Closed-incision negative-pressure therapy decreases complications in ventral hernia repair with concurrent panniculectomy.

PURPOSE: Ventral hernia repair with concurrent panniculectomy (VHR-PAN) is associated with high wound complication rates despite reported increased patient satisfaction. Some surgeons believe negative-pressure therapy after primary closure of the surgical incision (ciNPT) may lower wound complications in high-risk abdominal wounds. This study aims to evaluate if ciNPT improves outcomes in patients undergoing VHR-PAN. METHODS: An 8-year retrospective cohort study was performed on patients who underwent VHR-PAN. Patients were divided into two groups: those who received closed-incision negative-pressure therapy ("ciNPT") and those who received standard sterile dressings ("SSD"). The primary outcome of interest was the rate of postoperative complications between these groups. Complications were subdivided into surgical site occurrences (which included surgical site occurrences that required an intervention), return to the operating room, and hernia recurrence. RESULTS: A total of 104 patients were analyzed: 62 in the ciNPT group and 42 in the SSD group. Median follow-up duration was similar between both groups (182 days vs 195 days, p = 0.624). Patients in the ciNPT group had fewer total complications (57% vs. 83%, p = 0.004) and fewer SSO (47% vs. 69%, p = 0.025). However, no differences were noted when comparing individual complications (SSI, wound dehiscence, skin necrosis, chronic wound, seroma, and hematoma). There was no difference in return to the operating room (27% vs. 26%, p = 0.890) or hernia recurrence (21% vs 19%, p = 0.811). Multivariate analysis showed that ciNPT decreased the risk of SSOPI nearly fourfold (odds ratio 0.28, 95% CI = 0.09-0.87, p = 0.027). CONCLUSIONS: This study showed that closed-incision negative-pressure therapy in ventral hernia repair with concurrent panniculectomy may decrease the rate of wound complications in this high-risk population.

Physiologic changes with abdominal wall reconstruction in a porcine abdominal compartment syndrome model.

PURPOSE: Abdominal compartment syndrome (ACS) is a severe complication of ventral hernia repair. The aims of this study were to investigate the effects of intra-abdominal pressure on the physiologic changes of abdominal wall reconstruction and component separation in a porcine model. METHODS: Ventral hernia repair (VHR) was simulated by abdominal fascial imbrication of a 10 × 15 cm defect in 45 Yorkshire pigs assigned to five experimental groups. ACS was simulated by a Stryker endoscopy insufflator with intra-abdominal pressure elevated to 20 mmHg in two groups. Component separation was performed in one of these groups and in one group without ACS. Physiological parameters were measured before and after the procedures and monitored for 4 h. The animals were euthanized for histologic analysis of organ damage. RESULTS: VHR led to an increase in intra-abdominal pressure, bladder pressure, and central venous pressure by an average of 14.89, 13.93, and 14.69 mmHg (p < 0.001) in all animals. Component separation was performed in 25 animals and the three pressures reduced by 9.11, 8.00, 7.89 mmHg (p < 0.001). ACS correlated with higher percentages of large and small bowel necrosis compared to groups without abdominal compartment syndrome. CONCLUSIONS: The results confirm that primary repair of large abdominal wall defects leads to increased intra-abdominal pressure, which can be reduced with component separation. In animals with ACS, component separation may reduce the risk of organ damage. Central venous pressure, bladder pressure, and other physiologic parameters accurately correlated with elevated intra-abdominal pressure and may have utility as markers for diagnosis of ACS.

Vascularized bone marrow-based immunosuppression inhibits rejection of vascularized composite allografts in nonhuman primates.

Vascularized composite allograft (VCA) transplantation (also referred to as composite tissue allotransplantation) has demonstrated clinical success in cases of hand, arm and face transplantation despite prior belief that skin provides an insurmountable barrier to allograft rejection. These overall good outcomes are facilitated by substantial immunosuppressive requirements in otherwise healthy patients, yet still demonstrate frequent rejection episodes. We developed a nonhuman primate model of facial segment allotransplantation to elucidate the unique pathophysiology and immunosuppressive requirements of VCA with addition of concomitant vascularized bone marrow (VBM). Heterotopically transplanted facial segment VCA with VBM treated only with tacrolimus and mycophenolate mofetil (MMF) demonstrated prolonged rejection-free survival, compared to VCA without VBM that demonstrated early rejection episodes and graft loss. While VCA with VBM demonstrated sporadic macrochimerism, acute and chronic rejection and graft loss occurred after discontinuation of immunosuppression. These data support an immunomodulatory role of VBM in VCA that reduces immunosuppressive requirements while providing improved outcomes.

[Awareness, attitudes, and practices of secondary school students in relation to HIV/AIDS in Abidjan, Ivory Coast]. / Connaissances, attitudes et pratiques des collégiens et lycéens d'Abidjan face au VIH/sida.

In May 2001, we conducted a descriptive transversal survey with a single data collection phase in 13 schools in Abidjan, Ivory Coast. The purpose of the study was to evaluate the awareness, attitudes, and practices of teenagers with regard to HIV/AIDS. Most respondents (66.5%) were female. Mean age was 16.32 years (range, 13 to 19 years). Most respondents stated that they had heard about AIDS and demonstrated good factual knowledge. The most frequently mentioned method of prevention was condom use (89.2%). A total of 338 (56.1%) had already experienced sexual intercourse. However most sexually active respondents stated that they did no always use condoms.

Biologic variability in mechanical ventilation rate and tidal volume does not improve oxygenation or lung mechanics in canine oleic acid lung injury.

Mechanical ventilation in patients with acute respiratory distress syndrome and acute lung injury (ALI) remains a difficult challenge because of the conflict between maintaining adequate gas exchange and furthering lung injury via overdistention. In a recent study, Lefevre and colleagues (Am. J. Respir. Crit. Care Med. 1996;154: 1567-1572) suggested that mechanical ventilation with natural biologic variability (BV) in breath-to-breath respiratory frequency (f) and VT could reduce lung injury and improve gas exchange without increases in mean airway pressure (Paw) or peak inspiratory pressure (PIP). However, significant differences in cardiac output (CO), Pa(CO(2)), pH, and delivered VT between the treatment groups in their study could have influenced these results. Because of the potential implications of these findings for patient care, we attempted to confirm these findings by Lefevre and colleagues in a canine model of oleic acid-induced lung injury. Eighteen mongrel dogs were anesthetized in the supine position, paralyzed, and mechanically ventilated with 50% O(2) at f = 15 breaths/min, and VT was adjusted to achieve an end-tidal CO(2) of 30 to 35 mm Hg. Lung injury was produced by infusion of 0.06 ml/kg oleic acid solution into the right atrium over a 30-min period. Animals were then randomized to either conventional ventilation at the baseline settings (n = 9) or to BV at the same mean VT and f (n = 9). Both groups received comparable degrees of injury, and hemodynamic and ventilatory parameters were closely matched, with no differences in mean VT, PIP, mean Paw, Pa(CO(2)), pH, CO, pulmonary artery occlusion pressure, or arterial pressure (Pa). However, no differences between the two groups were found in Pa(O(2)), shunt, or static compliance over a 4-h period. When hemodynamic and ventilatory parameters were well matched in a canine model of ALI, BV showed no advantage over conventional ventilation at constant VT and f.