Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial.

OBJECTIVE: A randomized controlled trial was undertaken to investigate the effect of prophylactic negative pressure dressings on postoperative surgical site infection (SSI) rates in closed laparotomy wounds. SUMMARY OF BACKGROUND DATA: Laparotomy wounds are associated with high rates of SSI. The effect of prophylactic negative pressure dressing of closed incisional wounds on SSI rate is unknown. METHODS: A randomized, controlled, open-label trial was conducted (clinicaltrials.gov registration number NCT02780453). Fifty patients undergoing open abdominal surgery were included, with 25 patients randomized to the negative pressure dressing group and 25 to the standard dressing group. The primary endpoint was SSI incidence at 30 days postoperatively. Secondary endpoints included SSI incidence at 4 days, length of stay, cosmetic outcome, and patient satisfaction. Statistical analysis was performed on a per-protocol basis using SPSS version 23.0. RESULTS: The incidence of SSI at 30 days postoperatively was significantly reduced in the treatment group compared with the control group [8.3% vs 32.0%, P = 0.043 (1-sided), P = 0.074 (2-sided)]. There was no difference in SSIs at 4 days postoperatively [4.1% vs 8.0%, P = 0.516 (1-sided), P = 1.0 (2-sided)]. Analysis of predictors of wound infection identified standard wound dressings as the only significant predictor of SSI development. Length of stay was significantly reduced in the negative pressure dressing group [6.1 vs 14.7 days, P = 0.019 (2-sided)]. Cosmetic outcome and patient satisfaction did not show any difference between the 2 groups. CONCLUSIONS: Prophylactic use of negative pressure dressings for closed laparotomy wounds significantly reduces the incidence of SSI at 30 days postoperatively.

NovoSorb® biodegradable temporising matrix (BTM) in the reconstruction of cutaneous malignancies in a major cancer centre: a case series.

BACKGROUND: Non-graftable or composite defect reconstruction represents a major challenge to the reconstructive surgeon, with many wounds requiring local flap or free microvascular tissue transfer approaches. The recent advent of synthetic skin substitutes such as Biodegradable Temporizing Matrix (BTM) have revolutionized the management of complex defects including those caused by burns, trauma and infection, with low-morbidity and low-complexity surgery. However, limited data exist supporting their use in cancer reconstruction in Australia. METHODS: We performed a prospective cohort study of patients undergoing cancer resection and reconstruction with BTM between February 2021 and February 2023 in our institution. Reported outcomes included matrix integration, infection, and return to theatre. RESULTS: Twelve patients underwent reconstruction of primary or secondary defects following cancer resection during this period. Eight patients were male, four female, mean age at surgery was 70 years. Pathology resected included squamous cell carcinoma (SCC) and melanoma of the head and neck, sarcoma resection of the lower limb, and osteoradionecrosis (ORN) of the scalp. T-stage of primary tumours ranged from T2 to T4 and one in-transit metastasis of melanoma. Four patients were treated with radiotherapy, two of whom received postoperative radiotherapy (PORT) and two who received neoadjuvant radiotherapy, three additional patients had an intervention to a previously irradiated wound bed for recurrence or ORN. Overall matrix integration was 83% (10/12), with a 50% integration rate (2/4) observed in the post-radiotherapy group, requiring return to theatre for alternative reconstructive approaches. CONCLUSION: We report our experience with a synthetic dermal matrix (BTM) in cancer reconstruction, the largest cohort of this type in the Australian literature. BTM represents an exciting reconstructive tool for the cancer reconstructive surgeon, with a high rate of success and low morbidity.

Use of a Synthetic Dermal Matrix for Reconstruction of 55 Patients with Nongraftable Wounds and Management of Complications.

The aim of this study was to investigate the role of a completely synthetic dermal matrix (Biodegradable Temporizing Matrix [BTM]) for staged reconstruction of complex wounds. The authors defined complex wounds as wounds not amenable to reconstruction with skin grafting alone due to an inherent avascularity such as the presence of bare bone, tendinous, or neural structures. A retrospective review of a prospectively maintained database of complex wounds as defined above was carried out. Fifty-five patients were identified who underwent staged BTM and autologous skin graft reconstruction for complex wounds affecting a wide variety of patient demographics, treatment indications, and body sites. Wound etiology included burn injury and nonburn-related trauma such as degloving injury or infective complications. Caveats relating to the successful application of staged dermal matrix reconstruction, techniques, tips, prevention, and management of complications are outlined. This large consecutive case series demonstrates the integral role dermal substitutes play in providing biological wound cover for avascular wound beds which may otherwise require complex distant flap or free tissue transfer for reconstruction. Staged synthetic dermal matrix reconstruction has proven robustness in the face of unfavorable wounds compared with nonsynthetic dermal matrices, physiologically covering avascular structures, allowing for early graft take, expediting rehabilitation, and mobilization with good scar cosmesis and limited contracture formation.

Management of Hydrocarbon Burns: Considering Mental Health and Biochemical Abnormalities.

Volatile substance misuse, particularly the inhalation of hydrocarbons, is a growing issue globally. Consequences of volatile substance misuse, both acute and chronic cause cardiovascular, respiratory, renal, metabolic, and central nervous system damage. Whilst the effects of hydrocarbon abuse have been reported, the combination of intoxication with hydrocarbon and burns sustained has not yet been presented. A retrospective case series of patients who presented in the last 5 years to the Royal Adelaide Hospital with hydrocarbon-related burns in the context of illicit use was undertaken. Our aims are to present to the wider scientific community the high morbidity and mortality of hydrocarbon burn injuries and why this tertiary Burns Unit feel it most appropriate to medically stabilize these patients prior to definitive surgery for their burn. All patients that presented with acute hydrocarbon intoxication and sustained concomitant burns had significant psychiatric disorder and substance abuse history and three of five had either not eaten in several days resulting in acute malnourishment, refeeding syndrome or had evidence of chronic malnourishment with deranged electrolytes and hypoalbuminemia. Their definitive burns surgery was delayed where appropriate in order to facilitate medical stabilization as they were too high risk of cardiac membrane instability, electrolyte derangement, and/or respiratory compromise to undergo safe general anesthetic and burns debridement. We propose a multidisciplinary team approach, utilizing not only our Burns Unit care model of physiotherapists, psychologists, social work, and burns trained nurses and surgeons but also Intensive Care, Toxicology, Addiction medicine and General Medical physicians in the management of these patients.

A double-blind, placebo-controlled randomised trial of intraparenchymal administration of local anaesthetic in elective breast augmentation.

INTRODUCTION: Several methods of controlling pain post-bilateral breast augmentation (BBA) have been described. BBA is frequently performed as a day case procedure; therefore, a simple effective method of controlling pain in the immediate post-operative period is desired. METHODS: We conducted a prospective, double-blinded, placebo-controlled randomised study of 20 women undergoing BBA. Women were randomly assigned to receive intraparenchymal infiltration intra-operatively prior to implant placement with either local anaesthetic (LA) (chirocaine) or normal saline. The primary outcome was post-operative pain scores immediately, and at 6 h. Our secondary endpoint was post-operative narcotic consumption. RESULTS: Twenty patients were included in this study. The average pain score in the immediate post-operative period was 3.4 in the control group versus 0.7 in the treatment group (p = 0.013). In 6 h post-operatively, the average pain score was 2.4 in the control group versus 0.9 in the treatment group (p = 0.03). Sixty-six percentage of patients in the control arm required post-operative opiates compared with 27% in the treatment group (p = 0.17) CONCLUSION: This randomised controlled trial demonstrates a technique of intraparenchymal infiltration of LA that significantly reduces post-operative pain scores after BBA.

Biodegradable Temporizing Matrix Reconstruction of Complex Perineal Burn Wound: A Case Report.

This case report details our experience using a two-stage Biodegradable Temporizing Matrix (NovoSorb® PolyNovo Ltd) and autograft for acute reconstruction of a complex perineal burn wound in an elderly comorbid patient. A 77-year-old man sustained 42% full-thickness burns extending circumferentially from bilateral thighs and buttocks, across the entire perineal and genital regions up to his mid-trunk, following self-immolation using an accelerant. Early total burn wound excision was carried out with acute application of Biodegradable Temporizing Matrix to all affected sites. Excellent integration and vascularization of Biodegradable Temporizing Matrix took place despite the challenge of intermittent fecal contamination affecting the perineal and buttock burn sites and matrix colonization with multidrug-resistant organisms. Delamination and serial split-thickness skin autografting were carried out 42 days after the first matrix application with complete and robust graft take. Perineal burns present a reconstructive challenge due to the proximity of specialized structures such as the genitalia, urethral, and anal orifices. Restoration of complex anatomy and function may be required after debridement with increased risks of infection, contracture formation, and mortality compared with burns affecting other anatomical sites. Two-stage Biodegradable Temporizing Matrix represents a reliable reconstruction option for complex extensive perineal wounds in frail elderly patients, despite an unfavorable local microbial environment.

Neuroimaging provides relevant clinical information in patients with burn injuries.

INTRODUCTION: Neurological assessment of patients with burn injuries may be complicated by a variety of factors including artificial ventilation and sedation, cerebral hypoxia and intoxication. Medically unstable intubated patients present logistical challenges for radiological imaging. The role of neuroimaging as an adjunct to clinical assessment of burn injured patients has not yet been determined. AIM: This study aims to investigate the indications, findings and outcomes of neuroimaging studies performed for burn injured patients. METHODS: A retrospective case series study of adult burn patients admitted over an 8 year period was completed in the National Burns Centre at St James's Hospital, Dublin. Neuroimaging studies carried out for patients admitted during the study period were reviewed by a Consultant Radiologist and Consultant Stroke Physician. Outcomes included neuroimaging findings, prevalence of white matter disease (Fazekas scale), length of stay, discharge destination, predicted and observed mortality. RESULTS: 1328 consecutive patients with burn injuries were admitted during the study period. 56 patients underwent neuroimaging studies with computerised tomography, magnetic resonance imaging or both. 46 out of 56 neuroimaged patients (82.1%) had significant radiological findings, including 14 patients (25%) with acute findings. There was a high prevalence of white matter disease (mean total Fazekas score: 3.59) and acute cerebral infarction (7 patients). Patients with radiological findings required additional in-patient rehabilitation and had increased length of stay (Median 47.0 days vs. 27.5 days, p < 0.027). Patients with resuscitation burns or associated inhalation injury were significantly more likely to undergo neuroimaging (p < 0.0001) and to have positive radiological findings. Predicted mortality was higher in patients with positive neuroimaging findings compared to patients with normal neuroimaging studies, although there was no significant difference in observed mortality between these two groups. CONCLUSION: Neuroimaging is used appropriately in patients admitted with burns and provides valuable applicable clinical information when indicated.

Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap.

BACKGROUND: Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases. METHODS: This study aimed to determine the distance (cm) and surface area (cm2 ) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens. RESULTS: The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm2 compared to 85.36 cm2 after division of both the origin and insertion. CONCLUSION: Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects.

Preoperative measurement of cutaneous melanoma and nevi thickness with photoacoustic imaging.

Photoacoustic imaging (PAI) is an emerging biomedical imaging technology, which can potentially be used in the clinic to preoperatively measure melanoma thickness and guide biopsy depth and sample location. We recruited 27 patients with pigmented cutaneous lesions suspicious for melanoma to test the feasibility of a handheld linear-array photoacoustic probe in imaging lesion architecture and measuring tumor depth. The probe was assessed in terms of measurement accuracy, image quality, and ease of application. Photoacoustic scans included single wavelength, spectral unmixing, and three-dimensional (3-D) scans. The photoacoustically measured lesion thickness gave a high correlation with the histological thickness measured from resected surgical samples ([Formula: see text], [Formula: see text] for melanomas, [Formula: see text], [Formula: see text] for nevi). Thickness measurements were possible for 23 of 26 cases for nevi and all (6) cases for melanoma. Our results show that handheld, linear-array PAI is highly reliable in measuring cutaneous lesion thickness in vivo, and can potentially be used to inform biopsy procedure and improve patient management.

The 50 Most Cited Papers in Craniofacial Anomalies and Craniofacial Surgery.

BACKGROUND: Citation analysis is a recognized scientometric method of classifying cited articles according to the frequency of which they have been referenced. The total number of citations an article receives is considered to reflect it's significance among it's peers. METHODS: Until now, a bibliometric analysis has never been performed in the specialty of craniofacial anomalies and craniofacial surgery. This citation analysis generates an extensive list of the 50 most influential papers in this developing field. Journals specializing in craniofacial surgery, maxillofacial surgery, plastic surgery, neurosurgery, genetics and pediatrics were searched to demonstrate which articles have cultivated the specialty within the past 55 years. RESULTS: The results show an intriguing compilation of papers which outline the fundamental knowledge of craniofacial anomalies and the developments of surgical techniques to manage these patients. CONCLUSIONS: This citation analysis provides a summation of the current most popular trends in craniofacial literature. These esteemed papers aid to direct our decision making today within this specialty.

Spectrum of all-terrain vehicle injuries in adults: A case series and review of the literature.

INTRODUCTION: Serious injury secondary to all terrain vehicle usage has been widely reported since the 1970s. All-terrain vehicles (ATV) or 'quad bikes' are four wheeled vehicles used for agricultural work, recreation and adventure sport. Data collected in the U.S. indicates that ATV related injury and fatality is increasing annually. PRESENTATION OF CASES: This case series describes 3 cases of significant ATV related trauma in adults presenting to one regional hospital in the West of Ireland over a 12month period. DISCUSSION: Epidemiology, mechanisms of injury, spectrum of injury in adults and preventative measures to reduce the number of ATV related injuries and fatalities are discussed here with a review of the literature. CONCLUSION: A paucity of research outside of North America is highlighted by this case series. Mandatory reporting of ATV related injury, educational, training and legislative measures are suggested as injury prevention strategies.

Recurrent femoral hernia and associated ovarian pathology.

The following case describes an ovarian tumour presenting in a highly unusual manner-in the form of a recurrent femoral hernia. Recurrent femoral herniae are unusual and should prompt awareness of underlying pathology causing increased intra-abdominal pressure.

Spontaneous intramural oesophageal haematoma: an unusual cause of chest pain.

The following case describes a 29-year-old previously well gentleman who presented with an acute onset of chest pain, dysphagia, odynophagia and vomiting without haematemesis. An oesophageal lesion was visualised on CT angiography and further investigation via oesophogastroduodenoscopy (OGD) diagnosed a spontaneous intramural oesophageal haematoma as the cause of his symptomatology. Conservative medical management in the form of triple therapy and softened diet was well tolerated and a follow-up OGD at 6 weeks after discharge from hospital showed spontaneous resolution of the haematoma.

Radiolucent wooden foreign body masquerading as a depressed skull fracture.

The following case describes a head injury in an older male patient in which a large wooden foreign body, forming a subcutaneous tract in the scalp, was mistaken for a depressed skull fracture on initial clinical assessment. This foreign body was not visualised on CT brain imaging until specialised views were used retrospectively, after surgical exploration of the scalp laceration. Appropriate radiological techniques for the detection of radiolucent foreign bodies are discussed.