RESUMO
INTRODUCTION: Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence. METHODS: A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2. RESULTS: Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028). CONCLUSIONS: Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.
Assuntos
Parede Abdominal , Produtos Biológicos , Hérnia Ventral , Humanos , Hérnia Ventral/cirurgia , Telas Cirúrgicas , Resultado do Tratamento , Parede Abdominal/cirurgia , Estudos Retrospectivos , Herniorrafia , Produtos Biológicos/uso terapêutico , RecidivaRESUMO
BACKGROUND: The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Retrospective review has previously shown a decrease in lifetime return to operating room (RTOR) with no change in 90-day complications when a muscle or omental flap is used for coverage after washout for infection. We wished to determine if early plastic surgery intervention led to a decreased length of stay for these patients. METHODS: Patients with LVAD readmitted for LVAD infection at a single institution from 2008 to 2021 were identified using a preexisting database. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with χ2 and analysis of variance testing was used to analyze outcomes. RESULTS: Of 568 patients admitted with an LVAD infection, 104 underwent operative debridement and closure by plastic and reconstructive surgery (PRS) or cardiothoracic surgery (CTS). Fifty-three underwent PRS closure, and 51 underwent CTS closure. There was an increased incidence of diabetes among the PRS group (P < 0.001); otherwise, there was no difference in baseline characteristics. There was increased RTOR over a lifetime with CTS closure compared with PRS (P = 0.03) and increased 90-day risk of infection (P = 0.007). Patients with PRS closure had an increased risk of postoperative hematoma (P = 046). Plastic and reconstructive surgery was typically consulted on hospital day 10. Both PRS and CTS closure patients were discharged on postoperative day 7, on average (P = 0.542). CONCLUSIONS: Plastic surgery involvement with surgical decision making and closure of infected LVAD devices has a decrease in lifetime RTOR and decreased 90-day complications related to infections. There may be a benefit to earlier PRS consultation for coverage assessment.
Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Infecções Relacionadas à Prótese , Cirurgia Plástica , Humanos , Coração Auxiliar/efeitos adversos , Estudos Retrospectivos , Salas Cirúrgicas , Infecções Relacionadas à Prótese/etiologia , Insuficiência Cardíaca/cirurgia , Insuficiência Cardíaca/etiologia , Resultado do TratamentoRESUMO
Subacute groin complications associated with extracorporeal membrane oxygenation (ECMO) cannulation are well recognized, yet their effects on clinical outcomes remain unknown. This single-center, retrospective study reviewed all patients receiving venoarterial ECMO from 01/2017 to 02/2020. Cohorts analyzed included transplanted patients (TPs) and non-transplanted patients (N-TPs) who did or did not develop ECMO-related subacute groin complications. Standard descriptive statistics were used for comparisons. Logistic regressions identified associated risk factors. Overall, 82/367 (22.3%) ECMO patients developed subacute groin complications, including 25/82 (30.5%) seromas/lymphoceles, 32/82 (39.0%) hematomas, 18/82 (22.0%) infections, and 7/82 (8.5%) non-specified collections. Of these, 20/82 (24.4%) underwent surgical interventions, most of which were muscle flaps (14/20, 70.0%). TPs had a higher incidence of subacute groin complications than N-TPs (14/28, 50.0% vs. 68/339, 20.1%, P = 0.001). Seromas/lymphoceles more often developed in TPs than N-TPs (10/14, 71.4% vs. 15/68, 22.1%, P = 0.001). Most patients with subacute groin complications survived to discharge (60/68, 88.2%). N-TPs who developed subacute groin complications had longer post-ECMO lengths of stay than those who did not (34 days, IQR 16-53 days vs. 17 days, IQR 8-34 days, P < 0.001). Post-ECMO length of stay was also longer among patients who underwent related surgical interventions compared to those who did not (50 days, IQR 35-67 days vs. 29 days, IQR 16-49 days, P = 0.007). Transplantation was the strongest risk factor for developing subacute groin complications (OR 3.91, CI95% 1.52-10.04, P = 0.005). Subacute groin complications and related surgical interventions are common after ECMO cannulation and are associated with longer hospital stays. When surgical management is warranted, muscle flaps may reduce lengths of stay compared to other surgical interventions.
Assuntos
Oxigenação por Membrana Extracorpórea , Linfocele , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Virilha , Estudos Retrospectivos , Linfocele/etiologia , Seroma/etiologia , Tempo de Internação , CateterismoRESUMO
In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods: A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions: Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.
RESUMO
Background: Hypersensitivity reaction in a tattoo secondary to red ink is a relatively rare complication, particularly as the biochemical composition of tattoo dye has been refined. Most hypersensitivity reactions are amenable to conservative management, but less common is the necessity for full surgical excision and reconstruction. Methods: A 50-year-old female patient with a chronic tattoo granuloma causing excessive pruritus, erythema, and ulceration, refractory to conservative and minimally invasive techniques, underwent full surgical excision and skin-graft reconstruction of the areas affected by the red dye. Additionally, literature was reviewed for similar reports requiring excision. Results: The patient reports complete symptomatic resolution and satisfaction with the result. The literature reveals a small set of cases reporting a necessity for surgical excision following red-ink hypersensitivity. Conclusions: Tattoo hypersensitivity secondary to a red ink-induced allergic reaction is relatively rare. Most cases are amenable to conservative treatment; however, surgical excision and reconstruction provides a viable option in cases refractory to traditional and less invasive management.
RESUMO
In the setting of chronic primary mitral regurgitation, the benefit of mitral valve repair over replacement is well established. However, data comparing outcomes for mitral valve surgery for endocarditis is limited. We sought to determine whether mitral valve repair offers traditional advantages over replacement in the endocarditis population. Retrospective review of our institutional mitral valve database (N = 8,181) was performed between 1998 and 2019 for all adult patients undergoing isolated mitral valve surgery for endocarditis. Patients were stratified by mitral valve repair or replacement and propensity score matching was performed to adjust for differences in baseline characteristics and degree of valve damage. Overall, 267 surgeries (124 repair, 153 replacement) met inclusion criteria during the study period. Following propensity matching, the repair cohort was associated with shorter initial ventilator times (5.6 vs 7.9 hours, p = 0.05), shorter ICU (28 vs 52 hours, p = 0.03), and hospital lengths of stays (7 vs 11 days, p < 0.01). Thirty-day mortality (0% vs 2.1%, p = 0.01) and 10-year survival (88% vs 86%, p = 0.55) were similar between cohorts. Patients in the repair cohort were less likely to require repeat mitral valve intervention at our institution for recurrent endocarditis than those in the replacement cohort (0% vs 10.6%, p = 0.03). Mitral valve repair is safe, when feasible, in the setting of isolated native valve endocarditis and may provide patients faster recovery. Experienced mitral surgeons should approach this patient population with a "repair if feasible" methodology.
Assuntos
Endocardite , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral , Adulto , Endocardite/diagnóstico , Endocardite/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Transversus Abdominis Release (TAR) during ventral hernia repair (VHR) allows for further lateral dissection by dividing the transversus abdominis muscles (TAM). The implications of division of the TAM on clinical and patient-reported outcomes has not be extensively studied. METHODS: Adult patients undergoing retrorectus (RR) VHR with biosynthetic mesh with or without bilateral TAR were retrospectively identified. Post-operative and patient-reported outcomes (PROs) were collected. RESULTS: Of 50 patients, 24 underwent TAR and 26 had RR repair alone. Median defect sizes were 449 cm2 and 208 cm2, respectively (p < 0.001). Rates of SSO and SSI were similar (p > 0.05). One TAR patient (4.2%) and four RR patients (15.4%) recurred (p = 0.26), with median follow up of 24 and 38 months. PROs improved significantly in both groups (p < 0.05). CONCLUSION: Despite more complex abdominal wall reconstruction on larger defects, TAR has minimal major adverse events, low recurrence rates, and does not negatively affect PROs.
Assuntos
Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Músculos Abdominais/cirurgia , Parede Abdominal/cirurgia , Adulto , Hérnia Ventral/etiologia , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Humanos , Hérnia Incisional/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Telas CirúrgicasRESUMO
Heterochromatin is essential for regulating global gene transcription and protecting genome stability, and may play a role in tumor suppression. Drugs promoting heterochromatin are potential cancer therapeutics but very few are known. In order to identify drugs that can promote heterochromatin, we used a cell-based method and screened NCI drug libraries consisting of oncology drugs and natural compounds. Since heterochromatin is originally defined as intensely stained chromatin in the nucleus, we estimated heterochromatin contents of cells treated with different drugs by quantifying the fluorescence intensity of nuclei stained with Hoechst DNA dye. We used HeLa cells and screened 231 FDA-approved oncology and natural substance drugs included in two NCI drug libraries representing a variety of chemical structures. Among these drugs, streptonigrin most prominently caused an increase in Hoechst-stained nuclear fluorescence intensity. We further show that streptonigrin treated cells exhibit compacted DNA foci in the nucleus that co-localize with Heterochromatin Protein 1 alpha (HP1α), and exhibit an increase in total levels of the heterochromatin mark, H3K9me3. Interestingly, we found that streptonigrin promotes heterochromatin at a concentration as low as one nanomolar, and at this concentration there were no detectable effects on cell proliferation or viability. Finally, in line with a previous report, we found that streptonigrin inhibits STAT3 phosphorylation, raising the possibility that non-canonical STAT function may contribute to the effects of streptonigrin on heterochromatin. These results suggest that, at low concentrations, streptonigrin may primarily enhance heterochromatin formation with little toxic effects on cells, and therefore might be a good candidate for epigenetic cancer therapy.