Negative Pressure Level and Effects on Bacterial Growth Kinetics in an in vitro Wound Model.

Negative Pressure Wound Therapy (NPWT) has been widely adopted in wound healing strategies due to its multimodal mechanism of action. While NPWT's positive impression on wound healing is well-established, its effect on bacterial load reduction remains equivocal. This study investigates NPWT's efficacy in reducing bioburden using an in vitro porcine skin model, focusing on the impact of Staphylococcus aureus and Staphylococcus epidermidis. Custom-made negative pressure chambers were employed to apply varying negative pressures. Porcine skin was cut into 5 × 5 cm squares and three standardized wounds of 6 mm each were created using a biopsy punch. Then, wounds were infected with S. aureus and S. epidermidis bacterial suspensions diluted 1:10,000 to obtain a final concentration of 1.5 × 104 CFU/ml and were placed in negative pressure chambers. After incubation, bacterial counts were expressed as colony-forming units (CFU) per ml. For S. aureus at 120 hours, the median CFU, mean area per colony, and total growth area were notably lower at -80 mmHg when compared to -250 mmHg and -50 mmHg, suggesting an optimal negative pressure for the pressure-dependent inhibition of the bacterial proliferation. While analyzing S. epidermidis at 120 hours, the response to the negative pressure was similar but less clear, with the minor CFU at -100 mmHg. The influence of intermittent negative pressure on the S. epidermidis growth showed notably lower median CFU with the interval therapy every hour compared to the S. aureus control group. This study contributes valuable insights into NPWT's influence on the bacterial load, emphasizing the need for further research to reformulate its role in managing contaminated wounds.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects.

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Analysis of risk factors for conversion in laparoscopic adrenalectomy: a single-institution series of 256 patients.

Introduction: Although introduction of the laparoscopic approach for adrenal gland surgery revolutionized the strategy in management of adrenal gland tumors, open surgery is still a method of choice in some clinical scenarios. Moreover, laparoscopy may have limitations resulting in conversion. Aim: To assess risk factors predisposing for conversion based on our own material, including 256 laparoscopic adrenalectomies performed in 2009-2016. Material and methods: A retrospective analysis of patients who underwent adrenalectomies between 2009 and 2016 was conducted. Patients were analyzed for sex, body mass index (BMI), size of the adrenal gland lesion, final histopathological diagnosis and operated side of the adrenal gland, its impact on conversion rate. Results: A total of 256 patients underwent laparoscopic adrenalectomy. The reported study comprised of 94 (36.7%) men and 162 (63.3%) women. The most common indication for adrenalectomy were adrenal cortex adenoma (n = 149; 58.2%) and pheochromocytoma (n = 48; 18.75%). The conversion rate was 3.91% (n = 10 patients). Mean BMI of patients without conversion was 27.6 kg/m2, whereas in the group of patients with conversion, BMI was 29.7 kg/m2 (p > 0.05). The conversion rate was precisely the same when comparing the right (5/126; 3.9%) and left (5/126; 3.9%) adrenal gland. There was no correlation between the size of the adrenal lesion and the risk of conversion. Conclusions: The laparoscopic approach remains an efficient and safe procedure for adrenal gland tumors. Based on our study, obese patients and those with pheochromocytoma are associated with a higher risk of conversion but without any statistical significance. There was no difference in the conversion rate when analyzing the size of the adrenal gland tumor. No difference was also revealed in the conversion rate when comparing both sides of laparoscopic adrenalectomy.

Stoma close to the abdominal wound: a real technical problem. A description of a novel care strategy.

IntroductionIn some clinical scenarios, stoma site may be located close to the abdominal wound edge impeding optimal wound management and stoma care. We present a novel strategy of utility NPWT for management of simultaneous abdominal wound healing with stoma presence. Material and methodsRetrospective analysis of seventeen patients treated with a novel wound care strategy was conducted. Application of NPWT within wound bed, around stoma site and skin between allows for: 1) separating wound from stoma site, 2) maintaining the optimal environment for wound healing, 3) protecting peristomal skin and 4) facilitating application of ostomy appliances.ResultsThe study group comprised of twelve female (70,6 %) and five male (29,4%) with the mean age of 49.1 18.4 years The most common underlying pathology was Crohn s disease (n-5; 29,4%). Since NPWT was implemented, patients had undergone from 1 to 13 surgeries. Thirteen patients (76,5%) required intensive care unit admission. The mean time of hospital stay was 65,3 28,6 days (range: 36 134). The mean session of NPWT was 10.8 5.2 (range: 5 - 24) per patient. The range of the level of negative pressure was from -80 to 125 mmHg. In all patients, progress in wound healing was achieved resulting in granulation tissue formation, minimizing wound retraction and thus reduction of the wound area. As a result of NPWT, wound was granulated entirely, tertiary intension closure were achieved or patients were qualified for reconstructive surgery.DiscussionNPWT is safe and useful therapy for complicated abdominal wounds with the presence of stoma close to wounds edges. A novel care strategy allows for simultaneous technical opportunity to separate stoma from wound bed and facilitate wound healing.

Challenges in restoring bowel continuity: An analysis of 91 patients undergoing a reversal procedure

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m2. Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5­24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications.

Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study.

INTRODUCTION: The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI. AIM: To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery. MATERIAL AND METHODS: As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed. RESULTS: The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03-3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group. CONCLUSIONS: CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.

Endoscopic vacuum therapy with instillation (iEVT) - a novel endoscopic concept for colorectal anastomotic leak and perianal complications.

INTRODUCTION: Anastomotic leaks remain the most fearful complications. AIM: We present a novel endoscopic salvage therapy known as endoscopic vacuum therapy with instillation (iEVT) as a combination of standard endoscopic vacuum therapy (EVT) and negative pressure wound therapy with instillation (iNPWT). MATERIAL AND METHODS: A case series of 6 consecutive patients treated with iEVT is presented. A Redon drain and a central venous catheter were introduced within polyurethane foam used as a self- made device for iEVT and antimicrobial solution was instilled. RESULTS: A total of 6 patients with the mean age of 29.5 ±8.9 were treated with iEVT. The mean number of iEVT sessions was 5.8 ±2.3. The mean time of iEVT management was 20.7 ±8.8 days. Locally, a reduction in purulent discharge and defect's dimension with contraction were revealed confirmed with imaging studies. CONCLUSIONS: iEVT is a very encouraging, novel method for complicated perianal diseases and anastomotic leak.

LapVac - a laparoscopic approach for negative pressure wound therapy application in open abdomen management: a porcine animal model.

INTRODUCTION: Negative pressure wound therapy (NPWT) in the open abdomen (OA) is recognized as a gold standard management method. Currently minimally invasive procedures are implemented in many clinical scenarios. AIM: To demonstrate the feasibility of using negative pressure wound therapy in a laparoscopic approach for OA management in a porcine model termed as a laparoscopic vacuum (LapVac). MATERIAL AND METHODS: An adult female swine underwent a laparoscopic procedure. Briefly, a small incision was made and secured with a wound protector, pneumoperitoneum was created and two additional ports were placed. Then, a non-adhesive layer was precisely placed within the abdominal cavity. RESULTS: Finally, polyurethane foam and adhesive drape were applied. A volume of 200 ml of saline solution was instilled and drained completely within 30 min. We did not observe any technical problems with NPWT application. CONCLUSIONS: This study confirmed the technical feasibility of NPWT application in the laparoscopic approach. LapVac seems to be a promising technique which may minimize the trauma and lead to better outcomes.

Ileal pouch anal anastomosis leak after restorative proctocolectomy without protective stoma successfully treated with endoscopic vacuum therapy.

Aim An ileal pouch anal anastomosis (IPAA) leak is one of the most severe complication after restorative proctocoletomy (RPC). We present a rare case of a successful management of IPAA leak after RPC without defunctionig stoma with the utility of endoscopic vacuum therapy. Methods A 57-year-old male with a ileal pouch anal anastomosis leak after RPC due to ulcerative colitis with presacral abscess was qualified for endoscopic vacuum therapy (EVT). The abscess of the left buttock was drained and secured with suction drain (redon drain). Due to the lack of defunctioning stoma, a system for contain and divert fecal matter was placed within afferent limb of the J-pouch and EVT was placed directly within IPAA dehiscence. EVT was changed every third day. Results The patient underwent a total of five EVT sessions. Improvement of patient's general condition characterized with lack of pelvic pain, fever and reduction of inflammatory markers was achieved. Locally, anastomosis dehiscence was healed with prominent reduction in the defect's dimension, contraction and revascularization. Based on imaging studies no chronic presacral sinus or any other perianal disturbances were revealed at the time of five months follow up. Conclusions EVT is a promising method for management of IPAA leak. Although, it remains extremely difficult, EVT may serve as a method of choice in early pouch-related septic complications after RPC performed without defunctioning stoma.

Ringer's lactate solution enhances the inflammatory response during fluid resuscitation of experimentally induced haemorrhagic shock in rats.

INTRODUCTION: Hemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock. MATERIAL AND METHODS: A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer's acetate (RAG); and Ringer's lactate (RLG). Microhaemodynamic parameters were measured during the experiment. RESULTS: A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the lactate Ringer (LR) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer's lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle. CONCLUSIONS: The present study revealed that fluid resuscitation with Ringer's lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer's acetate solution reduces local inflammation and could therefore be recommended as the "first line" crystalloid of the fluid resuscitation during haemorrhagic shock.

A novel model of acellular dermal matrix plug for anal fistula treatment. Report of a case and surgical consideration based on first utility in Poland.

Anal fistula (AF) is a pathological connection between anus and skin in its surroundings. The main reason for the formation of anal fistula is a bacterial infection of the glands within the anal crypts. One of the modern techniques for the treatment of fistulas that do not interfere with the sphincters consists in implantation of a plug made from collagen material. We are presenting the first Polish experience with a new model of biomaterial plug for the treatment of anal fistula. We also point out key elements of the procedure (both preoperative and intraoperative) associated with this method. In the authors' opinion, the method is simple, safe and reproducible. Innovative shape of the plug minimizes the risk of its migration and rotation. It also perfectly blends with and adapts to the course and shape of the fistula canal, allowing it to become incorporated and overgrown with tissue in the fistula canal. The relatively short operation time, minor postoperative pain and faster convalescence are with no doubt additional advantages of the method. Long-term observation involving more patients is essential for evaluation of the efficacy of the treatment of fistulas with the new type of plug.

The influence of rifaximin on diverticulitis rate and quality of life in patients with diverticulosis.

Diverticulosis, its associated symptoms and complications are one of the most common pathologies of the gastrointestinal tract in more economically developed countries. Presence of diverticuli and their clinical consequences can be divided into four categories: 1) diverticulosis, i.e. an asymptomatic presence of diverticuli that are usually found by accident 2) symptomatic uncomplicated diverticulosis 3) diverticulitis (acute uncomplicated diverticulitis) 4) complications of diverticulitis (conditions requiring hospital stay). The aim of this study was to retrospectively analyze the efficacy of rifaximin in preventing diverticulitis in patients visiting proctology clinics. The diagnostic criterium for diverticulosis was confirmation by colonoscopy, barium enema or CT colography (virtual colonoscopy) as well as history of at least one documented episode of diverticulosis. History of diverticulosis was evaluated based on medical records, clinical symptoms, elevated level of CRP (>5.0) and/or diagnostic imaging (ultrasound, CT). After setting strict exclusion criteria, 248 patients were qualified for the study out of 686, and they were later divided into two groups: control group (group I - 145 patients) and studied group (group II - 103 patients receiving rifaximin prophylaxis). Diverticulitis rate was comparable in both groups over a period of 6 months before study (p = 0.1306) and 6 months of treatment (p=0.3044). Between the 6th and 12th month of treatment, a significantly lower rate of diverticulitis was noted in the group receiving rifaximin compared to control group (p<0.0001). Patients receiving rifaximin reported higher quality of life (which was assessed using the VAS scale) compared to control group after 12 months. The results confirmed the efficacy of riaximin in prevention of diverticulitis, even in the scheme of repeated courses every 3 months. Not only did application of rifaximin lower the rate of diverticulitis and its complications in patients after an episode of diverticulitis, but also it improved the patients' quality of life. It seems that diverticulitis prophylaxis based on rifaximin can be economically efficient, however, it requires further research.

Conservative Measures for Managing Constipation in Patients Living With a Colostomy.

PURPOSE: The purpose of this study was to determine the effect of a conservative regimen for the treatment of constipation in persons living with a colostomy. DESIGN: Prospective, noncontrolled, single-center study. SUBJECTS AND SETTING: The study sample comprised 35 patients with a colostomy who were diagnosed with constipation. Subjects with morphologic changes causing constipation such as stomal stenosis and neoplastic and inflammatory changes were excluded. The study was conducted in the Proctology and Stoma Outpatient Clinic at Poznan University of Medical Sciences. METHODS: Patients at our Stoma Outpatient Clinic underwent baseline evaluation, and those with symptoms of constipation (prolonged periods between bowel movements, passage of pasty or hardened fecal effluent, and associated symptoms such as abdominal discomfort or bloating, flatulence, and pain with passage of effluent into the stoma) received individualized dietary recommendations that typically included an increase in dietary fiber and fluid intake, along with increased fluid intake. The outcomes of dietary changes were evaluated during a follow-up visit 3 months later. If dietary changes alone did not improve constipation symptoms, we prescribed a psyllium-based bulk-forming agent, an osmotic stool softener, and a probiotic, with or without a prokinetic agent such as metoclopramide taken 3 times daily. RESULTS: Dietary interventions alone were deemed successful in 60% of study subjects (n = 21); the remaining 14 patients required additional treatment. CONCLUSIONS: Dietary modifications alone relieved constipation in more than half of a group of 35 patients with constipation. We therefore recommend a trial of dietary modifications prior to the initiation of pharmacotherapy in patients with a colostomy.

The comparison of acute toxicity in 2 treatment courses: Three-weekly and weekly cisplatin treatment administered with radiotherapy in patients with head and neck squamous cell carcinoma.

The most appropriate cisplatin treatment schedule delivered with radiotherapy in patients with head and neck squamous cell carcinoma (HNSCC) is unknown. The aim of this study was to compare the acute toxicity and its impact on the course of the treatment, administered cisplatin and radiation doses, the length of hospitalization and supportive drugs administration in patients with HNSCC receiving 2 different cisplatin treatment schedules administered with radiotherapy.In this retrospective analysis, 104 patients with HNSCC were enrolled. Patients received radiation concurrently with 100 mg/m cisplatin administered 3-weekly (n = 50; group A) or 35 to 40 mg/m cisplatin administered weekly (n = 54; group B). Chemoradiotherapy was performed in locally and/or regionally advanced disease (stage III-IV), in a definitive radical upfront setting (71.1%) or after surgical resection in patients with high-risk factors (28.8%).Both study groups were equally distributed in terms of age, gender, stage of the disease, Eastern Cooperative Oncology Group performance score, chronic diseases and primary tumor site. The schedule of cisplatin dosing did not influence the duration of hospitalization, the number of additional supportive drugs (antibiotics, opioids) administered or total doses of received radiotherapy. However, postponement of radiotherapy due to adverse events was significantly more frequent in patients treated with 35/40 mg/m (55.56% vs 32%; P = .015). Furthermore, patients treated with weekly treatment schedule received lower total cisplatin dose (160 mg/m) in comparison to those treated with the 3-weekly schedule (200 mg/m). Grade 3 and 4 mucositis occurred more frequently in patients treated in group A (70% vs 50%; P = .037). Leukopenia was also observed more frequently in group A (88% vs 72.2%; P = .04), however there was no difference in grade 3/4 leukopenia between both study arms. There was no statistically significant difference in any other adverse effects.These results do not demonstrate the advantage of modified weekly schedule over standard 3-weekly cisplatin treatment plan. However, severe mucositis occurred more frequently in patients receiving 3-weekly cisplatin, both chemotherapy schedules seemed to present similar toxicity. Due to conflicting efficacy and toxicity, the results and compliance of weekly and 3-weekly cisplatin schedules should be evaluated in further randomized, controlled trials and retrospective studies.

Checklist in colorectal surgery - proposal of experts of the Polish Club of Coloproctology and National Consultant in general surgery.

A checklist is a collection of information that helps reduce the risk of failure due to limitations in human memory and attention. In surgery, the first Surgical Safety Checklist (SSC), created under the supervision of WHO (World Health Organization), was established in 2007 and covers three stages related to the patient's stay in the operating theater and operation: 1. Prior to initiation (induction) of anesthesia; 2. before cutting the skin; 3. before the patient leaves the operating room Colorectal surgery is particularly at high risk for complications and relatively high mortality. Elimination or, more likely, reducing the risk of complications by standardizing perioperative procedures may be particularly important in this group. The introduction of "dedicated" colorectal checklist surgery seems to be justified. The checklist proposed by the authors in colorectal surgery is divided into four stages, in which conscientious completion of checklists is intended to reduce the potential risk of complications due to hospitalization and surgical treatment. The presented checklist is obviously not closed, as a new publications or recommendations appear, some points may be modified, new issues may be added to the checklist. At present, however, it is a tool considering the well-known and confirmed elements of intraoperative procedures, the compliance of which may significantly reduce the rate of adverse events or surgical complications.

Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature.

PURPOSE: Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material. METHODS: A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations. RESULTS: The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days. CONCLUSIONS: The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.