Reducing morbidity with surgical adhesives following inguinal lymph node dissections for the treatment of malignant skin tumors.

BACKGROUND: Inguinal lymph node dissection (ILND) is associated with a high rate of morbidity. To evaluate the clinical benefit of surgical adhesives to reduce complications in patients undergoing ILND, we compared the use of TissuGlu(®) Surgical Adhesive and ARTISS(®) fibrin sealant with a control population. MATERIAL AND METHODS: We conducted a retrospective analysis of patients undergoing ILND for metastatic malignant skin tumors at one hospital, Fachklinik Hornheide (Münster, Germany), from January 2011 through September 2013, assessing 137 patients with a total of 142 procedures. RESULTS: Complications occurred in 22/60 procedures in the TissuGlu group (TG), in 8/17 in the ARTISS group (AG), and in 29/65 in the control group (CG). Prolonged drainage and seroma were recorded in 16 (26.7%), four (23.5%), and 26 (40%) respectively (non-significant). TG showed less extended drainage vs. CG (p=0.082). Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). With regard to wound infection, there was a 15% reduction in TG and 74% increase in AG group. Revision surgery was reduced by 36% in TG and increased by 54% in AG. Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). Mean total post-operative drain volume was lower in TG and AG vs. CG (p<0.001 among groups, CG vs. TG p<0.001, CG vs. AG p<0.001). The mean body mass index (BMI) was significantly higher in patients with complications, 29.4±5.8 vs. 25.3±4.1 (p=0.000). CONCLUSION: The use of TissuGlu in our ILND patients was associated with a reduction in post-operative wound related complications and the need for revision surgeries compared to the control group. Daily drainage was significantly lower within the first 7 post-operative days with the use of ARTISS, but the benefit was lost due to the higher occurrence of wound infection and revision surgery. BMI above 29 is a risk factor for complications following ILND. ( LEVEL OF EVIDENCE: level IV, retrospective case study).

Are Multimorbidities Underestimated in Scoring Systems of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Like in SCORTEN?

OBJECTIVE: Toxic epidermal necrolysis and Stevens-Johnson syndrome have related high morbidity and mortality. We predict that preexisting multimorbidity is a major prognostic factor of both these diseases. METHODS: A retrospective analysis in toxic epidermal necrolysis and Stevens-Johnson syndrome patients over the past 10 years. Three severity categories (minor, moderate, and severe multimorbidity) were defined according to a point-rating system. RESULTS: Twenty-seven inpatients, with a median age of 63 years, diagnosed with toxic epidermal necrolysis (n = 13) or Stevens-Johnson syndrome/toxic epidermal necrolysis (n = 14) were assessed in this study. Of these, 14 patients died during the course of the study. Nonsurvivors showed significantly higher multimorbidity (P = .038), with higher scoring on the points system for disease severity (P = .003), than survivors and CART (Classification and Regression Trees) cross-validation (P < .05). LIMITATIONS: Restricted number of patients due to low prevalence rate. CONCLUSION: The complexity of associated multimorbidity appears to have a large influence on toxic epidermal necrolysis and Stevens-Johnson syndrome prognosis, which has not been considered in any of the established scoring systems.

Long-term dilatation of polyester and expanded polytetrafluoroethylene tube grafts after open repair of infrarenal abdominal aortic aneurysms.

OBJECTIVES: Since 1995, expanded polytetrafluoroethylene (ePTFE) grafts have been implemented in open surgical repair (OSR) of abdominal aortic aneurysms (AAA) and are supposed to show less dilatation than polyester grafts. This study examined differences in graft dilatation and clinical outcome. METHODS: This single-center long-term, prospective randomized study monitored 99 consecutive patients after OSR of AAA. Implanted were 90 tube ePTFE Gore-Tex Stretch grafts, 56 tube Dacron grafts (Uni-Graft KDV, polyester, B. Braun, knitted), and 51 tube Dacron grafts (Gelseal Plus, polyester, Vascutek, triaxial knitted). Follow-up with ultrasound examination was performed at discharge, at 12 months, and at 6 years. RESULTS: Patients were a mean age of 67 years. Thirty-day mortality was 2.5% (n = 5 of 199), without significant differences among the groups. The Kaplan-Meier analysis showed 5-year survivals of 0.82 (ePTFE/Gore), 0.81 (polyester/Braun), and 0.83 (polyester/Vascutek). Mean ± standard deviation dilatation of the midgraft segment was 1% ± 5% (ePTFE/Gore), 10% ± 9% (polyester/Braun), and 7% ± 8% (polyester/Vascutek) (P ≤ .001) at discharge; 8% ± 11% (ePTFE/Gore), 24% ± 7% (polyester/Braun), and 20% ± 13% (polyester/Vascutek; P ≤ .001) after 12 months; and 19% ± 21% (ePTFE/Gore), 33% ± 22% (polyester/Braun), and 23% ± 19% (polyester/Vascutek; (P ≤ .001) after 6 years. No graft failure or rupture occurred. Graft patency was 100%. CONCLUSIONS: After a mean implantation of 6 years, the ePTFE/Gore, polyester/Braun, and polyester/Vascutek tube grafts presented with significant differences. The ePTFE grafts showed a stronger resistance against dilatation than the two types of polyester grafts. Owing to similar perioperative and postoperative courses, no advantage could be identified in any group concerning the overall outcome. Vascular implants for OSR of AAA made of ePTFE and polyester are safe, even after a long implantation time. Therefore, the choice of the suitable graft does not depend on its postimplantation dilative characteristics. The outcome is not likely to be connected with dilatation of the implanted graft, because a causal connection between graft dilatation and death cannot be made. The study does not offer a basis for the preference of one of the three graft types. Nevertheless, continuous ultrasound examinations should be performed after implantation of an aortic tube graft to identify possible problems arising from changes in the graft and the residual vascular branches over time.

A rare desmoid tumor of the shoulder--excision, implantation of brachytherapy applicators and wound closure by pedicle musculus latissimus dorsi flap.

Desmoid tumors are non-metastatic mesenchymal tumors with an aggressive local growth. Depending on the anatomic location, morbidity varies. We report of a patient with a desmoid tumor of the right shoulder which was treated in our department by surgical excision, plastic-surgical wound closure and postoperative adjuvant radiation.

Impact of hypernatremia on burn wound healing: results of an exploratory, retrospective study.

Severely burned patients need extensive initial fluid resuscitation. Formulas to calculate fluid needs during burn shock are well established. However, protocols for normalizing circulating fluid volume after cellular integrity has recovered do not exist. Resultant electrolyte shifts can cause hypernatremia, a possible sign of hypovolemia, which may in turn result in decreased tissue perfusion, subsequently affecting burn wound healing. The purpose of this retrospective chart review was to explore the hypothesis that hypernatremia in burn patients is a possible sign of systemic dehydration and that dehydration may affect burn wound skin graft take. Medical chart data from otherwise healthy burn victims with deep partial-thickness burns (total burn surface area [TBSA] >10%) who underwent skin grafting 7 days post injury were reviewed. Thirty (11 female; 19 male) patients with an average TBSA of 30% (± 11%) and an Abbreviated Burn Severity Index (ABSI) score of 7.9 (± 1.8) were included. Of those, 17 had normal average serum levels between day 2 and 6 following injury and 13 developed hypernatremia (serum sodium ≥146 mmol/L) an average of 5.5 days (± 1.5) after injury. Patients in this group underwent an average of 1.3 (± 0.8) re-grafting procedures compared to 0.35 (± 0.5) for patients without hypernatremia (P = 0.001). There was good correlation (r = 0.525) between daily infusion-diuresis ratios (IDR) and serum sodium levels, as well as between serum sodium levels and re-skin grafting occurrences (r = 0.62). The results indicate that research to confirm that hypernatremia is an indicator of dehydration and affects skin graft take is warranted and that protocols to optimize fluid volume following burn shock treatment are needed.

Rhabdomyolysis and acute renal failure in severely burned patients.

Rhabdomyolysis (RML) is a precarious complication in severely burned patients and the principal treatment goal is prevention of acute renal failure (ARF). This 10-year retrospective study analyses the causes for RML in severely burned patients and evaluates treatment algorithms. Eight of 714 patients (1%) were diagnosed with RML. Percentage TBSA burn was 25 ± 13%. The mean abbreviated burn severity index score (ABSI) was 9 ± 2. ARF was found in 75% (6/8) of the patients. Serum myoglobin (MB) was reduced by 41 ± 16% after 24-h treatment by solitary volume repletion (VR) and by 44 ± 20% through VR+continuous veno-venous hemodiafiltration (CVVHDF). Mortality was 50% (4/8). Peak mean CPK-levels were more than two and MB-levels more than four times higher in non-survivors than in survivors. Burns associated with RML result in poor survival. VR and CVVHDF are effective measures in treating RML. CVVHDF is effective in removing MB when using high flux filter membranes. Early CVVHDF (within 24h of diagnosis) with high-cut off membranes could reduce the risk of ARF and mortality.

Transdermal fluid loss in severely burned patients.

INTRODUCTION: The skin protects against fluid and electrolyte loss. Burn injury does affect skin integrity and protection against fluid loss is lost. Thus, a systemic dehydration can be provoked by underestimation of fluid loss through burn wounds. PURPOSE: We wanted to quantify transdermal fluid loss in burn wounds. METHOD: Retrospective study. 40 patients admitted to a specialized burn unit were analyzed and separated in two groups without (Group A) or with (Group B) hypernatremia. Means of daily infusion-diuresis-ratio (IDR) and the relationship to totally burned surface area (TBSA) were analyzed. RESULTS: In Group A 25 patients with a mean age of 47 ± 18 years, a mean TBSA of 23 ± 11%, and a mean abbreviated burned severity index (ABSI) score of 6.9 ± 2.1 were summarized. In Group B 15 patients with a mean age of 47 ± 22 years, a mean TBSA of 30 ± 13%, and a mean ABSI score of 8.1 ± 1.7 were included. Statistical analysis of the period from day 3 to day 6 showed a significant higher daily IDR-amount in Group A (Group A vs. Group B: 786 ± 1029 ml vs. -181 ± 1021 ml; p<0.001) and for daily IDR-TBSA-ratio (Group A vs. Group B: 40 ± 41 ml/% vs. -4 ± 36 ml/%; p<0.001). CONCLUSIONS: There is a systemic relevant transdermal fluid loss in burn wounds after severe burn injury. Serum sodium concentration can be used to calculate need of fluid resuscitation for fluid maintenance. There is a need of an established fluid removal strategy to avoid water and electrolyte imbalances.

Does hypernatremia impact mortality in Toxic Epidermal Necrolysis?

INTRODUCTION: In-hospital hypernatremia is associated with increased mortality rates. We want to elucidate the impact of in-hospital acquired hypernatremia in mortality of Toxic Epidermal Necrolysis (TEN). PURPOSE: Is there an association between hypernatremia and mortality in patients with TEN? METHOD: Retrospective study of 25 patients with TEN. Laboratory electrolyte results, diuresis and survival were analyzed. Patients were separated in two groups without (Group A) or with (Group B) hypernatremia. RESULTS: In Group A 10 patients with a TBSA of 74 ± 25% (mean ± standard deviation), and a SCORTEN-Score of 2.7 ± 0.9 were summarized. Diuresis within the first 10 days after admission was 1 ± 0.3 ml/kg/hour. In Group B 15 patients with a TBSA of 76 ± 19%, and a SCORTEN-Score of 3.5 ± 1 were included. Diuresis within the first 10 days after admission was 1.4 ± 0.4 ml/kg/hour. Hypernatremia occurred on day 3.3 ± 2.4 after admission and persisted for 5.3 ± 2.9 days. Statistical analysis showed a significantly higher diuresis (p=0.007) and SCORTEN-Score (p=0.04) in the hypernatremic patients. One normonatremic and 8 hypernatremic patients died during ICU-stay (overall mortality rate 36%). A significantly higher mortality rate was found in Group B (odds ratio: 13,5; 95% confidence interval: 1.34-135.98; p=0.01) during ICU-stay. CONCLUSION: TEN patients with an in-hospital acquired hypernatremia have an increased mortality risk. Close electrolyte monitoring is advisable in these patients.

Latissimus dorsi muscle flap for lower extremity reconstruction in children.

UNLABELLED: Complete loss of free latissimus dorsi muscle flaps to the leg is frequently reported. The purpose of this study is to analyze the outcome of latissimus dorsi muscle flaps to the lower extremity in children. PATIENTS AND METHODS: This retrospective analysis includes 11 children treated with a free latissimus dorsi muscle flap after severe trauma to the lower leg and foot. RESULTS: Fourteen free latissimus dorsi muscle flaps were performed in 11 children with a mean age of 13 ± 4 years. The injuries were caused by traffic accidents, lawnmower accidents, and a crush trauma. Thirteen (92.8%) flaps needed surgical revision. Three complete flap losses and 1 partial flap loss were registered. CONCLUSIONS: Free latissimus dorsi muscle flaps seem to be a useful technique for lower extremity salvage after severe injury, but there is a relevant flap failure risk in children.

Increased mortality in hypernatremic burned patients.

INTRODUCTION: In-hospital hypernatremia develops usually iatrogenically from inadequate or inappropriate fluid prescription. In severely burned patient an extensive initial fluid resuscitation is necessary for burn shock survival. After recovering of cellular integrity the circulating volume has to be normalized. Hereby extensive water and electrolyte shifts can provoke hypernatremia. PURPOSE: Is a hypernatremic state associated with increased mortality? METHOD: Retrospective study for the incidence of hypernatremia and survival in 40 patients with a totally burned surface area (TBSA) >10%. Age, sex, TBSA, ABSI-Score and fluid resuscitation within the first 24 hours were analyzed. Patients were separated in two groups without (Group A) or with (Group B) hypernatremia. RESULTS: Hypernatremia occurred on day 5+/-1.4. No significant difference for age, sex, TBSA, ABSI-Score and fluid resuscitation within the first 24 hours were calculated. In Group A all patients survived, while 3 of the hypernatremic patient in Group B died during ICU-stay (Odds-ratio = 1.25; 95% CI 0.971-1.61; p=0.046). CONCLUSION: Burned patients with an in-hospital acquired hypernatremia have an increased mortality risk. In case of a hypernatremic state early intervention is obligatory. There is a need of a fluid removal strategy in severely burned patient to avoid water imbalance.

Complete free flap loss due to extensive hemodilution.

BACKGROUND: Free tissue transfer in reconstruction of lower extremity wounds is well established. Controversy surrounds type and regimen of intravenous fluid application during microsurgery. Hemodilution is supposed to influence haemostatic process. PATIENTS AND METHODS: We performed an analysis of 48 patients treated with a free latissimus dorsi muscle flap to the lower leg for posttraumatic soft-tissue coverage. Postoperative latissimus dorsi muscle flap perfusion was controlled by clinical monitoring. Intraoperative infusion management was evaluated retrospectively. RESULTS: In 4 of 48 included patients, a complete loss of free latissimus dorsi muscle flap was registered. Concomitant increased saline infusion was detected (4,534 ml versus. 6,125 ml; P = 0.048). Similar findings for relation of total infusion volume to body weight were seen (44 ml/kg versus 69 ml/kg; P = 0.01). No significant colloid infusion was detected. CONCLUSIONS: We demonstrate the clinical relevance of extensive intraoperative hyperhydration, which can provoke a complete free flap loss.