Vaginal Cuff Dehiscence in Transgender Patients After Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To compare rates of vaginal cuff dehiscence (VCD) in transgender patients with cisgender patients after minimally invasive hysterectomy (MIH). DESIGN: We performed a single-surgeon, retrospective cohort analysis comparing the rates of VCD in patients undergoing MIH for gender affirmation with other indications (benign, malignant, prophylactic) with our study surgeon between January, 2015, and December, 2021. SETTING: Major, urban, academic tertiary care hospital in the United States. PATIENTS: 166 patients met inclusion criteria with 49 of those patients undergoing MIH (29.5%) for gender affirmation. Of the remaining 117 patients, 92 (78.6%) underwent MIH for cancer, 15 (12.8%) for prophylaxis, and 10 (8.5%) for benign indications. INTERVENTIONS: Not applicable. MEASUREMENTS: We assessed included patients for baseline demographics, presence of risk factors for VCD, details of index hysterectomy, and details of cuff dehiscence events. MAIN RESULTS: Transgender patients tended to be younger at the time of surgery, but demographics were otherwise similar between both groups. Most transgender patients (n = 36, 73.5%) had both ovaries removed at the time of hysterectomy, 100% were on testosterone therapy pre- and postoperatively, and none used supplementary estrogen. Three of the 49 transgender patients (6.1%) experienced postoperative dehiscence of the vaginal cuff compared with 2 of the 117 cisgender patients (1.7%). This failed to reach statistical significance; however, our descriptive analysis showed that all cases of dehiscence in the cisgender group had identifiable precipitating factors (i.e., trauma). By comparison, all cases of dehiscence in the transgender group were spontaneous with few identifiable risk factors. CONCLUSION: Transgender patients undergoing MIH may be at increased risk of VCD, although the rarity of this surgical complication precluded determination of statistical significance in our data set. We propose testosterone exposure as a possible risk factor for VCD, although we cannot exclude other factors, such as young age, as drivers of VCD in this population. Future studies of biospecimens are needed to evaluate for cellular differences in these patients.

The Influence of Closing the Abdominal Donor-Site Superficial Fascial System in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes. METHODS: The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared. RESULTS: DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups. CONCLUSION: Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A case report of a woman after childbirth with a dehisced abdominal wound as well as fat liquefaction and large skin necrosis.

Recently high-frequency electric knife and abdominal binder are widely used in the abdominal operation in China. Nevertheless, with the high occurrence of the abdominal wound, we think that whether both these operations could be used or not. Here, we report the case of a 40-year-old female patient where negative pressure wound therapy (NPWT) was applied to her dehisced abdominal wound as well as fat liquefaction and large skin necrosis with pleasing results. The patient with high fever was referred to our department from her earlier hospital for 6 days after cesarean delivery. During the surgery, her earlier doctor used a high-frequency electric knife for convenient-using, and after the operation, the patient immediately used an abdominal binder for good shape. However, the abdominal surgical incision was opened at postoperative day 3, with fat liquefaction releasing large fatty acids along both abdominal sides with penetration under the abdominal binder. After admitted at postoperative day 6 with aggravating wound, surgery was considered because of no reduction in the size of the wound. A series of vacuum sealing drainage (VSD) or vacuum-assisted closure (VAC) as well as others, were operated. In the admitted 25th day, the wound was completely closed. NPWT is a practical and effective therapy for the treatment of numerous refractory and intractable wounds. Therefore, we suggest that the high-frequency electric knife and an abdominal binder should be avoided using an abdominal operation. This case is the first report of the use of NPWT over a dehisced abdominal wound with fat liquefaction and large skin necrosis on a postpartum patient in China.

Anastomotic healing in a rat model of peritonitis after non-steroidal anti-inflammatory drug administration.

The tissue inflammatory response can influence the outcome of anastomotic healing. Anastomotic leakage represents a dreadful complication after gastrointestinal surgery, in particular sepsis and intra-abdominal infections impair the restorative process of colic anastomoses. It has been debated whether the administration of non-steroidal anti-inflammatory drugs (NSAIDs) is a risk factor for dehiscence, since many patients receive NSAIDs in the early postoperative period. Our aim was, for the first time, to analyze the morpho-functional effects of postoperative administration of two commonly used NSAIDs, Diclofenac and Ketorolac, on the healing process of colo-colic anastomoses constructed under condition of fecal peritonitis in a rat model. Sixty adult male rats underwent two surgical procedures: peritonitis induction and colo-colic anastomosis, and were divided into three groups: 20 rats received saline; 20 rats 4 mg/kg Diclofenac and 20 rats 5 mg/kg Ketorolac. We assessed anastomosis strength, morphological features of tissue wound healing, immunohistochemical metalloproteinase 9 (MMP9) expression and collagen deposition and content by Sirius red staining and hydroxyproline level. We found no significant difference in bursting pressure, collagen content and organization and morphological features between the groups, except a significantly reduced presence of inflammatory cells and MMP9 expression in the groups treated with NSAIDs. Our findings showed that Diclofenac and Ketorolac administration did not affect post-surgical healing and did not increase the leakage risk of colo-colic anastomoses during peritonitis.

Ultrasonographic Features of Uterine Scar after Laparoscopic and Laparoscopy-Assisted Minilaparotomy Myomectomy: A Comparative Study.

STUDY OBJECTIVE: To evaluate uterine scar features after laparoscopic myomectomy (LM) compared with myomectomy performed by laparoscopy initially and then completed with minilaparotomy (LAM). DESIGN: Prospective cohort study. SETTING: An academic center for advanced endoscopic gynecologic surgery. PATIENTS: Sixty-nine symptomatic women who underwent myomectomy between July and December 2018. INTERVENTION: Patients underwent LM or LAM and 3-month follow-up ultrasonography. MEASUREMENTS AND MAIN RESULTS: Forty-four patients underwent LM and 25 underwent LAM. Demographic data, intraoperative parameters, and postoperative outcomes were collected. Two-dimensional color Doppler ultrasound was done at a 3-month follow-up to evaluate myomectomy scar features, myometrial thickness, and the presence of and vascularity of a heterogeneous mass. These features were compared with those of the intact myometrium on the opposite wall of the patient's uterus. The 2 groups had similar demographic characteristics, and there were no significant between-group differences in the number, maximum diameter, type, or location of myomas. The mean myometrial thickness at the scar site was 18.9 ± 3.22 mm in the LM group and 19.7 ± 3.50 mm in the LAM group, with no significant difference between the 2 groups. There was no meaningful difference in vascularity between the scar and normal myometrium. Heterogeneous masses were detected in 23% of patients in the LM group and in 24% of those in the LAM group. Other than mean operative time (207 minutes for LM vs 150 minutes for LAM; p < .001) and mean postoperative reduction in hemoglobin (1.77 mg/dL for LM vs 2.35 mg/dL for LAM; p = .023), there were no other statistical differences between the 2 groups. One patient in the LM group experienced a bowel injury resulting from morcellation. CONCLUSION: There were no differences in myometrial scar features after LM compared with after LAM, implying effective suturing via both approaches.

Sentinel lymph node biopsy in patients with malignant melanoma: analysis of post-operative complications.

BACKGROUND: This study investigates the incidence of post-operative complications and risk factors of sentinel lymph node biopsy (SLNB) in melanoma patients. METHODS: A retrospective cohort study was conducted at a single cancer institution on 408 consecutive SLNBs. RESULTS: Fifty-five post-operative complications occurred in 39 (9.5%) patients and included: wound infection in 24 (5.9%), seroma and lymphorrhea in 15 (3.7%), wound dehiscence in seven (1.7%), lymphocele in six (1.5%) and others in three (0.7%). Univariate analysis failed to identify possible risk factors (i.e. gender, age, lymph node region, number of excised lymph nodes, Breslow index, pT levels, comorbidities, length of surgery and hospital stay). Metastatic sentinel nodes occurred in four of 135 (3%) patients with thin melanoma (Breslow <1 mm) and in 68 of 262 (25.9%) patients with Breslow >1 mm. CONCLUSION: For patients with thin melanoma in whom the incidence of lymph node metastasis is low, the reported post-operative morbidity of almost 10% of SLNB highlights the need for careful patient selection.

Reduced Anterolateral Thigh Flap Donor-Site Morbidity Using Incisional Negative Pressure Therapy.

BACKGROUND: Primary closure of the donor-site after harvest of a large anterolateral thigh flap (ALT) is associated with significant morbidity. Incisional negative pressure therapy (INPT) may decrease complications in high-risk incisions. This study assessed if the incidence of complications after primary closure of the ALT flap donor-site decreases with INPT. METHODS: Retrospective cohort study of a prospectively maintained database including patients who underwent upper and lower limb reconstruction, using an ALT free flap with primary closure of the donor-site. Two groups were defined: primary closure and INPT (study group) and primary closure with traditional dressings (control group). Nonparametric statistics were employed to identify prognostic factors, p < 0,05. RESULTS: Fifty-eight free ALT flaps in 58 patients (study group n = 28; control group n = 30) were included. Median flap width and length were 9 cm (range: 5-14) and 25 cm (range: 10-48), respectively. Median follow-up was 19 months (range: 3-78 months). No significant differences in age or flap size were identified in both groups (p > 0.05). The global complication rate was 7.14% (n = 2) in the INPT group, and 37% (n = 11) in the control group (p = 0.007). The study group had a lower dehiscence and skin necrosis rate (p < 0.05). Multivariate logistic regression analysis showed IPNT was associated with a significant reduction of donor-site complications (p = 0.006), especially in patients with defects > 8 cm (p = 0.003). CONCLUSION: In this cohort study the use of INPT significantly reduced the donor-site morbidity after ALT flap harvest.

Tratamento Endoscópico de Deiscências de Anastomose Esofágica em Pacientes Oncológicos - Série de Casos / Endoscopic Treatment of Esophageal Anastomotic Leaks in Oncological Patients - Case Series

"Introdução: Deiscência de anastomose (DA) esofágica após esofagectomia ou gastrectomia total é uma complicação pós-operatória grave e uma das principais causas de morbimortalidade. Intervenções endoscópicas vem sendo utilizadas de maneira crescente em pacientes com DA, atualmente constituindo a primeira linha de terapia. Objetivos: Determinar a segurança e eficácia do tratamento endoscópico da DA esofágica após a cirurgia para o câncer esofagogástrico e destacar as suas melhorias recentes. Metodologia: Coleta de dados retrospectivos de pacientes com deiscências de anastomose esofágica após tratamento cirúrgico do câncer gastroesofágico que foram submetidos a tratamento endoscópico no INCA no período de janeiro de 2016 a fevereiro de 2019. Os tratamentos endoscópicos incluíram: (1) passagem de prótese metálica autoexpansível (PMAE) e (2) aplicação de terapia de pressão negativa (TPN). Após a coleta e análise dos dados foi realizada uma revisão da literatura para proporcionar uma comparação dos resultados obtidos. Resultados: Ao todo, 9 pacientes com deiscência de anastomose esofágica foram tratados com intervenção endoscópica. A idade média foi de 61 anos (variação: 50-69 anos). Dos 9 pacientes, 7 realizaram tratamento neoadjuvante. Sete cirurgias foram realizadas com intenção curativa e em dois casos foi realizada ressecção R2. O diâmetro do orifício fistuloso variou desde 2mm até deiscência quase completa da anastomose. O intervalo entre a identificação da deiscência e o tratamento endoscópico variou de 0 a 33 dias (média de 10 dias). A passagem de PMAE foi realizada em 7 pacientes, sendo 5 parcialmente e 2 totalmente recobertas. TPN foi o método de escolha em 2 casos. Ao todo, o tratamento endoscópico foi bem-sucedido em 7 pacientes (77.8%), sendo 5 (71%) nos casos de PMAE e 2 (100%) nos casos de TPN. Conclusão: DAs esofágicas após cirurgia de câncer de esôfago e estômago podem ser manejadas com sucesso e segurança com a terapia endoscópica. A TPN desponta como terapia inovadora, com resultados muito promissores. Novas terapias endoscópicas demonstraram segurança e estão constantemente criando evidências de eficácia em relação ao tratamento cirúrgico"(AU)

"Introduction: Esophageal anastomotic leaks (AL) after esophagectomy or total gastrectomy is a serious postoperative complication and one of its main causes of morbidity and mortality. Endoscopic interventions have been increasingly used in patients with AL, currently constituting the first line of therapy. Objectives: To determine safety and efficacy and to highlight recent improvements in the management of esophageal AL after surgery for esophageal and gastric cancer. Methodology: We retrospectively collected data of patients with esophageal anastomosis leaks after surgical treatment of gastroesophageal cancer who underwent endoscopic treatment at INCA from January 2016 to February 2019. Endoscopic treatments included: (1) passage of self-expandable metal stents (SEMS) and (2) application of endoscopic vacuum therapy (EVT). After data collection and analysis, a review of the literature was performed to provide a comparison of the results obtained. Results: Nine patients with esophageal anastomosis dehiscence were treated with endoscopic intervention. The mean age was 61 years (range: 50-69 years). Of the 9 patients, 7 underwent neoadjuvant treatment. Seven surgeries were performed with curative intent and in two cases R2 resection was performed. The diameter of the fistulous orifice ranged from 2mm to almost complete dehiscence. The interval between the identification of the leak and the endoscopic treatment ranged from 0 to 33 days (mean: 10 days). The SEMS passage was performed in 7 patients of whom 5 received a partially covered and 2 received a fully covered stent. EVT was the method of choice in 2 cases. Endoscopic treatment was successful in 6 patients (77.8%), 5 (71%) in the SEMS group and 2 (100%) in the EVT group. Conclusion: Esophageal AL after surgery for esophageal and stomach cancer may be, in most cases, successfully and safely managed with endoscopic therapy. EVT emerges as an innovative therapy, with very promising results. New endoscopic therapies have shown safety and are constantly creating evidence of efficacy in relation to surgical treatment"(AU)

Operative Management of Abdominal Wound Dehiscence: Outcomes and Factors Influencing Time to Healing in Patients Undergoing Surgical Debridement With Primary Closure.

INTRODUCTION: Plastic surgeons are often consulted by other surgical teams for management of wound dehiscence following abdominopelvic surgery. OBJECTIVE: The purpose of this study is to determine whether operative debridement and primary closure of abdominopelvic wounds are safe and expeditious for patients. MATERIALS AND METHODS: A retrospective analysis was conducted on a database of patients who underwent operative debridement and closure at a single institution between January 2011 and December 2015 for dehisced abdominal or pelvic wounds acquired from prior obstetric, gynecologic, transplant, plastic, or general surgery procedures. RESULTS: Of the 163 patient records identified, 43 patients met inclusion criteria. The median time from final debridement and primary surgical closure to complete wound healing was 27 days. Time to healing differed significantly by index procedure type (P = .004), with obstetric procedures requiring the shortest median time (12.0 days) and general surgery procedures requiring the longest (39.5 days). Wound healing took 3.6 times longer for patients with diabetes (P = .046) and 11.4 times longer for patients who experienced delayed superficial wound healing or redehiscence (P = .003). Nevertheless, with the exception of 4 patients who died of other causes, all wounds (39/39; 100%) achieved complete wound closure. CONCLUSIONS: Operative debridement and closure of abdominopelvic wound dehiscence through a multidisciplinary team approach with plastic surgery results in expeditious wound healing with minimal complications, and it may be safer and more cost effective than healing by secondary intention.

Percutaneous bone-anchored hearing implant surgery: linear incision technique with tissue preservation versus linear incision technique with tissue reduction.

OBJECTIVES: To identify differences in skin thickening and soft tissue reactions between the linear incision technique with tissue reduction (LITT-R) and the linear incision technique with tissue preservation (LITT-P). STUDY DESIGN: Retrospective cohort study. METHODS: All adult patients who underwent the LITT-R or LITT-P between August 2005 and December 2016 at a large general teaching hospital with a minimum follow-up of 6 months were included. RESULTS: A total of 83 implants were included using the LITT-R with a median follow-up of 74.0 months. In the LITT-P cohort 58 implants were included with a median follow-up of 16.5 months. Skin thickening was seen in seven implants (8.4%) in LITT-R cohort and 11 implants (19.0%) in the LITT-P cohort in the first 2 years of follow-up (p = 0.024). Skin thickening in need of treatment was registered in 5 (6.0%), respectively, 6 (10.3%) implants (p = 0.100). Moreover, treatment was successful in all cases. A soft tissue reaction (Holgers ≥ 1) was noticed in 28 (33.7%) implants in the LITT-R group compared to 16 implants (27.6%) in the LITT-P group (p = 0.679). An adverse soft tissue reaction (Holgers ≥ 2) was registered in 16 (19.2%), respectively, 2 (3.4%) implants. This difference was significant (p = 0.040). CONCLUSION: LITT-P has a significantly higher rate of skin thickening and LITT-R has a significantly higher proportion of adverse soft tissue reactions. Nevertheless, combined with the advantages of LITT-P described in other studies, this can be advocated as the preferred technique.

Severe Dehiscence of Gastrojejunal Anastomosis after Gastric Bypass: Its Cure by Using Partially Covered Stent and Avoiding Migration.

BACKGROUND: Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. MATERIALS AND METHODS: We present a video of a 39-year-old man with a body mass index of 40 Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastric leak was diagnosed 7 days after the bariatric surgery. At first, he was submitted to three reoperations: laparotomy with abdominal toilet, abdominal drain, and gastrostomy. Sepsis was controlled, but drain output maintained the same debit. On the 22nd POD, it was decided to place a metallic stent. As the first step, an endoscopist looked at the lesser curvature. There was no continuity to the alimentary limb, and the anastomosis was disrupted. Careful inflation and washing was done, allowing identification of the alimentary limb, followed by guidewire passage, with radioscopic control. Once the guidewire was positioned, stent placement was possible and safe. Upper edge of stent was placed in the lower third of the esophagus. RESULTS: Patient progressed uneventfully. After 4 weeks, stent removal was attempted. However, it was not possible due to endoluminal tissue hyperplasia. Argon plasma was used three times to promote proliferative mucosa ablation. Stent was removed after 53 days, with no migration. The abdominal drain was removed 1 week later. After 6-months follow-up, the patient remains asymptomatic. CONCLUSION: Early dehiscence closure was observed, without recurrence. The use of partially covered self-expandable metallic stent is associated with lower migration rates; however, removal can be technically difficult due to tissue hyperplasia.

A Unique Hybrid Approach to Complex Re-Do Aortic Root Surgery.

BACKGROUND: We present the case of a 23-year-old male with ventriculo-aortic dehiscence and a retrosternal false aneurysm communicating to the left ventricular outflow tract (LVOT) and ascending aorta. His history included aortic valve replacement (AVR) and mitral valve (MV) repair remotely, followed by two further operations for endocarditis and aortic root abscess. METHODS: The risk associated with the redo surgery required detailed planning and innovative techniques to allow it to be performed safely. These included femoral cannulation for cardiopulmonary bypass, venting the left ventricular apex via a small left anterior thoracotomy, use of a CODA® (COOK Medical, Bloomington USA) balloon to occlude the distal ascending aorta (placed via left brachial artery) and finally, the use of a PROPLEGE® (Edwards Lifesciences, Irvine, USA) retrograde cardioplegia cannula (placed via right internal jugular vein).

[Comparative analysis of laparotomy closure techniques]. / Sravnitel'nyi analiz sposobov ushivaniia laparotomnoi rany.

AIM: To assess experimentally different laparotomy closure techniques. MATERIAL AND METHODS: Experimental research on laboratory animals was performed. Laboratory animals underwent laparotomy followed by aponeurosis suturing by using of interrupted, continuous suture and continuous suture with an arrangement of stitches at different levels. Tensometric and histological examination of tissue specimens together with sutures was made in 7, 14, 60 days after surgery. RESULTS: Correlation of laparotomy closure technique with values of durability, elasticity and wound process course was obtained. CONCLUSION: Continuous suture after laparotomy promotes the formation of more mature granulation tissue and more solid scar with low elasticity compared with interrupted sutures.

Vacuum-assisted closure for skin necrosis after revision total knee arthroplasty.

Although skin necrosis following total knee arthroplasty or revision total knee arthroplasty is rare, it may cause severe complications. Skin changes begin with superficial infections and may result in removal of the prosthesis. Treatment of skin necrosis is an important factor, which determines the prognosis of the prosthesis. Several techniques have been defined for sufficient closure. In this article, we present the case of a patient who was treated for skin necrosis that developed after knee revision arthroplasty, using serial debridement, convergence sutures and an intermittent vacuum-assisted closure device (KCI Inc., San Antonio, TX).

Postoperative wound dehiscence: Predictors and associations.

The Agency for Healthcare Research and Quality patient safety indicators (PSI) were developed as a metric of hospital complication rates. PSI-14 measures postoperative wound dehiscence and specifically how often a surgical wound in the abdominal or pelvic area fails to heal after abdominopelvic surgery. Wound dehiscence is estimated to occur in 0.5-3.4% of abdominopelvic surgeries, and carries a mortality of up to 40%. Postoperative wound dehiscence has been adopted as a surrogate safety outcome measure as it impacts morbidity, length of stay, healthcare costs and readmission rates. Postoperative wound dehiscence cases from the Nationwide Inpatient Sample demonstrate 9.6% excess mortality, 9.4 days of excess hospitalization and $40,323 in excess hospital charges relative to matched controls. The purpose of the current study was to investigate the associations between PSI-14 and measurable medical and surgical comorbidities using the Explorys technology platform to query electronic health record data from a large hospital system serving a diverse patient population in the Washington, DC and Baltimore, MD metropolitan areas. The study population included 25,636 eligible patients who had undergone abdominopelvic surgery between January 1, 2008 and December 31, 2012. Of these cases, 786 (2.97%) had postoperative wound dehiscence. Patient-associated comorbidities were strongly associated with PSI-14, suggesting that this indicator may not solely be an indicator of hospital safety. There was a strong association between PSI-14 and opioid use after surgery and this finding merits further investigation.

Endoscopic evaluation of clinical colorectal anastomotic leakage.

BACKGROUND: Anastomotic leakage (AL) is a major complication after anterior resection. However, its therapeutic strategies and technical risk factors have not been well established. Therefore, we endoscopically evaluated anastomotic regions after laparoscopic colorectal anastomosis using a double-stapling technique (DST) for determination of treatment and investigation of technical factors. METHODS: In total, 191 consecutive patients underwent laparoscopic anterior resection with a DST from September 2008-January 2013. Anastomotic regions were endoscopically evaluated in patients suspected to have AL after surgery. RESULTS: Anastomotic dehiscence was observed in 19 patients, and AL was diagnosed in 18 (9.3%). Of the 19 patients, 12 were treated by creation of an intestinal stoma and 7 were treated conservatively based on their clinical status and endoscopic findings. Twenty-three dehiscences were observed among 19 anastomotic regions; all 23 were observed on the circular stapler anastomosis lines. Of these 23 dehiscences, 13 (56.5%) were located at the point at which the anastomosis lines of the circular and linear staplers overlapped, and 10 (43.5%) were located on the circumferential aspect between the overlapping points. CONCLUSIONS: Endoscopic evaluation of anastomotic regions is safe and useful for the determination of therapeutic strategies. The DST anastomotic technique itself may be closely related to the development of AL.

Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients.

Abdominal wall defects continue to be a challenging problem for reconstructive surgeons. The aim of our study was to report a 3-year experience using a simple Two-step Technique (TST) to treat abdominal wall defects. Between January 2008 and December 2010, 20 patients with abdominal wall defects were treated by TST. Patients had a mean age of 37·5 ± 14·9 years (range: 22-85 years); 5 were women and 15 were men. The size of the defects was prospectively analysed. Early and late complications were recorded. Hospital stay, post-procedure downtime and patient overall satisfaction were systematically assessed. A secondary defect resulting from self-manipulation and an infection were responsible for a complication rate of 10%. Both underwent successful surgical revision which led to full resolution. The average hospital stay was 11·2 ± 4·9 weeks for the series. Long-term complications were scar hyperpigmentation in 11 cases, scar hypertrophy in 5 cases and scar widening in 3 cases. Mean patient satisfaction was 8·3 ± 0·5 [visual analogue scale (VAS) 0-10]. Average downtime post surgery was 4·1 ± 1·2 weeks. The mean follow-up was 24·6 ± 6·7 months. Reconstruction of abdominal wall defect with the TST is a reliable and reproducible technique. This technique provides excellent outcomes, and we anticipate that it will become widespread in the near future.