Use of a dynamic tissue system and biological xenograft in complex traumatic wound closure.

OBJECTIVE: Asymmetrical dimensions and nonlinear margins of a multilayered traumatic wound often preclude healing via primary intention. We present the case of an otherwise healthy 21-year-old male who sustained trauma following a boating accident. METHOD: The patient sustained three lacerations to the posterior thighs from the boat propeller. The most extensive wound measured 25×10×6cm of muscle extrusion with a divot fracture involving the posterior femur. RESULTS: Primary closure and restoration of muscle biomechanics was achieved using a combination of a dynamic tissue system (DTS) and porcine urinary bladder matrix (PUBM) xenograft. After 24 days of treatment in hospital, the patient was discharged without the need for home health, outpatient wound care, or ongoing negative pressure wound therapy. The patient recovered full function of the legs and was cleared for participation in all activities. CONCLUSION: This complex traumatic boat propeller injury presented many challenges, including a transverse orientation on the extremity, degree of muscle injury/extrusion, and significant soft tissue loss. The combined application of a DTS with PUBM biological xenograft achieved a primary myocutaneous closure without the need for skin graft or flap reconstruction by plastic surgery.

Crush injury with significant soft tissue loss managed utilising biological and dynamic tissue systems: a case study.

Major traumatic crush injuries are difficult to manage, with high morbidity, requiring prolonged, complex treatment with many procedures. Free-flap reconstruction is often used yet full functionality still may not be regained. In this case study of a traumatic crush injury of the anterior distal tibia, ankle and foot of a 48-year-old male patient, we opted for an alternative management strategy using a combination of a dynamic tissue system (DTS) and biological xenografts (porcine urinary bladder matrix and a multi-tissue platform). The DTS was kept in place in an outpatient setting for four weeks postoperatively and removed after that time. At the 3-month follow-up, the wound was significantly smaller at about 15% of the original size. The wound healed completely before 6-month follow-up. Our patient's traumatic crush injury was successfully healed using an alternative management strategy, DTS and biologic xenografts.

Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call.

INTRODUCTION: Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS: A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS: Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

Two surgeons' collaboration to close an extreme open abdomen with loss of domain utilizing the abdominal dynamic tissue system and porcine urinary bladder matrix.

Acute open abdomen with loss of domain is an extremely difficult surgical scenario, and secondary complications are common. This case describes a 33-year-old woman who initially underwent an elective, laparoscopic endometrioma resection during which a complete iatrogenic transection of the left ureter and part of the sigmoid mesentery occurred. After discharge 5 days later, she was immediately readmitted for worsening abdominal pain. During the emergency abdominal reexploration, an ischemic, perforated sigmoid colon was removed and large volume paracentesis was performed due to fecal contamination. Nine additional reexplorations over 2 months resulted in an extreme acute open abdomen with loss of domain. Viscera was protected with negative pressure wound therapy, but primary myofascial closure was not feasible. Through surgical collaboration between two institutions, an abdominal dynamic tissue system was installed, which achieved primary myofascial closure 31 days after installation. Nine days later, complete wound closure utilizing porcine urinary bladder matrix was accomplished. This case highlights the successful achievement of primary myofascial closure and complete wound healing without a surgical site infection or hernia development in this heavily contaminated abdomen using dynamic tissue system biomechanics with porcine urinary bladder matrix biologics.

Alternative Lengthening of Telomeres in Cancer Confers a Vulnerability to Reactivation of p53 Function.

A subset of cancers across multiple histologies with predominantly poor outcomes use the alternative lengthening of telomeres (ALT) mechanism to maintain telomere length, which can be identified with robust biomarkers. ALT has been reported to be prevalent in high-risk neuroblastoma and certain sarcomas, and ALT cancers are a major clinical challenge that lack targeted therapeutic approaches. Here, we found ALT in a variety of pediatric and adult cancer histologies, including carcinomas. Patient-derived ALT cancer cell lines from neuroblastomas, sarcomas, and carcinomas were hypersensitive to the p53 reactivator eprenetapopt (APR-246) relative to telomerase-positive (TA+) models. Constitutive telomere damage signaling in ALT cells activated ataxia-telangiectasia mutated (ATM) kinase to phosphorylate p53, which resulted in selective ALT sensitivity to APR-246. Treatment with APR-246 combined with irinotecan achieved complete responses in mice xenografted with ALT neuroblastoma, rhabdomyosarcoma, and breast cancer and delayed tumor growth in ALT colon cancer xenografts, while the combination had limited efficacy in TA+ tumor models. A large number of adult and pediatric cancers present with the ALT phenotype, which confers a uniquely high sensitivity to reactivation of p53. These data support clinical evaluation of a combinatorial approach using APR-246 and irinotecan in ALT patients with cancer. SIGNIFICANCE: This work demonstrates that constitutive activation of ATM in chemotherapy-refractory ALT cancer cells renders them hypersensitive to reactivation of p53 function by APR-246, indicating a potential strategy to overcome therapeutic resistance.

Above and Below the Diaphragm: A Previously Undescribed Case of Recurrent Boerhaave Syndrome Diagnosed With Computerized Tomography Esophagram.

Boerhaave syndrome, defined as a spontaneous rupture of the esophagus, is an uncommon clinical entity. Recurrent spontaneous rupture of the esophagus is even rarer and has only been described in a handful of case reports. The rupture most often occurs in the thoracic esophagus. Spontaneous rupture of the intraabdominal esophagus is extremely rare. The extravasation of gastric contents, including bile, acid, and bacteria, into a body cavity precipitates severe sepsis. This results in a high mortality rate without emergent treatment. Such treatment often necessitates surgical repair with primary closure, tissue grafts, or esophagectomy in particularly severe cases. This is a case of a 64-year-old male who suffered Boerhaave syndrome twice separated by two years. The patient was transferred from an outside facility initially presenting with chest and abdominal pain, which developed after eating. CT esophagram with water soluble contrast demonstrated contrast extravasation into the right mediastinum/hemithorax, consistent with a diagnosis of Boerhaave syndrome. Repair was accomplished with an intercostal muscle pedicle patch, and the patient was subsequently discharged. This case report details, to our knowledge, the first case of a left intraabdominal and right thoracic esophageal rupture combination.

Surgeons Maintain Better Focus Working 12-Hour Shifts Compared to 24-Hour Calls.

BACKGROUND: In this quality improvement project, we analyzed surgeon focus and attention utilizing a visual tracking device. We hypothesized that surgeons maintained better focus working 12-hour shifts compared to 24-hour calls. MATERIALS AND METHODS: A prospective, quality improvement project was performed on surgery residents, medical students, and attending physicians working at a busy, tertiary referral, safety-net hospital with Level 1 trauma and burn centers. A visual tracking system was used to measure visual attention before and after a 12-hour, in-house shift and a 24-hour, surgical in-house call. A pupil tracker was utilized to measure attention impairment. Individual performance was rated on a scale of 0 to 6: Severely Impaired- 0; Impaired- 1; Low Average- 2; Average- 3; Above Average- 4; High Average- 5; Superior- 6. Data were analyzed for homogeneity. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between focus scores in the same group of individuals before and after shifts and/or calls. The Mann-Whitney U test was used to compare differences in focus between 12 and 24 hour in-house shifts and/or calls. RESULTS: A total of 21 surgeons provided a total of 61 visual tracking tests for analysis. Results were found to be nonhomogeneous. The project population was 46% men with a median age of 31 years IQR (28-33). General surgery residents accounted for 48 tests, medical students for 2, and attending surgeons for 11. Average hours of self-reported sleep before the shift/call was 6 (IQR; 6-7). There was almost no overall change in focus in individuals before and after a 12-hour, in-house shift -0.06 (SD 1.9), while after a 24- hour, in-house call, focus decreased by almost 2 full grades -1.8 (SD 1.6) (p = 0.013). There was no statistically significant difference in focus found between 12-hour day shift and 12-hour night shift. CONCLUSIONS: Twelve-hour shifts appear to preserve focus in surgeons better compared with 24- hour, in-house calls. More research is needed to establish the optimal time of surgeon focus maintenance and shift duration.

Pneumopericardium Resulting From Blunt Thoracic Trauma.

Pneumopericardium is a rare clinical condition defined by the presence of air in the pericardial sac. While this initially does not pose much danger, the accumulation of a sufficient amount of air can convert the pneumopericardium to a tension pathology. This may present with the classic signs, symptoms, and lethal dangers of cardiac tamponade. As with cardiac tamponade, treatment involves decompression of the pericardial sac through pericardiocentesis. This may be followed by insertion of a pericardial tube for continued drainage. While cardiac tamponade is well recognized by its classic findings, the rarer pneumopericardium may be more easily missed. This is further complicated by the backdrop of concurrent traumatic injuries in which it typically presents, as well as the absence of the defining accumulated pericardial effusion. We present a case of a 38-year old male who developed pneumopericardium and worsening hemodynamic status as a complication to blunt trauma, a rare etiology for this condition. CT of the chest demonstrated air in the pericardium and a coexisting pneumothorax. A bedside chest tube was placed. Upon resolution of the pneumothorax, his hemodynamic status improved. Repeat bedside ultrasound demonstrated complete resolution of his pneumopericardium. This case emphasizes the importance of early recognition and diagnosis of this rare yet easily missed condition.

Rectus Sheath Hematoma: A Rare Surgical Emergency.

A rectus sheath hematoma (RSH) is a rare medical condition that consists of blood accumulating in the rectus abdominis muscle sheath. RSH is most frequently due to a hemorrhage from the superior or inferior epigastric artery. RSH has many specific risk factors, such as anticoagulant use. As the use of anticoagulants increases, the incidence of RSH has also increased. This condition can present with the infrequent complication of abdominal compartment syndrome (ACS), which can require surgical decompression of the abdomen to avoid high morbidity and mortality. We present the case of a 79-year-old male who, after receiving anticoagulants, developed a right-sided RSH which progressed to ACS. The patient was transferred to our care for community-acquired pneumonia, pneumothorax, and increasing respiratory support. He was admitted to the medical intensive care unit (MICU), was placed on a nasal cannula, and given vancomycin and Zosyn for pneumonia. After two days, the patient was switched to enoxaparin for anticoagulation. After three days, the patient's pneumothorax had resolved. At this time, the patient reported swelling in his right lower quadrant (RLQ) with mild pain, nausea, vomiting, and difficulty voiding completely. The physical examination confirmed RLQ swelling, and a kidney, ureter, and bladder (KUB) x-ray and ultrasound were ordered. A CT with and without contrast was also obtained which showed a large right rectus sheath hematoma extension into preperitoneal space and a small amount of intraperitoneal fluid along the right paracolic gutter. Soon after, the patient became lightheaded and fell after using the restroom. Vitals at the time were a blood pressure of 79/56, heart rate (HR) of 127, and oxygen saturation of 88% with his hemoglobin dropping from 11.4 g/dL earlier that morning to 8.4 g/dL. The patient's care was transferred to our surgical team in the surgical intensive care unit (SICU). He received an arterial line, two doses of protamine, 1-liter of crystalloids, and two units of packed red blood cells (PRBC). The patient's vitals normalized. Interventional radiology (IR) was consulted but they requested the coagulopathy be corrected before any intervention. Reversal of his Lovenox® was thromboelastographic (TEG)-guided and included platelets, cryoprecipitate, and prothrombin complex concentrate/fresh frozen plasma (PCC/FFP), in addition to more PRBCs. During these interventions, the patient acutely decompensated with hypotension, difficulty breathing, and expansion of his hematoma. A bladder pressure in the 30s was obtained, causing him to be sent to the operating room (OR) for decompression, extraperitoneal packing, and the wound was temporarily closed. The patient returned and IR was able to embolize the right inferior epigastric artery. The patient was taken to the OR again for exploration, removal of packing, and closure. RSH is a rare complication that can occur due to trauma, coagulopathy, obesity, and muscle strains during a pregnancy. Larger hematomas tend to occur below the arcuate line because there is an absence of the posterior rectus sheath which enables the hematomas to spread. An RSH can be treated with conservative measures, but for patients who continue to bleed, more aggressive measures should be taken to avoid life-threatening complications, such as ACS.

Gangrenous appendicitis contained within a Spigelian hernia.

A 66-year-old man with abdominal pain had a 5-year-old mass subsequently identified as a Spigelian hernia. Exploratory laparotomy revealed a strangulated and gangrenous appendix contained within the hernia, necessitating an appendectomy. This case highlights the importance of early identification and exploration of this rare hernia, so that early management can prevent the development of more serious and dangerous symptoms.

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing.

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

Deployment of a Resuscitative Endovascular Balloon Occlusion of the Aorta Device in a Case of Gunshot Wound Injury to a Horseshoe Kidney.

A horseshoe kidney (HSK) is a urological malformation that is typically found incidentally after a traumatic injury due to its asymptomatic nature. We present a 25-year-old male with multiorgan injuries secondary to blunt abdominal trauma caused by a gunshot wound. We report the courses of action taken that led to the identification of the HSK and other associated intra-abdominal injuries and the subsequent surgical management. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an improving minimally invasive technique that was used to control hemorrhage in the early preoperative stages and during surgical repair of the injuries. Multiorgan injuries that involve an HSK are uncommon. Our interest in the case relies on the rarity and unique aspects of the injuries and the recovery of the patient following the use of REBOA.

Retrorectus repair of incisional ventral hernia with urinary bladder matrix reinforcement in a long-term porcine model.

AIM: Not all biologically derived materials elicit the same host response when used for reinforcement of ventral hernia repairs. This study aimed to evaluate the remodeling characteristics of the abdominal wall following reinforcement with urinary bladder matrix (UBM) in a large animal preclinical model of ventral hernia repair. MATERIALS & METHODS: Midline defects in 36 Yucatan minipigs were reinforced with UBM-derived surgical devices using a classic Rives-Stoppa-Wantz approach, and compared with primary repair controls. After 3 or 8 months, the abdominal wall was explanted for histological and mechanical analysis. RESULTS & CONCLUSION: All UBM-derived surgical devices were completely resorbed within 8 months and facilitated deposition of vascularized, biomechanically functional connective tissue in the retrorectus plane, with no evidence of hernia formation.

Porcine Urinary Bladder Matrix for Management of Infected Radiation Mastectomy Wound.

We present a case report on the successful healing of a Pseudomonas infection wound in a 52-year-old female with morbid obesity, noninsulin dependent diabetes mellitus and a history of tobacco use, who presented with Stage IIIA (T3, N2, Mo) infiltrating ductal carcinoma. The patient received neoadjuvant chemotherapy prior to her bilateral skin-sparing total mastectomies with right axillary sentinel lymphadenectomy. She also had staged reconstruction with temporary breast implants and plans for deep inferior epigastric perforator flaps. Two months after chest wall and regional nodal radiation therapy, she developed a marked soft tissue reaction to radiation. She underwent over 10 right chest wall open wound radical debridements resulting in a tissue defect of 25 cm in length, by 20 cm in width, by 10 cm in depth. Despite surgical debridement, intravenous antibiotics, hyperbaric oxygen therapy, colistin spray therapy, and heat lamp therapy, the infection failed to resolve and the wound failed to heal. She was left with an open wound that was extremely painful and required chronic pain management with opioids. The patient later was found to have developed a multidrug-resistant Pseudomonas infection in her wound. However, the experimental placement of a porcine bladder matrix (ACell©, Inc., Columbia, MD) on the wound resulted in the complete relief of pain just three days after the application of the product. After two weekly applications of ACell

Synchronous Uterine Metastases from Breast Cancer: Case Study and Literature Review.

Breast cancer rarely metastasizes to the uterus. Here, we report two breast cancer patients with synchronous metastases to the uterus. Case 1 highlights a 46-year-old female with invasive ductal carcinoma who presented with a breast mass and was found to have uterine enlargement on positron emission tomography (PET) scan. Biopsy revealed a metastatic 4 mm focus of breast cancer in the background of endometrial hyperplasia. Case 2 reports a 62-year-old postmenopausal female diagnosed with lobular carcinoma of the breast following an abnormal screening mammogram. A routine pap smear necessitated further workup, revealing simultaneous endometrial and cervical metastasis. Both patients did not have any gynecologic symptoms and presented a diagnostic challenge.

Merkel cell carcinoma in a vein graft donor site.

The development of malignancies in graft donor sites is rare and may be caused by de novo malignancies as well as metastatic and iatrogenic spread. Malignancies in graft donor sites are distinguished from Marjolin ulcers by some investigators because they occur in healed surgical wounds rather than in chronic wounds or unstable scars and tend to occur sooner after injury. We present a unique case of Merkel cell carcinoma (MCC) developing in a vein graft donor site 18 years after vein harvesting.