The Ferguson Operating Anoscope for Resection of T1 Rectal Cancer.

The Ferguson Operating Anoscope (FOA) is a surgical instrument, which can facilitate transanal excision of appropriate rectal tumors within 15 cm of the anal verge. Previous work showed low recurrence (4.3%) for favorable T1 tumors (no lymphovascular invasion, well/moderate differentiation, negative margins). This follow-up study evaluates outcomes in rectal cancer excised with FOA at a tertiary care center. T1 rectal cancer patients were identified in a prospectively maintained database. Tumor pathology and patient characteristics were reviewed. Primary outcomes include tumor recurrence and patient and disease-free survival. Secondary outcomes are quality of excision (intact specimen). Twenty-eight patients had pathologic stage T1 rectal cancer (average 8 ± 2.6 cm from the anal verge). Final path demonstrated 14 per cent to be well differentiated, 82 per cent moderately differentiated, and 93 per cent without angiolymphatic invasion. All specimens removed were intact. One patient had a true local recurrence and underwent a salvage operation 24 months after her index operation. Patient survival was 96.4 per cent (n = one death from primary lung cancer) at median follow-up 64 ± 35 months. With appropriate tumor selection and quality of initial resection, FOA has demonstrated utility in achieving optimal oncologic resection of T1 rectal tumors.

De-Escalation of Antibiotics Does Not Increase Mortality in Critically Ill Surgical Patients.

BACKGROUND: Overuse of broad-spectrum antibiotics results in microbial resistance and financially is a healthcare burden. Antibiotic de-escalation refers to starting treatment of a presumed infection with broad-spectrum antibiotics and narrowing drug spectrum based on culture sensitivities. A study was designed to evaluate antibiotic de-escalation at a tertiary care center. We hypothesized that antibiotic de-escalation would not be associated with increased patient mortality rates or worsening of the primary infection. METHODS: All infections treated in a single, tertiary care Surgical ICU between August 2009 and December 2011 were reviewed. Antibiotic treatment was classified by skilled reviewers as being either de-escalated or not. Outcomes were evaluated. Univariate statistics were performed (Fisher exact test, Chi-square for categorical data; student t-test for continuous variables). Multivariable logistic regression was completed. RESULTS: A total of 2,658 infections were identified. De-escalation was identified for 995 infections and non-deescalation occurred in 1,663. Patients were similar in age (de-escalated 55 ± 16 y vs. 56 ± 16, p = 0.1) and gender (de-escalated 60% males vs. 58%, p = 0.4). There were substantially greater APACHE II scores in non-deescalated patients (15 ± 8 vs. 14 ± 8, p = 0.03). A greater mortality rate among patients with infections treated without de-escalation was observed compared with those treated with de-escalation (9% vs. 6%, p = 0.002). Total antibiotic duration was substantially longer in the de-escalated group (15 ± 13 d vs. 13 ± 13, p = 0.0001). Multivariable analysis found that de-escalation decreased mortality rates (OR = 0.69; 95%CI, 0.49-0.97; p = 0.04) and high APACHE II score independently increased mortality rates (OR = 1.2; 95%CI, 1.1-1.2; p = 0.0001). Other parameters included were age and infection site. CONCLUSIONS: Antibiotic de-escalation was not associated with increased mortality rates, but the duration of antibiotic use was longer in this group. Greater mortality rates were observed in the non-deescalated group, but this likely owes at least in part to their relatively greater severity of disease classification (APACHE II). Further investigation will help evaluate whether antibiotic de-escalation will improve the quality of patient care.

Engineering vascularized soft tissue flaps in an animal model using human adipose-derived stem cells and VEGF+PLGA/PEG microspheres on a collagen-chitosan scaffold with a flow-through vascular pedicle.

Insufficient neovascularization is associated with high levels of resorption and necrosis in autologous and engineered fat grafts. We tested the hypothesis that incorporating angiogenic growth factor into a scaffold-stem cell construct and implanting this construct around a vascular pedicle improves neovascularization and adipogenesis for engineering soft tissue flaps. Poly(lactic-co-glycolic-acid/polyethylene glycol (PLGA/PEG) microspheres containing vascular endothelial growth factor (VEGF) were impregnated into collagen-chitosan scaffolds seeded with human adipose-derived stem cells (hASCs). This setup was analyzed in vitro and then implanted into isolated chambers around a discrete vascular pedicle in nude rats. Engineered tissue samples within the chambers were harvested and analyzed for differences in vascularization and adipose tissue growth. In vitro testing showed that the collagen-chitosan scaffold provided a supportive environment for hASC integration and proliferation. PLGA/PEG microspheres with slow-release VEGF had no negative effect on cell survival in collagen-chitosan scaffolds. In vivo, the system resulted in a statistically significant increase in neovascularization that in turn led to a significant increase in adipose tissue persistence after 8 weeks versus control constructs. These data indicate that our model-hASCs integrated with a collagen-chitosan scaffold incorporated with VEGF-containing PLGA/PEG microspheres supported by a predominant vascular vessel inside a chamber-provides a promising, clinically translatable platform for engineering vascularized soft tissue flap. The engineered adipose tissue with a vascular pedicle could conceivably be transferred as a vascularized soft tissue pedicle flap or free flap to a recipient site for the repair of soft-tissue defects.

Adipose-derived stem-cell-seeded non-cross-linked porcine acellular dermal matrix increases cellular infiltration, vascular infiltration, and mechanical strength of ventral hernia repairs.

Adipose-derived stem cells (ASCs) facilitate wound healing by improving cellular and vascular recruitment to the wound site. Therefore, we investigated whether ASCs would augment a clinically relevant bioprosthetic mesh-non-cross-linked porcine acellular dermal matrix (ncl-PADM)-used for ventral hernia repairs in a syngeneic animal model. ASCs were isolated from the subcutaneous adipose tissue of Brown Norway rats, expanded, and labeled with green fluorescent protein. ASCs were seeded (2.5×10(4) cells/cm(2)) onto ncl-PADM for 24 h before surgery. In vitro ASC adhesion to ncl-PADM was assessed at 0.5, 1, and 2 h after seeding, and cell morphology on ncl-PADM was visualized by scanning electron microscopy. Ventral hernia defects (2×4 cm) were created and repaired with ASC-seeded (n=31) and control (n=32) ncl-PADM. Explants were harvested at 1, 2, and 4 weeks after surgery. Explant remodeling outcomes were evaluated using gross evaluation (bowel adhesions, surface area, and grade), histological analysis (hematoxylin and eosin and Masson's trichrome staining), immunohistochemical analysis (von Willebrand factor VIII), fluorescent microscopy, and mechanical strength measurement at the tissue-bioprosthetic mesh interface. Stem cell markers CD29, CD90, CD44, and P4HB were highly expressed in cultured ASCs, whereas endothelial and hematopoietic cell markers, such as CD31, CD90, and CD45 had low expression. Approximately 85% of seeded ASCs adhered to ncl-PADM within 2 h after seeding, which was further confirmed by scanning electron microcopy examination. Gross evaluation of the hernia repairs revealed weak omental adhesion in all groups. Ultimate tensile strength was not significantly different in control and treatment groups. Conversely, elastic modulus was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). Cellular infiltration was significantly higher in the ASC-seeded group at all time points (p<0.05). Vascular infiltration was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). The presence of ASCs improved remodeling outcomes by yielding an increase in cellular infiltration and vascularization of ncl-PADM and enhanced the elastic modulus at the ncl-PADM-tissue interface. With the ease of harvesting adipose tissues that are rich in ASCs, this strategy may be clinically translatable for improving ncl-PADM ventral hernia repair outcomes.

Infectious complications in living-donor kidney transplant recipients undergoing multi-modal desensitization.

BACKGROUND: Pre-existing humoral barriers challenge the transplantation of living donor kidneys (LDK) into highly sensitized ABO- and human leukocyte antigen (HLA)-incompatible recipients. Conditioning these LDK recipients' immune systems is required before they undergo transplantation. We hypothesized that medical desensitization would yield higher post-transplantation rates of infection. METHODS: We conducted a study in which matched controls consisting of non-desensitized (NDS) LDK recipients were compared with desensitized (DS) receipients. Pre-transplantation desensitization included treatment with rituximab and mycophenolate mofetil followed by intravenous immunoglobulin (IVIg) and plasmapheresis. All participants in the study underwent induction therapy and maintenance immunosuppression. Primary outcomes included infection (opportunistic, local, systemic) within 12 mo after transplantation. RESULTS: Twenty-five patients underwent desensitization and LDK transplantation. Graft survival in the DS and NDS groups of patients was 96% and 98%, respectively. The mean 3- and 12-mo serum creatinine concentrations in the DS and NDS groups were 1.1±0.2 mg/dL and 1.2±0.3 mg/dL and 0.95±0.4 mg/dL and 0.73±0.8 mg/dL (p=0.3 and p=0.01), respectively. Thirty-six percent of the patients in the DS group had one or more infections, vs. 28% of those in the NDS group (p=0.1). No difference was observed in the frequency of opportunistic or systemic infections in the two groups. Local infections were statistically significantly more frequent in the DS group (60% vs. 30%, respectively; p=0.02). CONCLUSION: Pre-operative desensitization in highly sensitized LDK recipients is followed by a similar incidence of opportunistic and systemic infections as in NDS patients. Local infections were significantly more frequent in the DS than in the NDS patients in the study. With careful monitoring of infectious complications, pre-transplant desensitization permits LDK transplantation into highly sensitized patients.

Pneumomediastinum after percutaneous endoscopic gastrostomy tube placement.

The incidence of esophageal perforation or confounding mechanisms of pneumomediastinum specifically introduced by the addition of percutaneous endoscopic gastrostomy (PEG) tube insertion to esophagogastroduodenoscopy have not been described, and pneumomediastinum in the absence of esophageal perforation after PEG has not been reported. Typically, pneumomediastinum is an ominous finding, although benign causes exist. We present two cases of post-PEG pneumomediastinum not correlated with esophageal perforation on follow-up imaging. When pneumomediastinum is detected after PEG, appropriate studies should be undertaken to confirm its cause and to determine treatment plans. Further investigation may be warranted to ascertain the true incidence, causes, and clinical significance of post-PEG pneumomediastinum.

Options for closure of the infected abdomen.

BACKGROUND: The infected abdomen poses substantial challenges to surgeons, and often, both temporary and definitive closure techniques are required. We reviewed the options available to close the abdominal wall defect encountered frequently during and after the management of complicated intra-abdominal infections. METHODS: A comprehensive review was performed of the techniques and literature on abdominal closure in the setting of intra-abdominal infection. RESULTS: Temporary abdominal closure options include the Wittmann Patch, Bogota bag, vacuum-assisted closure (VAC), the AbThera™ device, and synthetic or biologic mesh. Definitive reconstruction has been described with mesh, components separation, and autologous tissue transfer. CONCLUSION: Reconstructing the infected abdomen, both temporarily and definitively, can be accomplished with various techniques, each of which is associated with unique advantages and disadvantages. Appropriate judgment is required to optimize surgical outcomes in these complex cases.

Adhesions and meshes: synthetic versus bioprosthetic.

Adhesions are common after intra-abdominal surgery and are associated with significant morbidity, including bowel obstruction, pain, and infertility. Abdominal wall reconstruction carries the risk of adhesion formation, notably to synthetic or bioprosthetic mesh. This article reviews the pathophysiology of adhesion formation, adhesion grading, and adhesions to synthetic and biologic mesh in vitro and clinically. Bioprosthetic mesh in vitro appears to elicit fewer lower-grade adhesions than synthetic mesh. However, direct comparisons in humans of adhesions with synthetic versus bioprosthetic mesh are lacking. Future studies are warranted to determine whether there are significant differences in clinical outcomes, especially regarding secondary complications from adhesions.

A comparative analysis between laparoscopic and open ventral hernia repair at a tertiary care center.

Laparoscopic ventral hernia repair reportedly yields lower postoperative complications than open repair. We hypothesized that patients undergoing laparoscopic repair would have lower postoperative infectious outcomes. Also, certain preoperative patient characteristics and preoperative hernia characteristics are hypothesized to increase complication risk in both groups. All ventral hernia repairs performed at University of Virginia from January 2004 to January 2006 were reviewed. Primary outcomes included wound healing complications and hernia recurrence. Categorical data were analyzed with χ(2) and Fisher's exact tests. Continuous variables were evaluated with independent t tests and Mann-Whitney U tests. Multivariable logistic regression was performed. A total of 268 repairs (110 open, 158 laparoscopic) were evaluated. Patient and hernia characteristics were similar between groups, though the percents of wound contamination (5.4% vs 0.6%; P = 0.02) and simultaneous surgery (7.2% vs 0%; P = 0.001) were greater in the open procedures. Univariate analysis also revealed that open cases had a greater incidence of postoperative superficial surgical site infection (SSI) (30.0% vs 10.7%; P < 0.0001). Multivariable analysis revealed that both diabetes and open repair were associated with an increased risk of superficial SSI (P = 0.019; odds ratio = 3.512; 95% confidence interval = 1.229-10.037 and P = 0.001; odds ratio = 4.6; 95% confidence interval = 1.9-11.2, respectively). Laparoscopic ventral hernia repair yielded lower rates of postoperative superficial SSI than open surgery. Other preoperative patient characteristics and preoperative hernia characteristics, with the exception of diabetes, were not found to be associated with an increased risk of postoperative complications.

Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs.

BACKGROUND: Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than conventional open CS. STUDY DESIGN: All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes, including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates, were compared between patient groups based on the type of CS repair, either MICSIB or open. RESULTS: Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. Mean follow-ups were 15.2 ± 7.7 months and 20.7 ± 14.3 months, respectively. Mean fascial defect size was significantly larger in the MICSIB group (405.4 ± 193.6 cm(2) vs 273.8 ± 186.8 cm(2); p = 0.002). The incidences of skin dehiscence (11% vs 28%; p = 0.011), all wound-healing complications (14% vs 32%; p = 0.026), abdominal wall laxity/bulge (4% vs 14%; p = 0.056), and hernia recurrence (4% vs 8%; p = 0.3) were lower in the MICSIB group than in the open CS group. CONCLUSIONS: MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.

Postoperative outcomes and reliability of "sensation-sparing" sural nerve biopsy.

Sural nerve biopsy is a valuable tool for the diagnosis of neuropathic disorders. However, concerns of persisting pain and numbness resulting from traditional whole sural nerve biopsy have led to interfascicular dissection techniques with inconsistent benefits over whole nerve biopsy. In this study we describe a novel technique of atraumatic anterior fascicular sural nerve biopsy designed to preserve calcaneal sensation while maintaining diagnostic benefit, without requiring significant interfascicular dissection. A 10-year chart review was conducted to identify patients who underwent anterior fascicular sural nerve biopsy. Pathology reports were reviewed to confirm specimen adequacy, and clinical notes were reviewed to determine if a diagnosis was rendered. Retrospective questionnaires were conducted to evaluate perioperative and long-term sequelae and patient satisfaction. The proportion of patients with symptoms involving the heel versus the dorsolateral foot was evaluated with Fisher's exact test. Specimens from all 53 patients were acceptable and permitted a diagnosis. Twenty-two patients completed the retrospective survey with an average follow-up of 5 years (1.2-11.4 years). Eight patients (34%) experienced numbness of the dorsolateral foot, and 1 patient (4.5%) reported numbness of the lateral heel that lasted >6 months (P = 0.001). Persistent dorsolateral foot pain and cold sensitivity were reported by 5 patients (22.7%), but no patients reported lateral heel symptoms (P = 0.04). Symptoms were noted by patients most commonly while standing or walking, but they did not result in functional impairment in any case. Atraumatic anterior fascicular sural nerve biopsy predictably preserved essential lateral heel sensation in patients with neuropathic disorders while providing diagnostic utility.

Bilateral adrenalectomy for refractory Cushing disease: a safe and definitive therapy.

BACKGROUND: Refractory Cushing disease (CD) is associated with considerable morbidity and mortality. Bilateral adrenalectomy (BA) offers effective permanent treatment. Both open and laparoscopic approaches have been used, but longterm comparisons are few. STUDY DESIGN: We reviewed 40 consecutive BA for refractory CD from 1995 through 2007. Surgical results were evaluated. A Short Form-36 Quality-of-Life (QOL) survey was performed. RESULTS: Eighty-five percent (34 of 40) of patients were women, and median age was 41.9 years (range, 22.2 to 78.3 years). All had persistent CD after transsphenoidal operation (mean, 1.7; range, 1 to 3). Median followup was 5.0 years. Thirty-eight percent (15 of 40) of procedures were performed laparoscopically; 1 was converted to open. There were no operative or 30-day mortalities, and there was 1 90-day mortality. Morbidities occurred in 7 of 40 (18%) patients. Median length of stay was shorter in the laparoscopic group (4 versus 6 days; p < 0.001). All patients achieved clinical reversal of hypercortisolism, including the 5 (13%) with ectopic adrenal tissue. Elevated serum ACTH (> 200 ng/mL) was present during followup in 33% (13 of 40). A QOL survey demonstrated 86% of patients felt good to excellent compared with 1 year pre-BA. Chronic fatigue was present most or all of the time in 46%, and patients were below population norms on 7 of 8 Short Form-36 scales. No difference was evident in QOL between laparoscopic and open adrenalectomy. CONCLUSIONS: Our experience demonstrates excellent survival and clinical results, despite the inherent risk in patients with CD. There are persistent fatigue and QOL deficits that are not ameliorated by laparoscopic compared with open resection.