Surgical wound infection prevention using topical negative pressure therapy on closed abdominal incisions - the 'SWIPE IT' randomized clinical trial.

BACKGROUND: Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients. It is unclear whether incisional negative pressure wound therapy (NPWT) can reduce the risk of SSIs in patients after open abdominal surgery. METHODS: A prospective, non-blinded multi-centre randomized controlled trial (RCT) was performed to evaluate the incidence of SSI post-laparotomy using incisional NPWT compared with a standard dressing. The primary outcome was the rate of superficial SSI. RESULTS: A total of 124 patients (61 patients in the NPWT arm and 63 patients in the control arm) were included. One hundred and nine (87.9%) patients underwent colorectal surgery; 61 patients (49.2%) had emergency surgery. There were more superficial SSIs in the control group than in the NPWT group, although not statistically significant (20.6% vs 9.8%, P=0.1). Upon multiple logistic regression analysis, control dressings were associated with increased risk of superficial SSI although again, not statistically significant (odds ratio (OR) 2.41, 95% confidence interval (CI) 0.81-7.17, P=0.11). There was no superficial non-SSI related wound dehiscence in the NPWT group compared with 9.5% in the control group (P=0.03). There was no difference in postoperative complications (P=0.15), nor in other wound complications (P=0.79). CONCLUSION: NPWT was not associated with decreased superficial SSI in this RCT. However, there was a statistically significant reduction in superficial wound dehiscence with NWPT dressings. The results of this study should be included in meta-analyses for better evaluation of NPWT on closed abdominal incisions.

The efficacy of selective arterial embolization in the management of colonic bleeding.

BACKGROUND: The aim of the present study was to determine the efficacy of mesenteric embolization in the management of acute haemorrhage from the colon. METHODS: A retrospective review was performed of a consecutive series of patients who underwent selective arterial embolization between 2002 and 2010 at two Australian institutions. An analysis was performed of each patient's present and past medical history, procedural details and subsequent post-procedural recovery. RESULTS: Seventy-one patients were reviewed in the study. Sixty-one patients (86 %) had immediate cessation of bleeding following embolization. In total, 20 % had some form of morbidity due to mesenteric embolization being performed, the three most common being worsening renal function, groin haematoma and contrast allergy (11, 9 and 7 %, respectively). Only one patient developed superficial bowel ischaemia. Overall, 11 patients (18 %) had recurrent bleeding. Of these patients, five had repeat embolization. Of the patients who underwent re-embolization, three stopped bleeding. Surgery was required in 5 patients 2 of whom died postoperatively of systemic complications. CONCLUSIONS: Colonic bleeding can be treated successfully in most patients by embolization, without causing ischaemia. Eighteen per cent of patients rebleed during the first hospital admission, and 20 % patients experienced a procedure-related complication. In those patients that proceed to surgery, the morbidity, mortality and length of hospital stay increase dramatically.

Effect of an omental wrap on the healing and vascularity of compromised intestinal anastomoses.

Adult Wistar rats were used to investigate the ability of an omental wrap to limit leakage from compromised intestinal anastomoses. Under ketamine anesthesia, a section of small bowel was divided and then reanastomosed using a "control" anastomosis, a "deficient" anastomosis, or an "ischemic" anastomosis, plus or minus the addition of a wrap of omentum. Initially 10 rats were randomly assigned to each group. Nineteen of the 20 rats with unwrapped compromised anastomoses died within six weeks, compared with five deaths in the rats protected by an omental wrap (Fisher's exact test; P less than 0.01). The experiment was then repeated with a sample of rats from each anastomotic group being sacrificed for histologic examination on days 2 to 7, 10, 14, and 42. At the time of sacrifice a dye was injected into the omental vasculature to determine its contribution to the healing anastomosis. An anastomosis could be demonstrated between omental and bowel wall vessels by the third postoperative day. At one week the infarcted bowel edges were being resorbed and the omentum formed a fibrotic cylinder aligning the separated ends of bowel wall. At six weeks the scar became more contracted and the bowel mucosa had started to grow onto its luminal surface. It is concluded from this study that the omental wrap is protective to a compromised anastomosis by providing a biologically viable plug to prevent early leakage and a source of granulation tissue and neovasculature for later wound repair.

Occult radiologic changes in the skull and jaw in familial adenomatous polyposis coli.

It has been suggested that radiology of the skull and jaw in familial polyposis coli may be a useful marker in up to 90 percent of cases. These x-rays were reviewed independently by a dental surgeon and a neuroradiologist in 51 patients. Only seven patients (14 percent) had significant lesion seen in the context of screening. Each of these patients also had other extracolonic manifestations of familial polyposis coli. The Cleveland Clinic Foundation experience with radiology of the jaw and skull is that it is not a useful screening tool.

Anal sphincter repair: a report of 60 cases and review of the literature.

This is a retrospective review of 58 patients undergoing surgery for anal incontinence at the Cleveland Clinic. Forty-four patients had overlapping sphincter repairs, nine had postanal repairs, three had a combination of overlapping repair and postanal repair and two had Silastic slings. An associated loop colostomy or ileostomy was performed in 19 patients (33%). Satisfactory continence was attained in 86% of patients with direct sphincter injury (overlapping sphincter repairs) and this is comparable with the experience of others. These results with the postanal repair for patients with neurogenic incontinence were poor, however, as four of the nine were complete failures. Poor results were directly related to the age of the patient (P less than 0.0001) and the duration of incontinence (P less than 0.02). It was concluded that direct sphincter injury (obstetric, operative or traumatic) is effectively treated by an overlapping sphincter repair. Incontinence secondary to a degenerative neuropathy affecting the anal sphincter mechanism, however, whether it occurs in conjunction with a pre-existing sphincter injury or alone, is often not cured by surgery, that is, by postanal repair.

Vertical forces acting on the feet of diabetic patients with neuropathic ulceration.

The vertical forces acting on the sole of the foot in walking have been measured in 24 diabetic patients with neuropathic ulceration of the foot using a load-sensitive surface divided into 128 load cells, and compared with those in two groups of controls: (a), 21 diabetic patients with peripheral neuropathy but no ulceration and (b) 47 normal individuals. The results showed that the patients with neuropathic ulceration were significantly heavier, that diabetic patients with neuropathy, with or without ulceration, transmitted proportionally less force through the toes than normal individuals, and showed a medial shift of the force transmitted through the metatarsal heads. All plantar ulcers occurred at the site of maximum loading. The absolute force at the site of maximum loading was significantly greater in the patients with ulcers than in both control groups, through there was a considerable overlap. A significant difference remained even when the absolute force had been corrected for differences in toe loading and body weight, indicating that a further factor (or factors) must contribute to the development of these localized areas of high loading.

Aorta-esophageal fistula induced by a foreign body: the first recorded survival.

Two cases of aorta-esophageal fistula (AEF) resulting from a foreign body in the esophagus are presented. One we believe to be the first recorded survival. Both cases illustrate the importance of early diagnosis, made on the classical history, followed by operation.