapy that is typically used as a last resort treatment for debriding wounds in patients with multiple comorbidities. We describe a case of serious bleeding in an 87-year-old woman treated in our wound care center for a mixed arterial-venous ulcer of the right leg. Daily home visits were completed by a wound care nurse, resulting in prompt recognition and management of the bleeding. The patient was transported to hospital via an ambulance, and rapidly stabilized with intravenous fluids and a blood transfusion. She subsequently returned to the home care setting for additional management of her lower extremity wound.

Use of autologous platelet-rich fibrin on hard-to-heal wounds.

This retrospective study found that use of autologous platelet-rich fibrin on a range of hard-to-heal wounds achieved full healing or a significant reduction in wound diameter with no adverse effects. Prospective studies are now needed

Extracellular matrix prevents split-skin grafting in selected cases.

Surgeons at a Dutch wound clinic close open wounds with split-skin grafts. Concerns about the risk of postoperative complications in some patients led them to find an alternative option. Use of an extracellular matrix dressing was effective.

[Diagnostic image (291). A man with a distended abdomen]. / Diagnose in beeld (291). Een man met een opgezette buik.

A 52-year-old mentally retarded man with abdominal distension had a volvulus of the sigmoid, with a 'bird beak' sign on a plain abdominal radiograph.

Necrotizing soft tissue infection of the thigh: consider an abdominal cause.

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved. METHODS: Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance. RESULTS: Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus. CONCLUSIONS: High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.

[Diagnostic image (277). A woman with epigastric pain 10 years after a mastectomy]. / Diagnose in beeld (277). Een vrouw met pijn in epigastrio 10 jaar na een mastectomie.

A 59-year-old woman presented with epigastric pain due to peritonitis carcinomatosa caused by breast cancer diagnosed and surgically treated 10 years earlier.

Perforation of the esophagus caused by the insertion of an intragastric balloon for the treatment of obesity.

Obesity is an enduring chronic disease, with multifactorial etiology. Many procedures and solutions have been proposed in the last 25 years. If patients do not meet the criteria for bariatric surgery, intragastric balloons may be used to achieve weight reduction. Contraindications to balloon therapy are a large hiatal hernia, severe esophagitis, peptic ulceration and previous gastric surgery. Although intragastric balloons are advocated as safe devices, major complications such as intestinal obstruction, gastric perforation and gastric ulceration have been described. We report a case of esophageal rupture due to insertion of an intragastric balloon for the treatment of morbid obesity, for which no contraindication existed. When abnormal pain or discomfort arises, or esophageal damage is noted after insertion of an intragastric balloon, patients must be closely monitored to diagnose a possible esophageal rupture early and thereby prevent severe complications.

[Maggot therapy for treatment of severe infections in trauma surgery: "back to the future!"]. / Maden: Ein neues Konzept in der Behandlung von Infektionen in der Traumatologie -- "Back to the Future!"

The ancient method of larval therapy for treatment of acute and chronic infections has become a revival and a new dimension with introduction of the Biobag (Vitapad). With use of this therapy trauma patients suffering infectious complications can be treated very effective, which can reduce the overall time needed for treatment and can result in diminished invalidity.

Necrotising fasciitis of the leg following a simple pelvic fracture: case report and literature review.

Necrotising fasciitis is a rare complication following pelvic fracture, but has a high mortality rate. Topical negative pressure and maggot debridement therapy can be used alongside the usual treatment of surgical debridement and antibiotic therapy.

Determining pain levels in patients treated with maggot debridement therapy.

OBJECTIVE: Pain as a complication of maggot debridement therapy (MDT) has been a topic of some controversy. This study set out to determine pain levels in patients treated with MDT. METHOD: A retrospective analysis using a visual analogue scale (VAS) was performed: 41 patients were treated with MDT for non-healing wounds (22 men and 19 women; average age: 67 years). Average wound duration was 14 months (range: two weeks to 132 months). Maggots were applied using the contained or the free-range techniques. Paracetamol (1 g three times daily) and Durogesic plaster (25 microg every three days and 50 microg the day before the maggot change) were given for pain relief in the outpatient clinic. RESULTS: Diabetic patients experienced the same amount of pain before and during MDT. Eight out of 20 non-diabetic patients experienced more pain during MDT than before; the remaining non-diabetic patients had the same amount of pain before and during the therapy. The difference between diabetic and non-diabetic patients was statistically significant (p<0.05) for all applications combined. CONCLUSION: In 78% of patients (29/37) pain can be adequately treated with analgesic therapy. However, if pain is unmanageable in the outpatient department, we believe that options include hospital admission, using the contained method of application or, in the worst case scenario, cessation of treatment. A standardised but individually tailored pain management protocol is mandatory.