Management of Pilonidal Disease: A Review.

Importance: The management of pilonidal disease continues to be a challenge due to high rates of recurrence and treatment-associated morbidity. Observations: There is a heterogeneous repertoire of treatment modalities used in the management of pilonidal disease and wide practice variation among clinicians. Available treatment options vary considerably in their level of invasiveness, associated morbidity and disability, risks of complications, and effectiveness at preventing disease recurrence. Conservative nonoperative management strategies, including persistent improved hygiene, depilation, and lifestyle modification, focus on disease prevention and minimization of disease activity. Epilation techniques using both laser and intense pulse light therapy are also used as primary and adjunct treatment modalities. Other nonoperative treatment modalities include phenol and fibrin injection to promote closure of pilonidal sinuses. The traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (ie, Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention. There has been a recent shift toward more minimally invasive operative approaches including sinusectomy (ie, trephination or Gips procedure) and endoscopic approaches. Overall, the current evidence supporting the different treatment options is limited by study quality with inconsistent characterization of disease severity and use of variable definitions and reporting of treatment-associated outcomes across studies. Conclusions and Relevance: Pilonidal disease is associated with significant physical and psychosocial morbidity. Optimal treatments will minimize disease and treatment-associated morbidity. There is a need for standardization of definitions used to characterize pilonidal disease and its outcomes to develop evidence-based treatment algorithms.

Plastic surgery wound closure following resection of spinal metastases.

OBJECTIVE: Surgical site infection and dehiscence are devastating complications of surgery for spinal metastases. Wound closure involving plastic surgeons has been proposed as a strategy to lower post-operative complications. Here we investigated whether plastic surgery closure is associated with lower rates of wound complications, wound infection, and wound reoperation compared to simple closure by spine surgeons. METHODS: Patients surgically treated for metastatic tumors at a single comprehensive cancer center between April 2013-2020 were retrospectively identified. Primary pathology, demographic information, clinical characteristics, pre-operative laboratory values, tumor location, operative characteristics, and post-operative outcomes were collected. Univariable analyses used student t-tests for continuous variables and χ2 tests for categorical variables. Multivariable regressions were performed to control for confounders. RESULTS: We included 317 patients, of which 56 underwent closure by plastic surgeons and 291 by neurosurgeons. Patients in the plastic surgery cohort were more likely to have received prior radiation to the surgical site, more often on long-term corticosteroid therapy, and more likely to have sacrococcygeal tumors. Operations involving plastic surgeons were more likely to be revision surgeries, corpectomies, and to involve a staged approach. Additionally, patients in the plastic surgery cohort had longer incision lengths, longer surgeries, greater intraoperative blood loss (IOBL), were more likely to receive transfusions, and had longer hospitalizations. Local paraspinous advancement flaps were the most common complex wound closure technique. Plastic surgery closure was not significantly associated with a difference in rates of post-operative wound complications, wound infection, or wound-related reoperations compared to simple wound closure. CONCLUSION: We identified that patients undergoing plastic surgery wound closure had worse baseline risk, longer surgeries, greater IOBL, and longer hospitalizations compared to patients receiving simple closure. Despite their increased risk, complex wound closure did not significantly alter the rates of post-operative wound complications, wound infection, or wound-related reoperations. Consideration may be given to plastic surgery closure in patients at high risk of wound complications or with extensive wound defects.

Nanoceutical Adjuvants as Wound Healing Material: Precepts and Prospects.

Dermal wound healing describes the progressive repair and recalcitrant mechanism of 12 damaged skin, and eventually, reformatting and reshaping the skin. Many probiotics, nutritional supplements, metal nanoparticles, composites, skin constructs, polymers, and so forth have been associated with the improved healing process of wounds. The exact mechanism of material-cellular interaction is a point of immense importance, particularly in pathological conditions such as diabetes. Bioengineered alternative agents will likely continue to dominate the outpatient and perioperative management of chronic, recalcitrant wounds as new products continue to cut costs and improve the wound healing process. This review article provides an update on the various remedies with confirmed wound healing activities of metal-based nanoceutical adjuvanted agents and also other nano-based counterparts from previous experiments conducted by various researchers.

Development of a Bioinspired, Self-Adhering, and Drug-Eluting Laryngotracheal Patch.

OBJECTIVES/HYPOTHESIS: Novel laryngotracheal wound coverage devices are limited by complex anatomy, smooth surfaces, and dynamic pressure changes and airflow during breathing. We hypothesize that a bioinspired mucoadhesive patch mimicking how geckos climb smooth surfaces will permit sutureless wound coverage and also allow drug delivery. STUDY DESIGN: ex-vivo. METHODS: Polycaprolactone (PCL) fibers were electrospun onto a substrate and polyethylene glycol (PEG) - acrylate flocks in varying densities were deposited to create a composite patch. Sample topography was assessed with laser profilometry, material stiffness with biaxial mechanical testing, and mucoadhesive testing determined cohesive material failure on porcine tracheal tissue. Degradation rate was measured over 21 days in vitro along with dexamethasone drug release profiles. Material handleability was evaluated via suture retention and in cadaveric larynges. RESULTS: Increased flocking density was inversely related to cohesive failure in mucoadhesive testing, with a flocking density of PCL-PEG-2XFLK increasing failure strength to 6880 ± 1810 Pa compared to 3028 ± 791 in PCL-PEG-4XFLK density and 1182 ± 262 in PCL-PEG-6XFLK density. The PCL-PEG-2XFLK specimens had a higher failure strength than PCL alone (1404 ± 545 Pa) or PCL-PEG (2732 ± 840). Flocking progressively reduced composite stiffness from 1347 ± 15 to 763 ± 21 N/m. Degradation increased from 12% at 7 days to 16% after 10 days and 20% after 21 days. Cumulative dexamethasone release at 0.4 mg/cm2 concentration was maintained over 21 days. Optimized PCL-PEG-2XFLK density flocked patches were easy to maneuver endoscopically in laryngeal evaluation. CONCLUSIONS: This novel, sutureless, patch is a mucoadhesive platform suitable to laryngeal and tracheal anatomy with drug delivery capability. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1958-1966, 2021.

Retrospective Analysis of Primary Suturing of the Internal Orifice of Perianal Fistula During FiLaC Procedure.

PURPOSE: We aimed to evaluate the results of the fistula-tract laser closure associated with primary closure of internal orifice. MATERIALS AND METHODS: The surgical objective was to seal the fistula tract using laser energy and closing internal orifice with purse-string suture. Between January 2017 and December 2018, 35 consecutive patients who underwent the laser closure plus internal orifice suturing included. In all 35 patients, the laser procedure was applied then internal orifice was primarily closed with 2-0 polyglactin suture after the debridement of necrotic tissue. RESULTS: Among 35 patients (11 female, 24 male), mean age was 43.9±12.9 years. Median follow-up was 11 months (6.0 to 17.6 mo). According to the Park classification; 21 patients (60%) had intersphincteric fistula, 12 (34%) had transsphincteric fistula, 2 (6%) had suprasphincteric or extrasphincteric fistula. There were low/simple and high/complex fistula in 21 (60%) and 14 patients (40%), respectively. Overall, 15/35 (42.9%) patients showed complete healing, 12/35 (34%) had slight drainage with minimal symptoms, 8/35 (22%) patients had persistent symptomatic drainage, and there was no patient with painful symptomatic drainage. On the basis of the Jorge-Wexner continence score, there was no significant difference in patients before and after the procedure. The perfect continence rate was achieved in 32 patients (91%). CONCLUSION: Although the absence of major and minor complications after Fistula Laser Closure (FiLaC) procedure seemed to be a major advantage, we thought that closure of the internal opening by primary suturing has no positive effect on the healing of the perianal fistula.

Acute lacerations: Assessment and non-surgical management.

BACKGROUND: Given appropriate case selection and capability, many acute lacerations can be managed in the primary care setting. An understanding of the basic pathophysiology, assessment and management principles is essential. OBJECTIVE: The aim of this article is to provide a basic framework for assessing and managing simple acute lacerations. DISCUSSION: The aim of assessment is initially to decide whether the laceration is suitable for office-based treatment, and then whether it requires formal surgical closure with sutures or staples. Two non-surgical techniques for skin closure in amenable wounds are described. A companion article in this issue provides details of surgical closure techniques and wound aftercare.

Contrast radiography before diverting stoma closure in rectal cancer is not necessary on a routine basis. / El estudio radiológico con contraste antes del cierre del estoma derivativo en el cáncer de recto no es necesario de forma rutinaria.

INTRODUCTION: Diverting stomata are recommended in patients with low anterior resection and risk factors in order to reduce the severity of anastomotic leaks. Usually, a radiology study is performed prior to the closure of the stoma to detect subclinical leaks. The aim of the present study is to assess the clinical utility of the radiology study. METHODS: A prospective cohort study of patients undergoing anterior rectal resection for rectal cancer and those who underwent stoma closure without contrast enema. This study was carried out after a retrospective review of radiology study results prior to the closure of the stoma in patients operated from 2007 to 2011. RESULTS: Eighty-six patients met the study criteria. Thirteen patients (15.1%) presented pelvic sepsis. Contrast enema before stoma closure was pathological in 8 patients (9.3%). Five out of the 13 patients with pelvic sepsis had a pathological radiological study, compared to only 3 out of the 73 patients without intra-abdominal complications after rectal resection (38.5% vs. 4.1%; P=.001). Based on these results, we conducted a prospective study omitting the contrast enema in patients with no postoperative complications. Thirty-eight patients had their stoma closed without a prior radiology study. None of the patients presented pelvic sepsis. CONCLUSIONS: Radiology studies of the colorectal anastomosis before reconstruction can safely be omitted in patients without pelvic sepsis after the previous rectal resection.

Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections.

BACKGROUND: Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested. METHODS: A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression. RESULTS: In a population with a mean BMI of 30 kg/m2 , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase. CONCLUSION: Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Impact of a Surgical Sealing Patch on Lymphatic Drainage After Axillary Dissection for Breast Cancer: The SAKK 23/13 Multicenter Randomized Phase III Trial.

BACKGROUND: Several studies and a meta-analysis showed that fibrin sealant patches reduced lymphatic drainage after various lymphadenectomy procedures. Our goal was to investigate the impact of these patches on drainage after axillary dissection for breast cancer. METHODS: In a phase III superiority trial, we randomized patients undergoing breast-conserving surgery at 14 Swiss sites to receive versus not receive three large TachoSil® patches in the dissected axilla. Axillary drains were inserted in all patients. Patients and investigators assessing outcomes were blinded to group assignment. The primary endpoint was total volume of drainage. RESULTS: Between March 2015 and December 2016, 142 patients were randomized (72 with TachoSil® and 70 without). Mean total volume of drainage in the control group was 703 ml [95% confidence interval (CI) 512-895 ml]. Application of TachoSil® did not significantly reduce the total volume of axillary drainage [mean difference (MD) -110 ml, 95% CI -316 to 94, p = 0.30]. A total of eight secondary endpoints related to drainage, morbidity, and quality of life were not improved by use of TachoSil®. The mean total cost per patient did not differ significantly between the groups [34,253 Swiss Francs (95% CI 32,625-35,880) with TachoSil® and 33,365 Swiss Francs (95% CI 31,771-34,961) without, p = 0.584]. In the TachoSil® group, length of stay was longer (MD 1 day, 95% CI 0.3-1.7, p = 0.009), and improvement of pain was faster, although the latter difference was not significant [2 days (95% CI 1-4) vs. 5.5 days (95% CI 2-11); p = 0.2]. CONCLUSIONS: TachoSil® reduced drainage after axillary dissection for breast cancer neither significantly nor relevantly.

Atención integral a una mujer con úlcera neoplásica latero cervical: un caso clínico en Atención Primaria / Comprehensive care for a woman with laterocervical neoplastic ulcer: a clinical case in primary care

El aumento de episodios oncológicos en la salud supone un incremento en las heridas de etiología neoplásica, las cuales tienen un abordaje diferente del de otro tipo de heridas. En el artículo se describe el caso clínico de una mujer de 71 años que presentaba una lesión neoplásica en la zona latero cervical derecha, a la que se le realizó un plan integral de cuidados de Enfermería con la intención de efectuar un abordaje holístico. La valoración permitió detectar un riesgo de baja autoestima situacional como diagnóstico enfermero, que fue abordado en el plan de cuidados junto a los problemas de colaboración: úlcera neoplásica latero cervical y dolor agudo secundario a la lesión neoplásica. Para el plan de cuidados se utilizaron las taxonomías NOC y NIC: Curación de la herida por segunda intención (NOC: 1103), Cuidados de las heridas (NIC: 3660) y Cuidado de las heridas: ausencia de cicatrización (NIC: 3664); Control del dolor (NOC: 1605) y Manejo del dolor (NIC: 1400); Aceptación: Estado de salud (NOC: 1300) y Apoyo emocional (NIC: 5270). Hasta la muerte de la paciente se cumplieron los objetivos generales de un abordaje terapéutico dirigidos a mejorar la calidad de vida del sujeto, optimizar su autoestima y su paz espiritual

The increase of oncological episodes in health represents an increase in the wounds with neoplastic etiology, which need a different approach from that used for other type of wounds. This article describes the clinical case of a 71-year-old woman who presented a neoplastic lesion in her right laterocervical area; a comprehensive Nursing Care plan was conducted with holistic approach as objective. Assessment allowed to detect the risk of situational low self-esteem as Nursing Diagnosis, which was addressed in the Nursing Plan alongside collaborative problems: laterocervical neoplastic ulcer and acute pain secondary to the neoplastic lesion. NOC and NIC taxonomies were used for the Care Plan: Wound healing: secondary intention (NOC: 1103), Wound care (NIC: 3660) and Wound care: Non-healing (NIC: 3664); Pain control (NOC: 1605) and Pain management (NIC: 1400); Acceptance: Health Status (NOC: 1300) and Emotional Support (NIC: 5270). Until the patient’s death, the general objectives were met regarding a treatment approach targeted to improving the patient’s quality of life, optimizing her self-esteem and her spiritual peace

An Overview of the Use of Bromelain-Based Enzymatic Debridement (Nexobrid®) in Deep Partial and Full Thickness Burns: Appraising the Evidence.

Recent introduction of rapid bromelain-based enzymatic debridement has been increasingly popular in its use in nonsurgical debridement in deep partial and full thickness burns. We designed this study to evaluate the evidence suggested by current studies on the perceived benefits of using Nexobrid® compared with traditional surgical standard of care in burns wound debridement. A comprehensive search on electronic databases Pubmed, Embase, and Web of Science was done to identify studies published between 1986 and 2017 involving the use of Nexobrid® in deep partial and full thickness burns. Studies were evaluated for proposed benefits and categorized under supporting evidence, contradicting evidence, and anecdotal opinions. Seven well-designed prospective studies met the inclusion comprising four randomized controlled trials. Six proposed benefits associated with the use of Nexobrid® were extracted including reduced time to complete debridement, need for surgery, area of burns excised, need for autograft, time to wound closure, and improved scar quality. Most proposed benefits have strong supporting evidences with minimal anecdotal opinions from controlled trials except the proposed improvement in scar quality and reduced time to wound healing that had at least three refuting evidence and one anecdotal evidence. Incidence of pain was also evaluated and was mainly anecdotal lacking formal objective assessment or cohort study. Despite the lack of literatures available, the benefits of Nexobrid® are evident in published randomized and single arm studies. Large number of studies is needed to aid further evaluating the proposed benefits of Nexobrid®.

Evidencia empírica de la miel como tratamiento eficaz. En la dehiscecia de sutura tras vulvectomía radical / Empirical evidence of honey as an effective treatment for wound dehiscence after a radical vulvectomy

El cáncer de vulva es uno de los tumores ginecológicos menos frecuentes. La mutilación producida por cirugías radicales, como la vulvectomía, pueden ocasionar importantes secuelas físicas, psíquicas y sexuales en la mujer. El caso clínico que presentamos es el de una mujer de 83 años diagnosticada de cáncer de vulva, a la que se intervino en nuestro centro por recidiva local y que presentó dehiscencia de la cicatriz pocos días después de la cirugía. Nuestro objetivo es mostrar que la cura con miel es una alternativa eficaz, por sus propiedades curativas, en la cura de dehiscencias en las vulvectomías, además de ser una terapia barata, accesible y fácil de aplicar (AU)

Vulvar cancer is one of the less common gynecological tumors. Nevertheless, the mutilation produced by a radical surgery such as the vulvectomy can cause important sequels in women, both physical and psychological. We present a clinical case of an 83-year-old woman diagnosed with vulvar cancer, who underwent a radical vulvectomy after local recurrence at our hospital. She presented a wound dehiscence a few days after the surgery. Our aim is to discuss that honey is an effective alternative cure of wound dehiscence in vulvectomy due to its healing properties; it is also a cheaper treatment, accessible, and easy to apply (AU)

Sustaining Improvement: Implementation and Spread of a Surgical Site Infection Bundle.

Surgical site infections (SSIs) are considered a quality metric across surgical specialties and are a major cause of increased readmissions and overall costs to surgical patients. Bundled interventions have demonstrated efficacy in reducing SSIs in various surgical fields, yet the ability to sustain and spread interventions while continuing to reduce infection rates is a significant challenge. This study assessed the implementation and sustainability of an SSI bundle, which was initially piloted within the colorectal surgery division and then spread to additional general surgery services. Outcomes (risk-adjusted ACS-NSQIP odds ratio and observed to expected (O:E) SSI rates) and process measures were monitored on run charts throughout the course of the intervention. By the end of the study period, ACS-NSQIP risk-adjusted odds ratios for SSIs decreased from 1.22 to 0.95 for colorectal procedure targeted and 1.32 to 1.04 for all general surgery procedures (P < 0.05). O:E ratios showed similar reductions. SSI reductions were associated with process measure compliance. This study demonstrates that effective implementation within a single surgical division provides the foundation for spread of a SSI bundle, which results in continued and sustained reductions in SSI rates.

Clinical Value of Contrast Enema Prior to Ileostomy Closure.

Purpose To determine the value of routine contrast enema of loop ileostomy before elective ileostomy closure regarding the influence on the clinical decision-making. Materials and Methods Retrospective analysis of contrast enemas at a tertiary care center between 2005 und 2011. Patients were divided into two groups: Group I with ileostomy reversal, group II without ileostomy closure. Patient-related parameters (underlying disease, operation method) and parameters based on the findings (stenosis, leakage of anastomosis, incontinence) were evaluated. Results Analyzing a total of 252 patients in 89 % (group I, n = 225) ileostomy closure was performed. In 15 % the radiologic report was the only diagnostic modality needed for therapy decision; in 36 % the contrast enema and one or more other diagnostic methods were decisive. In 36 % the radiological report of the contrast imaging was not relevant for decision at all. In 11 % (group II, n = 27) no ileostomy closure was performed. In this group in 11 % the radiological report of the contrast enema was the only decision factor for not performing the ileostomy reversal. In 26 % one or more examination was necessary. In 26 % the result of the contrast examination was not relevant. Conclusion The radiologic contrast imaging of loop ileostomy solely plays a minor role in complex surgical decision-making before planned reversal, but is important as first imaging method in detecting complications and often leads to additional examinations. Key points · Contrast enema of loop ileostomy before planned ileostomy closure is a frequently performed examination.. · There exist no general guidelines that give further recommendations on decision-making planning ileostomy closure.. · The radiologic contrast imaging of loop ileostomy solely plays a minor role in decision-making before planned reversal, but is important as first imaging method.. Citation Format · Goetz A, da Silva NP, Moser C et al. Clinical Value of Contrast Enema Prior to Ileostomy Closure. Fortschr Röntgenstr 2017; 189: 855 - 863.

Tratamiento de úlceras en el pie diabético. Revisión / Treatment of Diabetic foot Ulcers: A review

La Diabetes Mellitus se postula como una de las grandes epidemias del siglo XXI, siendo el pie diabético una de sus mayores complicaciones. Objetivo: Describir tratamientos novedosos que permitan la cura de úlceras diabéticas. Metodología: Búsqueda de artículos publicados en Pubmed y Scielo y repaso de la bibliografía disponible en la Universidad Rey Juan Carlos hasta el 3 de enero de 2016. Resultados: Han sido revisados el estándar de cuidado, terapias electrofísicas como las ondas de choque, la presión negativa tópica, el ozono o el oxígeno hiperbárico, factores de crecimiento y equivalentes de piel biológica, entre otros, en un total de doce artículos. Discusión: La ozonoterapia, la corriente continua de baja intensidad catódica, los sustitutos de piel de bioingeniería, el complejo ácido hialurónicofibroblastos autólogos y Targeted son terapias beneficiosas. Las ondas de choque, la presión negativa y el oxígeno hiperbárico recibieron bajo nivel de evidencia. Se recomienda el uso de factores de crecimiento endógenos por encima de los locales. Dermagraft aparece en confrontación entre artículos. El desbridamiento quirúrgico es el más eficaz, pero la terapia con larvas (desbridamiento biológico) cada vez tiene mayor peso. En descarga, la férula o yeso de contacto total y la férula o yeso de contacto total instantáneo resultaron ser útiles. Conclusiones: Los tratamientos existentes para las DFU son múltiples. No existe un protocolo específico de actuación, se debe ajustar el tratamiento al paciente. Son precisos más ensayos que generen resultados homogéneos y comparables entre estudios (AU)

Mellitus diabetes has gained the tittle of epidemy of the 21st century, in which the diabetic food is one its critics complication. Objective: To describe newfangled treatments which allow the cure of diabetic ulcerous. Methods: Research of articles published on «Pubmed» and «Scielo», as well as the review of the available bibliography on Rey Juan Carlos University unit January the 3rd 2016. Results: They have been revised the following techniques: The care standards, electromechanical therapies, such as shock waves, topical negative pressure, ozone or hiperbaric oxygen; growing factors and biological skin equivalents, amongst others; out of twelve articles. Discussion: the therapy based on ozone, low cathodic continuous flow, bio-ingeniering skin substitutes, hialuronic-fibroblasts autolugous and Targeted are beneficial therapies. The shock waves, topical negative pressure and the hiperbaric oxygen received a low evidence level. The use of endogenous growing factors recommended above the locals. There is a confrontation in the articles about Dermagraft. Surgical debridement is the most efficient, but larval therapy (biological debridement) is become more relevant. In discharge, splint or total contact plaster and splint or instantaneous total contact plaster resulted useful. Conclusions: The existent treatments for UDF are various. There is not a specific action protocol, it must be adapted to the patient. More medical tests are required for homogeneous and comparable results to be generated amongst researches (AU)

A "Shark Encounter": Delayed Primary Closure and Prophylactic Antibiotic Treatment of a Great White Shark Bite.

BACKGROUND: Shark bites are rare but sensational injuries that are covered in the lay press but are not well described in the medical literature. CASE REPORT: We present the case of a 50-year-old man who sustained two deep puncture wounds to his thigh from a great white shark in the waters surrounding Isla de Guadalupe off the coast of Baja California, Mexico, during a caged SCUBA dive. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss our strategy of closing the wounds in a delayed primary fashion 24 hours after injury, our antibiotic choices, and the patient's course and review marine pathogens and appropriate antibiotic coverage.

Updates of operative techniques for upper airway stimulation.

Selective upper airway stimulation has been established as an additional treatment for obstructive sleep apnea (OSA). Essential for the treatment is the precise placement of the cuff electrode for select branches of the hypoglossal nerve, which innervate the protrusors and stiffeners of the tongue. A direct approach to the distal hypoglossal nerve has been established to achieve this goal. For surgeons, detailed knowledge of this anatomy is vital. Another decisive step is the placement of the sensing lead between the intercostal muscles. Also, the complexity of follow-up care postoperatively should be kept in mind. The aim of this article is to provide the latest knowledge on the neuroanatomy of the hypoglossal nerve and to give surgeons a step-by-step guide on the current operative technique. Laryngoscope, 126:S12-S16, 2016.

Pediatric sutureless circumcision: an effective and cost efficient alternative.

INTRODUCTION: Circumcision is the most commonly performed surgical procedures in male children. Maine is one of 18 states in the United States which does not pay for neonatal circumcisions. The aim of this study was to perform outcomes and cost analysis of a sutureless circumcision technique versus circumcision using sutures. Specifically, we evaluated Dermaflex (2-octyl cyanoacrylate, 2-OCA) surgical glue circumcision as a cost effective, faster, and safe alternative to traditional suture circumcision. MATERIALS AND METHODS: Our study was a non-randomized series. We collected the operative details prospectively, abstracted clinical outcomes retrospectively, and performed data analysis retrospectively. One hundred and twenty-six circumcisions were performed by two pediatric urologists over a 1 year period. Suture circumcisions were performed exclusively during the first 6 months, and 2-OCA glue circumcisions were performed during the second 6 months. Billing charges were analyzed to extrapolate variable costs between the two surgical procedures. The technique used to perform the sutureless circumcision was a modification of the standard sleeve technique, with the use of monopolar diathermy instead of scalpel, and application of 2-OCA glue to approximate tissue edges. RESULTS: From Jan 2013 to Jan 2014, 72 patients underwent circumcision with suture, and 54 patients underwent circumcision with 2-OCA glue. Mean age in the glue group was 61 months (range 8-202 months), and 50 months in the suture group (range 5-215 months), p = 0.19. All cases were performed under general anesthesia, as outpatient surgery. Mean operative cut time was 18.4 min for the glue group, and 28.6 min for the suture group (p < 0.01). The 10.2 min operative time difference translated to a $378 cost savings per glue circumcision case. Complication rates were not statistically significant between the two groups. CONCLUSION: The use of 2-OCA tissue adhesive for sutureless circumcision is an alternative to the standard technique. It results in faster operative times, with a significant cost savings, while maintaining comparable complication rates to the standard suture technique. This is a viable, less expensive surgical option for patients whose circumcisions are not covered by Medicaid.