Which determinants are considered to be important for adherence to Negative Pressure Wound Therapy: A multimethods study.

AIM: To explore the extent of patients that choose to cease Negative Pressure Wound Therapy (NPWT) prematurely in a clinical setting, and to explore the determinants of nonadherence. METHOD: This study exists out of: (1) a retrospective study to assess the number of patients who ceased NPWT prematurely; (2) a narrative review (NR) to identify determinants of nonadherence; and (3) a survey among wound care specialists to explore specific determinants of nonadherence to NPWT. RESULTS: (1) Based on the retrospective study, 20% ceased NPWT prematurely because of experienced limitations in daily activities. (2) Based on 22 studies, 23 determinants that might influence nonadherence were identified and added as questions in the survey. (3) Twenty-two percent (n = 136) wound care specialists completed the survey. Confidence with the healthcare team, consistency in therapy advices, coping with pain, former negative experiences with NPWT, a normal activity pattern, social support from family or friends, and support from the healthcare team were identified as highly relevant determinants of nonadherence to NPWT. Only religion scored distinctively lower. CONCLUSION: This study is a first step in exploring the determinants of nonadherence to NPWT. In 20% NPWT was prematurely ceased at the request of the patient, this means that this therapy may have not been the best choice of therapy for this particular patient. The identification of potential determinants of nonadherence may help healthcare professionals in their dialogue with patients. The next step should be a prognostic study to assess which determinants best predict adherence to NPWT.

Surgical repair of an obstetric cloaca with review of the literature.

A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.

Complications and Impact on Quality of Life of Vertical Rectus Abdominis Myocutaneous Flaps for Reconstruction in Pelvic Exenteration Surgery.

BACKGROUND: Pelvic exenteration for malignancy sometimes necessitates flap reconstruction. OBJECTIVE: This study's aim was to investigate flap-related morbidity. DESIGN: A prospective database was reviewed from 2003 to 2016. All medical charts, correspondence, and outpatient follow-up records up to May 2017 were reviewed. SETTINGS: This study was conducted at a tertiary referral unit. PATIENTS: Patients who underwent pelvic exenteration surgery were selected. INTERVENTIONS: Reconstruction was performed with a vertical rectus abdominis myocutaneous flap. MAIN OUTCOME MEASURES: Primary outcome was flap-related complications (short or long term >3 months). Secondary outcomes were hospital stay, readmission, mortality, and quality of life (Short Form-36, Functional Assessment of Cancer Therapy for patients with colorectal cancer). RESULTS: Of 519 patients undergoing pelvic exenteration surgery, 87 (17%) underwent flap reconstruction. Median follow-up was 20 months (interquartile range, 8-39 months). Median age was 60 years (interquartile range, 51-66). Flap-related complications were found in 59 patients (68%), with minor recipient-site complications diagnosed in 33 patients (38%). In the short term, 15 patients experienced major recipient-site complications (17%), including flap separation (n = 7) and partial (n = 3) or complete necrosis (n = 4). Flap removal was required in 1 patient. Obesity was the single independent risk factor for short-term flap-related complications (p = 0.02). Hospital admission was significantly longer in patients with short-term major flap complications (median 65 days, p < 0.001) compared with patients without or with minor complications. There was no 90-day mortality. Patients who required flap reconstruction reported lower baseline quality-of-life scores than patients without flap reconstruction, but both recovered over time. In the long term, minor flap-related complications occurred in 12 patients, and 11 patients had major donor-site complications. Fourteen patients developed major recipient-site complications (16%), including sacral collections, enterocutaneous fistulas, perineal ulcer, or hernia. LIMITATIONS: This was a retrospective analysis of prospectively collected data. CONCLUSIONS: Vertical rectus abdominis myocutaneous flaps in pelvic exenteration surgery have a high incidence of morbidity that has significant impact on hospital stay and a temporary impact on quality of life. Flap reconstruction should be used selectively in pelvic exenteration surgery. See Video Abstract at http://links.lww.com/DCR/B274. COMPLICACIONES E IMPACTO EN LA CALIDAD DE VIDA DE LOS COLGAJOS MIOCUTÁNEOS DE MUSCULO RECTO DEL ABDOMEN EN CASOS DE RECONSTRUCCIÓN DE EXENTERACIÓN PÉLVICA: La exenteración pélvica (EP) para malignidad a veces requiere reconstrucción con colgajos musculares.El propósito del presente estudio fue investigar la morbilidad relacionada con los colagajos musculares.Revisión de una base de datos prospectiva de 2003-2016. Se evaluaron todas las historias clínicas, la correspondencia y los registros de seguimiento de pacientes ambulatorios hasta mayo de 2017.Unidad de referencia terciaria.Todos aquellas personas con cirugía de exenteración pélvica.Reconstrucción con colgajo miocutáneo de musculo recto vertical del abdomen.El resultado primario fueron las complicaciones relacionadas con el colgajo (a corto o largo plazo >3 meses). Los resultados secundarios fueron la estadía hospitalaria, la readmisión, la mortalidad y la calidad de vida (QOL; SF-36, FACT-C).De 519 pacientes sometidos a EP, 87 (17%) se sometieron a reconstrucción con colgajos miocutáneos. La mediana de seguimiento fue de 20 meses (RIC 8-39 meses). La mediana de edad fue de 60 años (IQR 51-66). Se encontraron complicaciones relacionadas con el colgajo en 59 pacientes (68%), con complicaciones menores en el sitio del receptor diagnosticadas en 33 pacientes (38%). A corto plazo, quince pacientes sufrieron complicaciones mayores en el sitio del receptor (17%), incluida la separación del colgajo (n = 7), necrosis parcial (n = 3) o necrosis completa (n = 4). Se requirió la extracción del colgajo en un paciente. La obesidad fue el único factor de riesgo independiente para complicaciones relacionadas con el colgajo a corto plazo (p = 0.02). El ingreso hospitalario fue significativamente mayor en pacientes con complicaciones de colgajos mayores a corto plazo (mediana 65 días p <0.001) en comparación con pacientes sin complicaciones menores o con complicaciones menores. No hubo mortalidad a los 90 días. Los pacientes que requirieron reconstrucción con colgajo informaron puntajes de calidad de vida basales más bajos que los pacientes sin reconstrucción con colgajo, pero ambos se recuperaron con el tiempo. A largo plazo, ocurrieron complicaciones menores relacionadas con el colgajo en 12 pacientes y 11 pacientes tuvieron complicaciones mayores en el sitio donante. Catorce pacientes desarrollaron complicaciones mayores en el sitio del receptor (16%), incluidas colecciones sacras, fístulas enterocutáneas, úlceras perineales o herniación.Análisis retrospectivo de datos recolectados prospectivamente.Los colgajos miocutáneos del musculo recto vertical del abdomen en casos de cirugía de exenteración pélvica tienen una alta incidencia de morbilidad conllevando a un impacto significativo en la estadía hospitalaria y un impacto temporal en la calidad de vida. Las reconstrucciones con colgajos deben aplicarse muy selectivamente en la cirugía de exenteración pélvica. Consulte Video Resumen en http://links.lww.com/DCR/B274.

A Review of Normal Intestinal Healing, Intestinal Anastomosis, and the Pathophysiology and Treatment of Intestinal Dehiscence in Foreign Body Obstructions in Dogs.

Small intestinal anastomoses are commonly performed in veterinary medicine following resection of diseased or devitalized intestinal tissue. Traditionally, suture has been employed to anastomose intestinal ends. However, use of intestinal staplers has become increasingly popular due to the ability to produce a rapid anastomosis with purported superior healing properties. Under normal conditions, intestinal healing occurs in three phases: inflammatory, proliferative, and maturation. Dehiscence, a devastating consequence of intestinal anastomosis surgery, most often occurs during the inflammatory phase of healing where the biomechanical strength of the anastomosis is almost entirely dependent on the anastomotic technique (suture or staple line). The resulting septic peritonitis is associated with a staggering morbidity rate upwards of 85% secondary to the severe systemic aberrations and financial burden induced by septic peritonitis and requirement of a second surgery, respectively. Intraoperative and postoperative consideration of the multifactorial nature of dehiscence is required for successful patient management to mitigate recurrence. Moreover, intensive postoperative critical care management is necessitated and includes antibiotic and fluid therapy, vasopressor or colloidal support, and monitoring of the patient's fluid balance and cardiovascular status. An understanding of anastomotic techniques and their relation to intestinal healing will facilitate intraoperative decision-making and may minimize the occurrence of postoperative dehiscence.

Bleb Plication for a Leaking Bleb After Trabeculectomy.

PURPOSE: The purpose of this work was to report a new method for the repair of ischemic bleb leaks. Bleb leakage is a serious complication of glaucoma filtering surgery with mitomycin C. Many surgical methods have been proposed to seal the leakage from a bleb; however, this novel plication method is effective, relatively easy to perform, and safe. METHODS: We describe the case reports of 2 patients with leakage from a bleb who were treated with the new method. The conjunctiva was lifted away from the sclera as extensively as possible around the ischemic conjunctiva toward the fornix using a bleb knife. Thereafter, 10-0 nylon sutures were applied between the nonischemic conjunctiva located just outside the ischemic conjunctiva and the corneal limbus. The ischemic conjunctiva was not removed, but covered with the nonischemic conjunctiva that was advanced toward the corneal limbus by these sutures. RESULTS: After treatment, no recurrence of bleb leakage was observed. Moreover, no ischemic changes were observed in the advanced nonischemic conjunctiva or plicated conjunctiva. CONCLUSION: This new method of bleb plication was effective for sealing bleb leakage.

Suturable mesh better resists early laparotomy failure in a cyclic ball-burst model.

PURPOSE: The small bites surgical technique supported by the STITCH trial has been touted as a strategy for preventing early laparotomy dehiscence through greater force distribution at the suture-tissue interface. However, this hernia prevention strategy requires an alteration in the standard closure technique that has not been widely adopted in the USA. This study seeks to determine whether incorporating a mid-weight polypropylene mesh material into a hollow-bore surgical suture material will effectively increase the force distribution at the suture-tissue interface and potentially help prevent early laparotomy dehiscence in an ex vivo model. METHODS: A cyclic stress ball-burst model was used to compare suturable mesh (0 DuraMesh™) to conventional suture. After midline laparotomy, 28 porcine abdominal wall specimens were closed with either 0 DuraMesh™ or #1 polydioxanone double-loop suture. A custom 3D-printed ball-burst test apparatus was used to fatigue the repair on a MTS Bionix Load Frame. The tissue was repetitively stressed at a physiological force of 15-120 N cycled at a rate of 0.25 Hz for a total of 1000 repetitions, followed by a load to failure, and the maximal force was recorded. RESULTS: The mean maximal force at suture pull-through was significantly higher (p < 0.0095) in the 0 DuraMesh suture group (mean: 850.1 N) compared to the 1 PDS group (mean: 714.7 N). CONCLUSION: This ex vivo study suggests that using rational suture design to improve force distribution at the suture-tissue interface may be a viable strategy for preventing the suture pull-through that drives incisional hernia.

Postoperative imaging following fetal open myelomeningocele repair: The clinical utility of magnetic resonance imaging and sonographic amniotic fluid volumes in detecting suspected hysterotomy scar dehiscence.

OBJECTIVES: Hysterotomy scar disruption, ranging from myometrial thinning to complete dehiscence, is a well-established complication of open-hysterotomy fetal myelomeningocele (MMC) repair. This study sought to (a) determine the feasibility of postoperative magnetic resonance imaging (MRI) in detecting signs of hysterotomy scar disruption and (b) identify the sonographic and clinical signs suggestive of subacute scar dehiscence, including decreasing amniotic fluid index (AFI) and uterine contractions, respectively. METHOS: A unique index case of suspected hysterotomy dehiscence following MMC repair prompted a retrospective review of 31 total open-hysterotomy fetal MMC repairs performed at our center, including 21 cases found to have intact hysterotomy scarring and 10 cases of non intact scarring detected at subsequent cesarean delivery. In each case, routine post operative MRI, performed 6 weeks after the MMC repair, was reviewed to evaluate the thickness of the hysterotomy site. Cases were also reviewed for sonographic and clinical patterns preceding delivery, including changes in AFI and the presence or absence of uterine contractions. RESULTS: Of the 31 total reviewed cases, 21 cases were found to have intact hysterotomy scar sites at the time of cesarean delivery. Among the intact cases, the net change in AFI from the time of MRI to delivery ranged from -45% to 47%, with a mean increase in fluid levels of 8% over an average of 5.6 weeks. The other 11 cases, including the index case, were found to have signs of scar disruption at delivery, including seven with thinned scar sites and four with grossly dehiscent sites. Amongst non-intact cases, AFI predominately decreased, with a net change ranging from -56% to 9% for a mean change of -24% over an average of 5.4 weeks. Regular uterine contractions close to the time of delivery occurred in 82% of the non intact cases. CONCLUSION: Hysterotomy scar disruption can rarely be detected by MRI following MMC repair. Decreasing AFI and contractions may serve as early warning signs of scar dehiscence and should be taken into consideration for obstetric management.

Sarcopenia como factor predictivo de dehiscencia de anastomosis en pacientes operados de cáncer de colon / Predictive value of sarcopenia for anastomotic dehiscense in colon cancer surgery

Resumen Introducción: Una complicación importante de la cirugía colorrectal es la dehiscencia de anastomosis (DA). El estado nutricional es uno de los factores importantes en la DA. Una forma objetiva para evaluar nutricionalmente a los pacientes es medir la sarcopenia, definida como disminución de masa muscular esquelética, que puede ser objetivada por análisis de Unidades Hounsfield (UH) y área muscular (AM) por medio de Tomografía Computarizada de Abdomen y Pelvis (TCAP). Objetivo: Evaluar si existe relación entre la DA y la presencia de sarcopenia detectada por medición de UH y AM en TCAP en pacientes sometidos a colectomía por cáncer. Materiales y Método: Estudio de casos y controles con estadística analítica. Se eligen de manera aleatoria 21 pacientes con DA y 40 sin DA. Se incluyen > 18 años, con colectomía por cáncer y anastomosis primaria. Fueron excluidos pacientes ostomizados, que no tuvieran TCAP preoperatoria o que éste no permitiera medir UH y AM. La evaluación imagenológica fue realizada por radiólogo experto. Resultados: La comparación entre grupos evidencia que son homogéneos con respecto al sexo (predomino hombres), edad (promedio 60 años) y localización. Se evidencia signos imagenológicos sugerentes de sarcopenia en el grupo de DA, puesto que existe disminución en UH con valores estadísticamente significativos y tendencia a presentar valores menores en el AM. Conclusiones: La presencia de sarcopenia evaluada por alteración de UH en estudio radiológico se correlaciona con DA, pudiendo ser un predictor de riesgo. La importancia de este hallazgo es que es un factor de riesgo potencialmente corregible.

Introduction: An important complication of colorectal surgery is anastomotic dehiscence (AD). Nutritional status is one of the important factors in AD. An objective way to evaluate the patients' nutritional status is to measure sarcopenia, which is the reduction of skeletal muscle mass. It is possible to standardize Sarcopenia using the analysis of the Hounsfield Units (HU) and the muscular area (MA) which consider Computed Tomography of Abdomen and Pelvis (CTAP). Aim: To evaluate whether there is a relationship between AD and the presence of sarcopenia detected by the measurement of HU and MA using CTAP. The situation considers patients undergoing colectomy for cancer. Materials and Method: Cases and controls were studied with analytical statistics. 21 patients with AD and 40 without AD were chosen randomly. They include > 18 years, with colectomy for cancer and primary anastomosis. Ostomized patients, who previous the surgery do not have CTAP or if it was not available to measure HU and MA, were excluded. The imaging evaluation was performed by an expert radiologist. Results: The comparison between groups shows that they are homogeneous with respect the sex (predominant men), age (average 60 years) and location. There are signs of imaging which suggest the presence of sarcopenia in the AD group. This is explained because there is an important statistical decrease in the HU values and a tendency to present lower MA values. Conclusions: The presence of sarcopenia due to alteration of HU in a radiological study is correlated with AD, and could be a predictor of risk. The importance of this finding is that this risk factor is potentially correctable.

The use of povidone-iodine and sugar solution in surgical wound dehiscence in the head and neck following radio-chemotherapy.

Povidone-iodine is known for successfully treating surgical wounds; the combination between povidone-iodine and sugar, also called Knutson's formula, has been proposed to improve wound healing. Currently, no studies have investigated the effects of Knutson's formula to treat defects in wound closure following radio-chemotherapy in the head and neck region. The aim of this study is to evaluate the efficacy of Knutson's formula in improving the wound-healing process in patients who underwent radio-chemotherapy after surgery for head and neck cancer. The study, conducted from August 2013 to January 2017, included a sample of 34 patients (25 males and 9 females; age range: 60-75 years) treated with radio-chemotherapy after head and neck cancer surgery. All patients suffered from defect of wound regeneration. Patients were randomly divided into two groups: patients in the study group (n = 18) were treated with Knutson's formula; patients in the control group (n = 16) were treated with traditional topical drugs. In the study group, 16 of 18 (88.9%) patients reached complete wound closure 1 month after treatment, with no wound infections. In the control group, only three patients (18.7%) showed complete wound closure within a month; in addition, one patient required systemic antibiotic treatment because of supra-bacterial infection of the wound. In our sample, the combination of povidone-iodine and sugar had a higher success rate compared with traditional topical treatment in the treatment of wound defect closure in oncological patients who underwent radio-chemotherapy.

The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping.

PURPOSE: Most biomechanical investigations of tendon repairs were based on output measures from hydraulic loading machines, therefore, accounting for construct failure rather than true gapping within the rupture zone. It was hypothesized that the elastic capacity of a tendon-repair construct influences the force necessary to induce gapping. METHODS: A tendon-repair model was created in 48 porcine lower hind limbs, which were allocated to three fixation techniques: (1) Krackow, (2) transosseous and (3) anchor fixation. Loading was performed based on a standardized phased load-to-failure protocol using a servohydraulic mechanical testing system MTS (Zwick Roell, Ulm, Germany). Rupture-zone dehiscence was measured with an external motion capture device. Factors influencing dehiscence formation was determined using a linear regression model and adjustment performed as necessary. A 3-mm gap was considered clinically relevant. Analysis of variance (ANOVA) was used for comparison between groups. RESULTS: The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping of 3 mm (F3mm) [ß = 0.6, confidence interval (CI) 0.4-1.0, p < 0.001]. Furthermore, the three methods of fixation did not differ significantly in terms of maximum force to failure (n.s) or F3mm (n.s). CONCLUSION: The main finding of this study demonstrated that the higher the elastic capacity of a tendon-repair construct, the higher the force necessary to induce clinically relevant gapping. LEVEL OF EVIDENCE: Controlled biomechanical study.

Suture dehiscence and collagen content in the human mitral and tricuspid annuli.

Postoperative suture dehiscence is an important mode of short-term mitral and tricuspid valve (MV, TV) repair failure. We sought to evaluate suture pullout forces and collagen density in human atrioventricular valves for a better understanding of the comparative physiology between the valves and the underlying mechanobiological basis for suture retention. Mitral and tricuspid annuli were each excised from hearts from human donors age 60-79 with no history of heart disease (n = 6). Anchor sutures were vertically pulled until tearing through the tissue. Suture pullout force (FP) was measured as the maximum force at dehiscence. Subsequently, tissue samples from each tested suture position were evaluated for collagen content using a standard hydroxyproline assay. Among all mitral positions, no significant differences were detected among positions or regions with mean FP values falling between 6.9 ± 2.6 N (posterior region) and 10.3 ± 4.7 N (anterior region). Among all tricuspid positions, the maximum FP and minimum FP were 24.0 ± 9.2 N (trigonal region) and 4.5 ± 2.6 N (anterior region). Although for the MV, a given sample's collagen content had no correlation to its corresponding FP, the same relationship was significant for the TV. Further, the TV exhibited comparable FP to the MV overall, despite a nearly 40% reduction in collagen content. These findings suggest that sutures placed in the trigonal region of the TV have higher pullout force than those placed along other segments of the annuli. Furthermore, there are likely differences in collagen orientation between the mitral and tricuspid annuli, such that collagen content strongly impacts FP in one, but not the other.

Why Does Postoperative Pancreatic Fistula Occur After Hand-sewn Parenchymal Closure and Staple Closure in Distal Pancreatectomy?

Hand-sewing (HS) and stapling are common parenchymal closure techniques after distal pancreatectomy. However, these methods cannot completely prevent postoperative pancreatic fistula (POPF). The mechanisms of POPF formation after closure are unknown. We performed distal pancreatectomy in mongrel dogs to identify the mechanisms of POPF formation after HS and staple closure. We measured the closed pancreatic duct burst pressures and examined the histology of the remnant pancreas. The after staple-closure burst pressures depended on stapler height; lower pressures were associated with greater stapler heights. Post-HS closure burst pressures were significantly higher than those at each stapler height (P<0.01). Post-HS closure pathologic findings showed extensive necrosis (day 3), and some regenerated pancreatic duct stumps (day 5). Necrosis was not observed around the stapled tissues. Although HS completely closes the pancreatic ducts, stump necrosis and blood flow disturbances may cause POPF. With stapler closure, pancreatic fluid leakage may occur even with appropriate stapler heights.

Aplicación de la terapia de vacío en el tratamiento de la dehiscencia completa de inserción mucocutánea del estoma / Vacuum-assited closure (vac) therapy in the treatment of the complete dehiscence of the mucocutaneous junction of the stoma

La aplicación de la terapia de vacío en la dehiscencia completa de la inserción mucocutánea de un estoma es algo novedoso, ya que hasta ahora, en el manejo de las complicaciones del estoma se limitaba su uso a dehiscencias parciales del mismo. Aunque es una complicación poco frecuente, tiene gran relevancia, ya que dificulta la adaptación de los dispositivos de ostomía, enlentece la cicatrización de la cavidad dehiscente, requiere el consumo de gran cantidad de recursos humanos y materiales e impacta directamente en la calidad de vida del paciente. El abordaje de este caso se realizó de manera multidisciplinar (Cirugía, Enfermería y Nutrición) implantando una dieta de absorción alta para reducir el débito del estoma, asociando el uso de la terapia de presión negativa en la cavidad dehiscente y dispositivos de ostomía adecuados para la situación

The use of vaccum-assisted therapy in the complete dehiscence of the mucocutaneous junction of the stoma is a new alternative since, to manage stoma complications, its use has been limited to partial dehiscence of the stoma during the last years. It is an uncommon complication, but it has a great relevance, because it complicates the stoma devices adaptation, it slows the healing of the wound, it requires spending more human and material resources and it has a direct impact over the quality of life of the patient. The approach to every case must be carried out in a multidisciplinary way (Surgery, Nursing and Nutrition) giving to the patient a special diet to reduce the stoma debit, associating the use of vaccum-assisted therapy in the dehiscent wound and employing suitable stoma devices for each situation

Randomized prospective evaluation of the wound integrity of primary clear corneal incisions made with a femtosecond laser versus a manual keratome.

PURPOSE: To compare the wound integrity of femtosecond laser-assisted 110-degree reverse side-cut clear corneal incisions (CCIs) with femtosecond laser-assisted 70-degree forward side-cut and manual CCIs in patients having cataract surgery. SETTING: Island Eye Surgicenter, Carle Place, New York, USA. DESIGN: Prospective case series. METHODS: Patients having cataract surgery were randomized into 3 treatment groups as follows: Group A had 110-degree femtosecond reverse side-cut CCIs, Group B had 70-degree femtosecond forward side-cut CCIs, Group C had manual CCIs. At the conclusion of surgery, the integrity of the CCI was measured by raising intraocular pressure (IOP) until the CCI began to leak. Postoperatively, the CCIs were assessed for wound leakage at 1 day, 2 weeks, and 1 month. RESULTS: The study comprised 45 patients (45 eyes, 15 in each treatment group). The mean IOP at which CCIs leaked (in response to anterior chamber balanced salt solution irrigation) was statistically significantly higher in Group A (28.20 mm Hg ± 11.69 [SD]) than in Group B (15.07 ± 10.64 mm Hg; P = .005) and Group C (9.93 ± 9.90 mm Hg; P < .001). At 1 day postoperatively, the Seidel test with pressure showed no leakage in any of the Group A eyes; however, 53% of eyes in Group B and 87% in Group C showed wound leakage. CONCLUSION: The femtosecond laser-created reverse side-cut CCIs required significantly higher IOP intraoperatively before leaking and resulted in better wound integrity with significantly less wound leakage postoperatively than laser-created forward side-cut or manual CCIs.

Smoking as an Independent Risk Factor for Postoperative Complications in Plastic Surgical Procedures: A Propensity Score-Matched Analysis of 36,454 Patients from the NSQIP Database from 2005 to 2014.

BACKGROUND: Smoking has been associated with wound healing complications and overall morbidity in multiple specialties, including plastic surgery. From 2005 to 2014, smoking prevalence among U.S. adults decreased from 20.9 percent to 16.8 percent. This study aims to investigate whether smoking prevalence among plastic surgery patients paralleled the national trend and whether smoking was an independent risk factor for postoperative complications. METHODS: The 2005 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was used to examine smoking prevalence and 30-day postoperative complications in 36,454 patients who underwent common plastic surgical procedures with extensive planes of dissection. Patients were propensity score-matched for demographics and comorbidities. Smokers were stratified by pack-years. RESULTS: Compared to the national trend, a significantly smaller percentage of plastic surgical patients were smokers (p = 0.01), with a less dramatic decline in prevalence. Smokers had significantly increased deep incisional surgical-site infections, incisional dehiscence, and reoperation (p < 0.01 for all). However, superficial surgical-site infection rates were not significantly different (p = 0.18). Smokers with 11 or more pack-years had significantly increased deep surgical-site infection (p < 0.01) and reoperations (p < 0.01). There were no significant differences in graft/prosthesis/flap loss (p = 0.07), bleeding (p = 0.40), sepsis (p = 0.87), or venous thromboembolism (p = 0.16) rates between smokers and nonsmokers. CONCLUSIONS: This is the first large-scale propensity score-matched database analysis isolating smoking as a risk factor for postoperative complications in plastic surgical procedures. Smoking was an independent risk factor for deep incisional surgical-site infection, incisional dehiscence, and reoperation. Interestingly, superficial surgical-site infection rates were not significantly different. The authors recommend continued judicious patient selection and preoperative smoking counseling to optimize postoperative outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Influence of continuous positive airway pressure on postoperative leakage in bariatric surgery.

BACKGROUND: Obstructive sleep apnea (OSA) affects two third of morbidly obese individuals undergoing bariatric surgery. Perioperative usage of continuous positive airway pressure (CPAP) is advised for moderately and severe OSA to avoid respiratory failure and cardiac events. CPAP increases the air pressure in the upper airway, but also may elevate the air pressure in the esophagus and stomach. Concern exists that this predisposes to mechanical stress resulting in suture or staple line disruption (further referred to as suture line disruption). OBJECTIVES: To evaluate whether perioperative CPAP usage is associated with an increased risk of suture line disruption after bariatric surgery. SETTING: Obesity Center Amsterdam, OLVG-west, Amsterdam, the Netherlands. METHODS: All patients who underwent bariatric surgery including a suture line were eligible for inclusion. Only patients with information regarding OSA severity as defined by the apnea-hypopnea-index and postoperative CPAP usage were included. RESULTS: From November 2007 to August 2016, postoperative CPAP status was documented in 2135 patients: 497 (23.3%) used CPAP postoperatively, whereas 1638 (76.7%) used no CPAP. Mean body mass index was 44.1 kg/m2 (standard deviation 6.6). Suture line disruption occurred in 25 patients (1.2%). The leakage rate was not associated with CPAP usage (8 [1.6%] in CPAP group versus 17 [1%] in non-CPAP group, P = .300). CPAP was no risk factor for suture line disruption in multivariable analysis as well. CONCLUSION: Postoperative CPAP does not appear to increase the risk of suture line disruption in bariatric surgery. CPAP is recommended in all patients with moderate or severe OSA who undergo bariatric surgery.

Outcomes of Bleb Repair for Delayed Bleb Leaks and Sweating Blebs.

PURPOSE: To report the outcomes of bleb repair for delayed onset leaking blebs and sweating blebs following glaucoma filtering surgery. MATERIALS AND METHODS: Medical records of 76 eyes of 76 subjects that underwent bleb repair for either leaking bleb or sweating bleb between 1990 and 2015 were reviewed. Complete success was resolution of bleb leak and or hypotony with intraocular pressure ≥5 and ≤21 mm Hg with no antiglaucoma medication. RESULTS: There were 45 eyes with leaking bleb and 31 eyes with sweating bleb that underwent bleb repair by either conjunctival autograft or conjunctival advancement (P=0.11). Before bleb repair, complications like blebitis and hypotony maculopathy were significantly higher in sweating bleb group (13/31) compared with bleb leak group (5/45) (P=0.002). Median follow-up after bleb repair was >2 years in both groups (P=0.69). After repair, eyes in leaking bleb group had higher immediate (P=0.01) and long-term intraocular pressure elevation (P=0.06) compared with sweating bleb group. Complete success probability in sweating bleb group was significantly better (88%, 78%, and 71%) compared with leaking bleb group (54%, 45%, and 40%) at 1, 3, and 6 years, respectively (P=0.01). One eye in each group had blebitis, 2 eyes in leaking bleb group and 1 eye in sweating bleb group needed repeat glaucoma intervention. CONCLUSIONS: Higher complication rate before bleb repair in eyes with sweating bleb warrants early bleb repair. Bleb repair helped retain bleb function in majority of the eyes with sweating blebs, strengthening our recommendation.

Collagen cross-linking as an adjunct for repair of corneal lacerations: a cadaveric study.

OBJECTIVE: To determine the efficacy of collagen cross-linking (CXL) as an adjunct to suturing in the repair of corneal lacerations. METHODS: A cadaveric study was undertaken in which a linear 5 mm corneal laceration was created in the central cornea of 20 eyes. The eyes were then randomized to receive 1 (n = 8), 2 (n = 8), or 3 (n = 4) standard corneal sutures. The burst pressure of the wound was then measured. All eyes in the 1- and 2-suture group then underwent standard CXL, with burst pressure repeated afterward. RESULTS: The initial wound burst pressure in the 1-, 2-, and 3-suture groups was 54.9, 74.0, and 201.2 mm Hg, respectively. After CXL, wound burst pressure increased by a mean of 3.2 and 62.3 mm Hg in the 1- and 2-suture groups, respectively. This change was statistically significant in the 2-suture group (p = 0.017). After CXL, the 2-suture group still had a significantly lower burst pressure compared with the 3-suture group (p = 0.011). CONCLUSIONS: The study highlights a potential novel application for CXL to strengthen corneal wounds. Provided that suture density is sufficient to appose the wound edges, CXL may result in short-term wound strengthening. This could potentially allow for decreased corneal suture density and a corresponding decrease in suture-related complications.

Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy.

BACKGROUND: Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery. RESULTS: A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010). CONCLUSION: Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .