Closed-wound negative pressure therapy dressing after loop ostomy closure: a retrospective comparative study.

Closed-wound negative pressure wound therapy (NPWT) dressings were recently introduced with the purpose to reduce incisional surgical site infections (iSSI) in high-risk wounds. The aim of this study was to compare iSSI rates in patients after ostomy closure with and without additional application of a closed-wound NPWT dressing. Single-center retrospective analysis of consecutive patients undergoing ileo- or colostomy closure over an 8-year period (January 2013-January 2021). Intradermal non-purse string technique with absorbable sutures were used in all patients. Since November 2018, all patients (study group) received a NPWT device for a maximum of 5 days postoperatively (PICO, SMITH AND NEPHEW). Primary outcome was iSSI rate within 30 days of surgery. SSI was defined in accordance with the Center of Disease Control (CDC) classification and included superficial and deep incisional SSI. Data was retrieved from the institutional enhanced recovery after surgery (ERAS) database, with standardized complication assessment by trained abstractors. In total, 85 patients (25%) in the study group were comparable with 252 (75%) patients in the control group regarding demographics (age, gender, body mass index, ASA score), ostomy type and anastomotic technique (all p > 0.05), but not wound contamination class (class III: 5% vs 0%, p < 0.001). Median time to NPWT removal was 4 (IQR 3-5) days. Incisional SSI were observed in 4 patients (4.7%) in the study group and in 27 patients (10.7%) in the control group (p = 0.097). These preliminary results suggest a potential benefit of systematic application of the NPWT device after loop ostomy closure. A randomized controlled study is needed.

Spigelian hernia: current approaches to surgical treatment-a review.

BACKGROUND: Spigelian hernias (SpH) belong to the group of eponymous abdominal wall hernias. Major reasons for diagnostic difficulties are its low incidence reaching maximum 2% of abdominal wall hernias, a specific anatomical localization with intact external oblique aponeurosis covering the hernia sac and non-constant clinical presentation. METHODS: A literature review was completed to summarize current knowledge on surgical treatment options and results. RESULTS: SpH presents a high incarceration risk and therefore should be operated upon even if the patient is asymptomatic. Both laparoscopic and open repair approaches are validated by current guidelines with lesser postoperative complications and shorter hospital stay in favour of minimally invasive surgery, regardless of the technique used. Overall recurrence rate is very low. CONCLUSION: All diagnosed SpH should be planned for elective operation to prevent strangulated hernia and, therefore emergency surgery. Both open and laparoscopic SpH treatment can be safely performed, depending on surgeon's experience. In most cases, a mesh repair is generally advised.

Timing, diagnosis, and treatment of surgical site infections after colonic surgery: prospective surveillance of 1263 patients.

BACKGROUND: Surgical site infections (SSIs) are the most frequent complication after colorectal surgery and have a major impact on length of stay and costs. AIM: To analyse the incidence, timing, and treatment of SSIs within 30 days after colonic surgery. METHODS: This was a quality improvement project through retrospective analysis of consecutive colonic surgeries between February 2012 and October 2017 at Lausanne University Hospital (CHUV). SSIs were prospectively assessed by an independent national surveillance programme (www.swissnoso.ch) up to 30 postoperative days. Treatment strategies including drainage of infection (direct wound opening or percutaneous) and surgical management were reviewed. FINDINGS: The study cohort included 1263 patients with 532 procedures (42%) performed as emergencies. SSIs were observed in 271 patients (21%), occurring at median postoperative day (POD) 9 (interquartile range (IQR): 4-16). Specifically, 53 (4%) were superficial incisional, 65 (5%) deep incisional, and 153 (12%) organ space infections (anastomotic insufficiency included). Superficial incisional SSI occurred at a median of POD 10.5 (IQR: 7-15), deep incisional at a median of POD 10 (8-15) and organ space at a median of POD 8 (5-11). Diagnosis was performed post discharge in 64 cases (24%). Whereas 47% of organ space infections were detected by POD 7, this rate was only 26% for superficial and deep incisional infections (P = 0.003). Surgical management was necessary in 133 cases (49%), and the remaining cases were managed by drainage without general anaesthesia (138 cases, 51%). CONCLUSION: Organ space infections occurred early in the postoperative course, whereas incisional infections were mostly detected post discharge over the entire 30-day observation period, emphasizing the importance of proper follow-up using a systematic, complete and independent surveillance programme.

Gastric liposarcoma in a patient with severe obesity.

Liposarcoma is the most common soft tissue sarcoma in adults. Predominant locations are the limbs and retroperitoneum. Intra-abdominal liposarcoma represents only 2% of all cases and visceral location is exceptional. Gastric liposarcoma is extremely rare, with fewer than 20 cases reported. The treatment of choice is wide en-bloc surgical resection. If the tumour arises in the area of the cardia, resection involves resection of the proximal stomach as well as the distal oesophagus. Traditional reconstruction with oesophagogastrostomy often leads to troublesome reflux. We report a case of gastric liposarcoma arising in the gastro-oesophageal junction in a severely obese patient.

Transrectal specimen extraction after laparoscopic left colectomy: a case-matched study.

AIM: Avoiding 'mini-laparotomy' to extract a colectomy specimen may decrease wound complications and further improve recovery after laparoscopic surgery. The aim of this study was to develop a new technique for transrectal specimen extraction (TRSE) and to compare it with conventional laparoscopy (CL) for left sided colectomy. METHOD: Eleven patients with benign disease requiring either sigmoid or left colon resection underwent TRSE. The unfired circular stapler was inserted transanally and used as a guide to suture-close the recto-sigmoid junction laparoscopically and as a handle to pull the sutured sigmoid through the opened rectum inside a laparoscopic camera bag. The anvil was inserted into the lumen of the intussuscepted sigmoid and pushed to the level of the anastomosis. The anastomosis was fashioned end-to-end in the first patients and side-to-end in the following patients to improve safety. Intra-operative and postoperative outcomes of patients undergoing TRSE were compared with those of a group of 20 patients undergoing CL, who were matched for type of resection, body mass index and age. RESULTS: The procedure was successful in all but the first patient who was converted to conventional laparoscopic colectomy without any additional morbidity. Two patients in the end-to-end anastomosis group, but none in the side-to-end group, developed peri-anastomotic sepsis. Compared with CL, patients undergoing TRSE did not show any significant differences in operative time, recovery or morbidity. CONCLUSION: Transrectal specimen extraction after left colectomy using the circular stapler technique is feasible. A side-to-end anastomosis appears safer than an end-to-end anastomosis. Further studies are needed to explore the potential advantages of this procedure over CL.

[Older people admitted to the emergency department after a fall: what to do?]. / Patients âgés admis aux urgences suite à une chute: que faire?

Falls in older people are frequent. Falls may lead to serious injuries and are associated with greater morbidity, mortality, and reduced overall functioning in the older population. Evidences exist regarding the beneficial effects of fall prevention programs. However, these interventions are rarely implemented in our health system. Older people admitted to the emergency department after a fall should get careful attention in order to initiate specific interventions to prevent new falls. This article provides a clinical assessment strategy to evaluate older persons after a fall and proposes an algorithm for discharge planning decision.

[Usefulness of a predictive score in subarachnoid hemorrhage diagnosis]. / Suspicion d'hémorragie sous-arachnoïdienne: place d'un score prédictif dans la stratégie diagnostique actuelle?

Usefulness of a predictive score in subarachnoid hemorrhage diagnosis Nearly half of the patients with non-traumatic subarachnoid hemorrhage (SAH) present with no neurological signs, inducing clinical underestimation of the gravity of their affection. As the outcome of aneurismal SAH is highly dependant on the initial neurological status and the recurrence of untreated hemorrhagic events, these neurologically intact patients stand to suffer the most from delayed diagnosis. Although there is currently no validated predictive score that reliably identifies SAH-induced headache, a combination of clinical criteria derived from a cohort of sudden-onset headache patients should allow risk stratification and identification of those patients requiring further investigation.

[Emergency medicine: update 2010]. / Médecine d'urgence.

Several scores with predictive value for morbidity or mortality have been published this year. Their current purpose is to improve the direction of admissions and lengths of stay in hospital. Their use permits more directed care, especially for the elderly, and therefore could improve the proper orientation and admission of patients. Also this year, certain procedures are undergoing evaluation, namely: new assays for troponin, and non-contrast CT in the diagnosis of acute appendicitis. Furthermore in the therapeutic realm: the importance of cardiac massage and the advantages of therapeutic hypothermia in cardiac arrest, and the efficacy of oxygen therapy in cluster headache.

Sacral inflammatory pseudotumor revealed by paraneoplastic syndrome.

There is still debate on whether inflammatory pseudotumor should be considered benign or malignant. This lesion has only been reported twice in bone, apart from cases complicating foreign body reaction to joint replacement arthroplasty. We report here a third case, localized at the sacrum. A 31-year-old man had inflammatory dorsalgia and polyarthralgia without synovitis but with fever, asthenia, and erythema nodosa. Biological tests and X-rays were not informative, but technetium scintigraphy revealed a high level of left sacroiliac tracer binding. Several nonsteroidal anti-inflammatory drugs and sulfasalazine treatment were given over 3 months but ineffective. Pelvic magnetic resonance imaging showed an osteolytic tumor of the sacrum. Biopsy suggested a malignant fibrosarcoma, but complete evaluation after surgical resection demonstrated an inflammatory pseudotumor. All clinical symptoms disappeared within a few days after surgery, which is suggestive of a paraneoplastic syndrome. No relapse has occurred after 4 years.

Detection of the tax gene of HTLV-I in labial salivary glands from patients with Sjögren's syndrome and other diseases of the oral cavity.

OBJECTIVE: To confirm a possible association between Sjögren's syndrome (SS) and the tax gene of human T lymphotropic virus type I (HTLV-I). METHODS: We studied by PCR labial salivary glands (LSG) from 50 patients with definite SS and from 58 controls including 32 patients with LSG involved by other inflammatory processes and 26 normal LSG. Antibodies to HTLV-I and antibodies to the Tax protein were searched for in serum. RESULTS: We detected the tax gene of HTLV-I in LSG from 15/50 (30%) of patients with SS but also in specimens from 9/32 (28%) patients with LSG involved by other inflammatory processes (3/9 graft-versus-host disease, 5/19 extra-vasated cysts, 1/4 sarcoidosis) and from only 1/26 (4%) normal LSG. A 652 bp region, sequenced in 2 SS patients, was 98-98.5% homologous to the canonic sequence of tax HTLV-I. The HTLV-I gag, pol and env genes were never detected. The serum of the SS patients did not contain antibodies to HTLV-I. However, anti-Tax antibodies were detected in the serum of 18/25 (72%) SS patients, 10/10 (100%) patients positive for tax DNA in their LSG and 8/15 (53%) patients negative for tax DNA in their LSG. CONCLUSION: Our observations raise the possibility that a very low number of copies of the tax gene may be harbored innocuously in cells within the oral cavity in some healthy individuals, but that this gene may play a role as a co-factor in the development of SS or other diseases of oral cavity.

[Biosphonates in oncology]. / Les bisphosphonates en cancérologie.

MECHANISM OF ACTION: Tumor-induced osteolysis or lytic bone disease is mediated by osteoclast activation. Bisphosphonates inhibit bone resorption by reducing osteoclastic activity. INDICATIONS: Bisphosphonates were shown to be effective in treating cancer-related hypercalcemia. Recent large randomized clinical trials have shown the efficacy of bisphosphonates in reducing bone pain, pathological fractures and spinal cord compression for patients with multiple myeloma and breast cancer metastatic to bone. The potential survival benefit from pamidronate in patients with advanced myeloma warrants further study. FUTURE: Future clinical trials will use more potent bisphosphonates (zoledronate, ibandronate) with the ultimate goal of trying to prevent bone metastases.

[Renal cancer: bone metastases, immunotherapy and interleukin-6]. / Cancer du rein: métastases osseuses, immunothérapie et interleukine 6.

In renal cell carcinoma, bone metastases remain a major medical challenge because they are refractory to the antiproliferative effects of immunotherapy. We critically review the biological and clinical data which implicate interleukin-6 in the tumor growth, the pathogenesis of the bone metastases and the response to immunotherapy.

[Multicentric liposarcoma. Apropos of a case]. / Liposarcome multicentrique. A propos d'un cas.

INTRODUCTION: Though rare, observations of multiple liposarcomas show that the development of secondary tumors occur in sites usually considered as primary locations. This would be more frequent for myxoid liposarcomas than for other subtypes of the disease. Their origin, either multicentric (i.e., coexistence of several primary tumors) or due to metastatic spreading, is still debated. EXEGESIS: We report a case of myxoid-type multicentric (i.e., right popliteal fossa, retroperitoneum and soft tissue of the left arm) liposarcomas of different sizes, without pulmonary, hepatic or osseous involvement. These liposarcomas were simultaneously diagnosed in a patient who presented with pain in the right knee. CONCLUSION: This support the hypothesis that multiple liposarcomas have a multicentric origin. Initial and follow-up staging of such tumors must investigate not only usual metastatic sites but also classical primary locations.