Outcome after autologous dermal sling-assisted immediate breast reconstruction.

BACKGROUND: In selected patients undergoing mastectomy and immediate reconstruction, a de-epithelialized skin flap (dermal sling) may be used to complete the submuscular pocket. This study examined the safety and efficacy of an autologous dermal sling in providing inferolateral support to the implant or tissue expander during immediate breast reconstruction. METHODS: Patients were identified from an electronic prospective database. Records of all patients were reviewed for details of management, complications and follow-up. Patient satisfaction and quality of life in the postoperative period were determined using the BREAST-Q(©) questionnaire. RESULTS: Between October 2008 and August 2010, 21 patients underwent 28 dermal sling-assisted breast reconstruction procedures. Their median age was 48 (range 30-70) years. Median hospital stay was 5 (range 3-7) days. Drains were removed at a median of 5 (range 3-7) days after surgery. During the operation a median volume of 150 ml was added to the tissue expander. The most common postoperative complication was superficial -junction breakdown in five patients, followed by seroma and infection each in three patients, but no implant required removal. BREAST-Q(©) responses indicated a high level of satisfaction overall with the reconstructed breast. CONCLUSION: Dermal sling-assisted immediate breast reconstruction has a low serious complication rate, provides stable soft tissue cover for the tissue expander and is associated with a high level of patient satisfaction. A larger pocket can be created, permitting more fluid to be added to the expander.

A randomized prospective study of cefoxitin versus piperacillin in appendicectomy.

A randomized prospective study of antibiotic prophylaxis using a single dose of either cefoxitin or piperacillin is presented. The trial was carried out in Al Ain Hospital in the period 1989-1992 on 250 adult patients with non-perforated appendicitis. One group (124 patients) received 2 g cefoxitin, the other group (126 patients) 2 g piperacillin. Antibiotics were administered intravenously in the operating theatre immediately before surgery. Wound infection occurred in three patients, 2.4% of the cefoxitin group and in five patients (4%) of the second group (with no significant difference). The commonest infecting organisms were Escherichia coli (5 out of 8). Mean hospital stay for patients with wound infection was 15 days (range 12-21) compared with 6 days, (range 4-8) for non-infected cases. Prophylactic cefoxitin or piperacillin were each therefore similarly effective in minimizing the rate of wound infections in patients with non-perforated appendicitis.

Simple surgical audit: an aid to undergraduate curriculum development.

This study investigates the usefulness of a simple surgical audit in designing the undergraduate surgical curriculum in the newly established medical school of the United Arab Emirates. The audit system was designed for use by people previously unaccustomed to this activity. The pattern of disease is found to be biased towards a young male expatriate population. It has been possible to predict the likelihood of a particular disease being available for teaching purposes and has drawn attention to the relative absence of some conditions which are commonly found elsewhere. Allowances need to be made for this and teaching strategies other than those which require direct patient contact should be considered. This method of curriculum design may find use in other places where health care patterns are changing.

Altered regulation of atrial natriuretic peptide in essential hypernatremia.

Hypothalamic osmoreceptor dysfunction resulting in hypodipsia and altered regulation of vasopressin secretion is well established as the pathogenetic mechanism in the syndrome of 'essential hypernatremia'. However, little is known about the secretory pattern of atrial natriuretic peptide (ANP) in this syndrome. Therefore, we assessed ANP regulation by determining ANP concentrations in a patient manifesting this syndrome of essential hypernatremia during several well-established experimental protocols. The serum ANP level was within normal limits despite severe euvolemic hypernatremia (serum Na+ 163 mEq/l) during one of the many admissions and remained unchanged following normalization of serum Na+. Furthermore, a decline in serum ANP instead of an appropriate rise was noted when hypernatremia (serum Na+ 152 mEq/l) was induced by either hypertonic (3%) saline infusion or following a high-Na+ (300 mEq/day) diet for several days (serum Na+ 161 mEq/l). Similarly, exogenous pitressin administration failed to cause a rise in ANP, although an appropriate fall in ANP concentration occurred following fluid deprivation. Therefore, it is apparent that ANP regulation may be significantly altered in essential hypernatremia. However, further studies are required to define whether it plays a role in the pathogenesis of hypernatremia in this syndrome.

Helicobacter pylori infection in perforated peptic ulcer disease.

This study examined a possible aetiological agent, namely, Helicobacter pylori, in perforated peptic ulcer disease and its relationship to persisting ulcer. Twenty-nine patients with perforated peptic ulcer underwent simple closure of the perforation at laparotomy. A 13C urea breath test carried out on the eighth day after operation was positive in 24 patients. Fourteen of 17 patients who underwent upper gastrointestinal endoscopy 6 weeks after discharge from hospital had a positive 13C urea breath test. The biopsy urease test performed on mucosal samples taken at endoscopy was positive in 12 of these 14 patients, indicating continuing active infection with H. pylori. Seven patients with positive 13C urea breath and biopsy urease tests had persisting duodenal ulceration. None of the three patients with a negative 13C urea breath test had evidence of duodenal ulceration at endoscopy. The association between a high rate of duodenal ulcer persistence and a high incidence of H. pylori infection suggests that antibiotic therapy to eradicate this microorganism should be given to all patients with perforated peptic ulcer disease.

Early patient discharge following appendicectomy: safety and feasibility.

One hundred and twenty patients with non-perforated acute appendicitis were discharged within 72 h of operation; 50 left hospital within 48 h of surgery. Criteria adopted for early discharge were: stable vital signs, active bowel sounds, ambulation and ability to tolerate fluid and food without discomfort. The patient's contact address was taken and every patient was requested to report to the out-patient department on the 7th post-operative day to remove stitches and assess the wound. There were three re-admissions. Five patients, however developed wound problems, three had wound infections, one had an indurated painful wound and the last developed erythema; the latter two patients were treated on an out-patient basis. Twenty patients were not happy about early discharge. Early discharge following appendicectomy is safe and can be practiced in uncomplicated cases of acute appendicitis.

Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial.

OBJECTIVE: To assess two techniques of primary closure after excision of pilonidal sinus. DESIGN: Prospective randomised study. SETTING: University department of surgery, United Arab Emirates. SUBJECTS: 46 patients with chronic pilonidal sinus disease, 24 treated by rhomboid flap transposition, and 22 by deep suturing technique. MAIN OUTCOME: Early mobility and recurrence. RESULTS: All patients in the rhomboid flap transposition group healed their wounds primarily compared with 17 in the primary deep suturing group (77%). (P = 0.02). Five patients wounds broke down as a result of haematoma and infection (23%). The mean hospital stay for the rhomboid flap technique was 6 days compared with 9 days after deep suturing, and the mean follow up for both groups was 18 months, the rhomboid flap group returned to work a mean of nine days earlier than the deep suturing group (23 days). No recurrence has been identified yet in the rhomboid flap group, while 2 recurrences have developed in the deep suturing group (9%). CONCLUSION: Primary closure after excision of pilonidal sinus with a transposed rhomboid flap is successful in the management of pilonidal sinus and is superior to primary closure by deep suturing.