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.

Impacto en la calidad de vida e importancia de estomaterapeuta en pacientes con complicaciones de ostomía / No disponible

Los pacientes ostomizados pueden presentar importantes complicaciones que afectan gravemente a su vida diaria. Presentamos el caso de un varón de 79 años diagnosticado de Adenocarcinoma en tercio medio del recto, al que se le hizo una ileostomía de protección, que presentó posteriormente un prolapso, por lo que se realiza cirugía urgente para cierre de la misma y colostomía terminal en FII. En el postoperatorio inmediato, presenta infección de herida quirúrgica a nivel del cierre de la ileostomía y dehiscencia completa de inserción mucocutánea del estoma. Se inician curas con Terapia de Presión Negativa VAC(R), siguiendo dicha terapia en CCEE. Una vez se consiguió el crecimiento del tejido de granulación viable, se retiró la terapia y se continuó la cura con accesorios y dispositivos de ostomía hasta cierre completo de lesiones.Los cuidados al paciente ostomizado deben proporcionarlos profesionales formados, sensibilizados con sus necesidades y que desarrollen su trabajo desde la profesionalidad, ofreciendo al paciente y a su familia los conocimientos necesarios para su cuidado así como tratar y prevenir las complicaciones posibles

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The Impact of Surgical Wound Dehiscence on Body Image.

OBJECTIVE: To identify changes in body image in patients with surgical wound dehiscence. DESIGN AND SETTING: This cross-sectional, descriptive, analytical study was conducted in a university hospital and nursing care center in Brazil. PATIENTS AND INTERVENTION: Sixty-one adult surgical patients of both genders from different inpatient wards or receiving outpatient care were selected. Forty-one participants had surgical wound dehiscence, and 20 had achieved complete wound healing (controls). MAIN OUTCOME MEASURE: The Body Dysmorphic Disorder Examination (BDDE), Body Investment Scale (BIS), and a questionnaire assessing clinical and sociodemographic characteristics of patients were used for data collection. MAIN RESULTS: Surgical wound dehiscence defects were 0.5 to 30 cm in length, located on the arms, legs, and chest. They were significantly associated with being white (P = .048), number of children (P = .024), and presence of comorbid conditions (P = .01). Overall, men reported higher BIS scores (positive feelings about the body) than women (P = .035). Patients with wound dehiscence had higher BDDE scores (negative body image) than controls (P = .013). The BDDE scores were associated with presence of surgical wound dehiscence (P = .013), number of children (P = .009), and wound length (P = .02). There were significant correlations between BIS scores in men with wound dehiscence (P = .042), number of children (P < .001), and BDDE scores (P < .001) and between BDDE scores and number of children (P = .031), wound length (P = .028), and BIS scores (P < .001). CONCLUSION: Surgical wound dehiscence had a negative impact on body image.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study.

OBJECTIVE: To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT). DESIGN: A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology. PARTICIPANTS AND SETTING: A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes. RESULTS: Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options. CONCLUSIONS: To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option. TRIAL REGISTRATION NUMBER: ISRCTN05754020; results.

Impact of surgical wound dehiscence on health-related quality of life and mental health.

OBJECTIVE: To assess the impact of surgical wound dehiscence on health-related quality of life and mental health. Dehiscence of surgical wounds is a serious postoperative complication associated with high morbidity and mortality. METHOD: Sixty-one adult patients, who had undergone neurological, general, colorectal, orthopaedic, gynaecological, plastic, cardiovascular, urological or neurological surgery in a university hospital in Brazil, were assessed between 30 and 180 days after surgery. Twenty participants who achieved complete wound healing were allocated to the control group and 41 participants who developed surgical wound dehiscence were allocated to the dehiscence group. Patients unable to complete the questionnaires because of cognitive impairment and those who declined to participate or died were excluded from the study. Data were collected using a questionnaire assessing sociodemographic and clinical characteristics of participants; the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36); and the Beck Depression Inventory (BDI). RESULTS: Surgical wound dehiscences were 0.5-30 cm in length, 0.5-7 cm in depth, and located in the arms, legs or trunk. There were significant between-group differences in mean scores on the physical functioning (p<0.01), role physical (p<0.01), social functioning (p=0.01), and bodily pain (p=0.01) dimensions of the SF-36. Participants with wound dehiscence reported significantly higher BDI scores (more depressive symptoms) than controls (p=0.01). CONCLUSION: Surgical wound dehiscence had a negative impact on the physical functioning, role physical, social functioning, and bodily pain dimensions of health-related quality of life and on mental health. DECLARATION OF INTEREST: No conflict of interest to declare.

Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia.

OBJECTIVE: Long-term quality of life and body image of patients with abdominal wound dehiscence were assessed. METHODS: Thirty-seven patients with abdominal wound dehiscence from a prospectively followed cohort of 967 patients (2007-2009) were reviewed. Patients completed the Short Form 36 quality of life questionnaire and Body Image Questionnaire and participated in semi-structured telephone interviews. For each patient, four controls were matched by age and gender. Analyses were adjusted for age, gender, comorbidity, and follow-up length. RESULTS: Of the 37 patients with abdominal wound dehiscence, 23 were alive after a mean follow-up of 40 months (range 33-49 months). Nineteen patients developed incisional hernias (83 %). Patients with abdominal wound dehiscence reported significantly lower scores for physical and mental component summaries (p = 0.038, p = 0.013), general health (p = 0.003), mental health (p = 0.011), social functioning (p = 0.002), and change (p = 0.034). No differences were found for physical functioning (p = 0.072), role physical (p = 0.361), bodily pain (p = 0.133), vitality (p = 0.150), and role emotional (p = 0.138). Patients with abdominal wound dehiscence reported lower body image scores (median 16.5 vs. 18, p = 0.087), cosmetic scores (median 13 vs. 16, p = 0.047), and total body image scores (median 30 vs. 34, p = 0.042). CONCLUSIONS: At long-term follow-up, patients with abdominal wound dehiscence demonstrated a high incidence of incisional hernia, low body image, and low quality of life.

[Stoma creation during low anterior resection: the cons]. / Stoma bei tiefer anteriorer Resektion: Kontra.

Creation of a protective stoma is nowadays considered the standard of care in patients undergoing low rectal resection to protect these patients from the potentially hazardous consequences of an anastomotic leak. This appears reasonable in patients with acknowledged risk factors such as male gender, low anastomosis, preoperative radiochemotherapy, intraoperative complications, or steroid treatment to ensure patients' safety. However, from our view, it is debatable, if patients without these risk factors can undergo low rectal resection without a stoma. This approach can prevent patients form potential risks of stoma creation as well as closure and the associated readmission to the hospital. Based on reliable patient selection, avoiding a protective stoma during low rectal resection can increase patients' satisfaction and decrease primary and secondary medical costs. However, this approach is hampered by the lack of evidence for patient selection, leading to legal concerns that justify this approach only in highly motivated patients after detailed counseling of the individual patient.

[Protective stoma after deep anterior rectal resection: pro]. / Protektives Stoma nach tiefer anteriorer Rektumresektion: Pro.

There is still controversy about the necessity of a diverting stoma after deep anterior resection with total mesorectal excision for rectal cancer. Recent results of randomized controlled trials and from systematic reviews have improved the currently available data. A significant benefit was shown for patients with diverting stoma in terms of clinically relevant anastomotic leakage and re-operation rates. The influence on mortality is not as clear. However, analysis of the data of 19 prospective studies within a systematic review including more than 9,000 patients, revealed a significant benefit for stoma creation. Furthermore, the rate of patients with stoma 5 years after primary resection was lower in the group of patients with diverting stoma. The purpose of this manuscript is to show the necessity of a diverting stoma based on the currently available data.

[Living with a chronic abdominal wound--the patients' perspective]. / Leben mit einer chronischen Bauchwunde--Die Erfahrung Betroffener und ihre Erwartungen an die betreuenden Fachpersonen.

Chronic abdominal wounds lead to prolonged hospital stays. However, no data exist that describe the experience of persons living with a chronic abdominal wound. The aim of this qualitative study was to explore the experience of persons living with chronic abdominal wounds and elicit their expectations in health professionals. Narrative interviews were conducted with five women and four men. Using content analysis techniques, five categories with one to four subcategories emerged from the data. "Returning to everyday life without a wound" represents the main goal of the participants and is driven by their hope to achieve this outcome. "Everyday life with the wound" illustrates the reality of participants' lives, which is affected by suffering. "The patients' work" demonstrates the component that patients contribute to managing their wound. "The work of primary support persons" shows the importance of the work of people close to the patient. "The work of professionals" includes the expectations that patients have in their caregivers. Teamwork between professionals, patients and primary support persons seems to be an essential condition for the successful healing of an abdominal wound.

A home care wound care challenge: its rewards, inspiration, and positive outcomes.

Quite often, home health team members are presented with a challenge to provide management for a patient who has undergone a complex gastrointestinal surgery. An appropriate plan of care includes the incision, wound, and colostomy care, as well as the psychosocial support, time management, and cost issues. Many times this requires ingenuity and flexibility on the part of the home care team. Comorbidities often increase the acuity of the nursing care as well. In any case and no matter how difficult the circumstances, the goal for the patient's plan of care is to achieve an optimal outcome that will encourage independence and a feeling of self-worth.

Using negative pressure therapy for healing of a sternal wound.

Lisa Clubley and Lorraine Harper examine the treatment provided to a patient who had cardiac surgery and developed complications that resulted in the development of an extensive open sternal wound. The consultant surgeon responsible for the care made a decision to use negative pressure therapy (vacuum-assisted closure) despite such therapy for a wound of this nature being contraindicated in the manufacturer's clinical guidelines

The management of a pilonidal sinus and its follow-up care.

This article describes the care of a young man following surgery for a pilonidal sinus and the follow-up care after removal of the sutures from the wound. Unfortunately, the wound became infected and dehisced on removal of the sutures, causing the patient to have problems with both wound healing and body image.

[Scars of the soul--wounds of the body: plastic surgery and psychotherapy]. / Narben der Seele--Wunden des Körpers: Plastische Chirurgie und Psychotherapie.

With the example of two case reports of chronic wounds the connection between somatic and psycho-social factors is shown on the basis of the biopsycho-social model of disease. Both in aetiology as well as in therapy the dilemma of "somatic OR psychic" can thereby be solved. The inclusion of psychotherapeutic interventions in conservative or surgical strategies increases the probability of healing.

Healing of a free tracheal autograft is enhanced by topical vascular endothelial growth factor in an experimental rabbit model.

OBJECTIVE: In 1996, we introduced the free tracheal autograft technique for repair of congenital tracheal stenosis from complete tracheal rings in infants and children. Sources of possible concern with this procedure include the potential for autograft ischemia, patch dehiscence, and recurrent stenosis. Vascular endothelial growth factor is a potent angiogenic inducer (particularly in the setting of ischemia, hypoxia, or both) and is postulated to promote tissue healing. The purpose of this study was to test the hypothesis that pretreatment of tracheal autografts with topical vascular endothelial growth factor would enhance tracheal healing. METHODS: In a rabbit model of tracheal reconstruction (n = 32), an elliptically shaped portion of the anterior tracheal wall was excised. The excised portion of trachea was one third of the tracheal circumference and 2 cm in length (6 tracheal rings). This portion of trachea (the autograft) was soaked in either vascular endothelial growth factor (5 microg/mL, n = 16) or normal saline solution (n = 16) for 15 minutes before being reimplanted in the resultant tracheal opening. Animals were killed and autografts were examined at 2 weeks, 1 month, and 2 months postoperatively for gross and microscopic characteristics. RESULTS: By 2 weeks, and progressing through 1 and 2 months, autografts treated with vascular endothelial growth factor, as compared with control autografts, had reduced luminal stenosis, submucosal fibrosis, and inflammatory infiltrate (P <.05). The autografts tended to become malaligned in control animals, whereas the tracheal architecture was preserved in rabbits treated with vascular endothelial growth factor. Microvascular vessel density was significantly greater in all vascular endothelial growth factor groups (P <.05) at all time intervals. CONCLUSIONS: Topical treatment of free tracheal autografts with vascular endothelial growth factor in a rabbit tracheal reconstruction model enhanced healing, as evidenced by accelerated autograft revascularization, reduced submucosal fibrosis and inflammation, and preservation of the normal tracheal architecture. Topical vascular endothelial growth factor may improve future results of tracheal reconstruction.

The interdisciplinary approach to oral, facial and head pain.

BACKGROUND: Chronic oral, facial and head pain is a common clinical problem, and appropriate diagnosis and management are a challenge for health care professionals. Patients often will first seek the care of dentists because of the pain's localization in the oral cavity and surrounding structures. This article emphasizes the importance of establishing accurate diagnoses and conducting appropriate triage of the patient with complex orofacial pain. CASE DESCRIPTIONS: The authors present two case reports illustrating the complex nature of oral, facial and head pain, and the potential and actual pitfalls in management of this condition. These representative cases demonstrate how orofacial pain--which appears to be localized in the peripheral dental and oral structures--can have extremely complex etiologies involving other anatomical structures, the central nervous system and psychological factors. The reports point to the need for the expertise of a number of specialists in such cases. CLINICAL IMPLICATIONS: If the symptoms and clinical findings do not appear to be consistent with typical oral disease, or if standard treatments do not alleviate the pain, the dental clinician must consider other, more complex orofacial pain diagnoses. The dental professional should not hesitate to make referrals to key specialists or to members of an interdisciplinary team at a pain treatment center who have the expertise to appropriately diagnose and manage chronic oral, facial and head pain.

Futility of muscle flaps for self-inflicted wounds.

Unacceptable forms of self-mutilation usually are resistant to surgical intervention and have a basis in psychopathology. Establishing this diagnosis may be as difficult as is the treatment, frequently involving a prolonged process of exclusion of other known disease entities. Management of these chronic self-inflicted wounds demands flexibility by the surgeon who must be aware of this possibility and willing to deviate from the normal approach to wound healing. Simplicity is of paramount importance. The use of vascularized tissues and, in particular, the sacrifice of scarce muscle flaps probably is unwarranted except as a last resort because these wounds nevertheless remain recalcitrant to permanent healing. Instead, a nonconfrontational approach with long-term psychotherapy should be a major part of the initial therapy with surgery considered only important in an adjunctive role.