Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review.

OBJECTIVE: Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes. METHOD: A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'. RESULTS: A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery. CONCLUSION: The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

Complete Cervicouterine Dissociation After Repeat Cesarean Sections: A Case Report.

INTRODUCTION: The number of cesarean deliveries (CDs) has extremely increased in the last decades. Although it is a common and relatively safe surgical procedure, there are several potential complications. To the best of our knowledge, complete cervicouterine dissociation after several CDs has not been reported before in the medical literature. CASE REPORT: A 28-year-old woman with a history of 6 CDs presented with abdominal pain and vaginal bleeding. The patient's most recent CD happened three weeks before the current presentation. Transabdominal ultrasonography examination and magnetic resonance imaging revealed the absence of continuity with the uterine cervix and corpus with associated pelvic hematoma. Laparotomy findings confirmed the imaging findings, and the displaced uterine corpus was removed with the evacuation of the associating pelvic hematoma. CONCLUSION: Uterine dehiscence and rupture are among the relatively common complications of CD. Uterine rupture and dehiscence are focal disorders, and complete cervicouterine dissociation has not been seen before. Multiple CDs are among the risk factors for complete cervicouterine dissociation, and abnormal uterine bleeding is the most common symptom. Imaging findings allow a quick and definitive diagnosis, and surgical intervention may be planned accordingly based on the imaging findings.

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men.

BACKGROUND: The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique. OBJECTIVES: To present and discuss the Transgender Standard of Care and our personal experience. METHODS: Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed. RESULTS: Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis. CONCLUSIONS: A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.

Conceptual Paper: Abdominoplasty and Liposuction in Systemic Sclerosis.

BACKGROUND: Surgical interventions in patients with systemic sclerosis (SSc), in particular plastic procedures, might cause undesired consequences. Notably, liposuction seems to possess greater risk as adipose tissue has been shown to play an important role in treating wounds and ulcers in patients with SSc. While anticentromere antibodies were found to be correlated with vasculopathy in SSc, patients with SSc and anticentromere antibodies might be more vulnerable to surgical wound complications following liposuction. A 46-year-old female patient, who had been diagnosed with SSc at the age of 31 years, had antinuclear as well as anticentromere antibodies. She underwent abdominoplasty with liposuction and developed severe skin necrosis of the abdomen following the procedure and at the site of liposuction. The correlation with anticentromere and the role of liposuction in skin necrosis in SSc are presented.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

PURPOSE: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients. METHODS: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks. RESULTS: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006). CONCLUSION: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Long-Term Metabolic Assessment of Cryopreserved Sternal Allograft: A Case Series.

BACKGROUND: Sternal resection and reconstruction with cryopreserved allografts provides a safe alternative to traditional methods of anterior chest wall reconstruction. Despite favorable results, successful integration of the graft sternum has never been demonstrated owing to the invasiveness of bone biopsy. We describe our experience of using 18F-sodium fluoride positron emission tomography/computed tomography scans as a noninvasive method of evaluating graft integration. METHODS: Seven patients underwent surgery and radiologic follow-up. Surgical indications were sternal metastases (n = 5) and sternal dehiscence (n = 2). Sternal reconstruction was performed using a cryopreserved cadaveric sternal allograft fixed in place with titanium plates and screws. Follow-up with 18F-sodium fluoride positron emission tomography/computed tomography scans was performed at 1 and 2 years after surgery. RESULTS: Three patients underwent total sternectomy. Two underwent partial upper sternectomy involving the manubrium, clavicle (1 patient only), and upper sternal body; and 2 had partial sternectomy of the sternal body and xiphoid process. Focal tracer accumulation occurred at the junctions between native bone and graft bone. The median maximum standardized uptake value at 1 year was 16.8 (range, 11.2 to 37.9; interquartile range, 13.6 to 19.4), and at 2 years it was 10.8 (range, 6.1 to 30.2; interquartile range, 8.9 to 15.1). In 6 cases accumulation was lower at the second scan, whereas in 1 patient the accumulation was higher at the second scan. CONCLUSIONS: Sternal reconstruction with cryopreserved allograft is safe and well tolerated. The 18F-sodium fluoride positron emission tomography/computed tomography scans are a useful and promising noninvasive method of demonstrating the metabolic activity of the graft and its incorporation into the host skeleton during follow-up.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION: colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications. OBJECTIVES: to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection. METHODS: a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed. RESULTS: after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm. CONCLUSION: endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection

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Lung transplant graft salvage using aortic homograft for bronchial dehiscence.

The use of aortic homograft in infective pathology is well described. Its use in the repair of post-transplant airway complications has been seldom reported. Herein, we report our experience with the successful use of aortic homograft in the management of post-transplant large airway complications in two patients.

Management and outcomes of anastomotic leakage after McKeown esophagectomy: A retrospective analysis of 749 consecutive patients with esophageal cancer.

PURPOSE: Cervical anastomotic leakages may manifest either cervically or intrathoracically. We retrospectively investigated the management strategies and clinical outcomes of patients who developed anastomotic leakages after McKeown esophagectomy and the spectrum of its clinical manifestations. METHODS: Patients with esophageal cancer who underwent McKeown esophagectomy with cervical anastomosis (n = 749) between January 2015 and December 2018 were included. RESULTS: Cervical anastomosis leakage was diagnosed in 53/749 (7.3%) patients. The leakage was primarily limited to cervical region in 16 (30.2%) patients, whereas intrathoracic spread was present in 37 (69.8%) patients. Intrathoracic manifestations were more commonly accompanied by fever (75.7% vs. 18.8%, P < 0.001) and leukocytosis than cervical manifestations (81.1% vs. 25.0%, P < 0.001). Compared to patients with cervical manifestations, those with intrathoracic manifestations had a longer duration of hospital stay (median; 58 vs. 40 days, P = 0.006) and higher incidence of tracheal fistula (21.6% vs. 0%, P = 0.045). Drainage through the neck wound was effective in all patients with cervical manifestations. Patients with intrathoracic manifestations who had transnasal inner drain or mediastinal drain placed intraoperatively achieved satisfactory drainage (27/37, 73.0%). Subsequent healing of anastomotic leaks was observed in 50 (94.3%) patients. There was no mortality associated with complications related to anastomotic leakage. CONCLUSION: Intrathoracic manifestations of cervical anastomotic leakage are common in patients after McKeown esophagectomy. However, they are diagnosed later and are associated with more severe clinical consequences than cervical manifestations. Thus, a high index of suspicion and an early intervention policy for such anastomotic leaks should be adopted and strengthened to decrease the incidence of adverse clinical outcomes.

Laparoscopic assessment and transvaginal reparation of post-coital vaginal cuff dehiscence with bowel evisceration: a case report.

Vaginal cuff dehiscence (VCD) is a rare postoperative complication of total hysterectomy. Presenting symptom is acute pelvic or abdominal pain accompanied by nausea and vomiting. Immediate recognition and surgical repair are crucial for successful management. A 40-year-old para 1+0 presented with complaints of pelvic pain associated with sexual activity, three months after a total laparoscopic hysterectomy. Speculum examination revealed the presence of bowel into the vagina. Diagnostic laparoscopic assessment combined with VCD repair through the transvaginal route. The occurrence of VCD after laparoscopic hysterectomy has been linked to overuse of electrocautery, prolonged inflammatory response and suturing methods. Laparoscopic, abdominal and vaginal approaches are the routes for repairing VCD. However, it depends on the clinical presentation and surgeon expertise. Careful history, and physical examination are vital factors in guiding clinicians to diagnose and treat VCD. Nevertheless, an ideal modality remains variable to each case.

Telemedicine and the COVID-19 Pandemic: Are We Ready to Go Live?

Telemedicine use in the field of wound care had been increasing in popularity when the novel coronavirus 2019 paralyzed the globe in early 2020. To combat the constraints of healthcare delivery during this time, the use of telemedicine has been further expanded. Although many limitations of telemedicine are still being untangled, the benefits of virtual care are being realized in both inpatient and outpatient settings. In this article, the advantages and disadvantages of telemedicine are discussed through two case examples that highlight the promise of implementation during and beyond the pandemic.

Two-Year Delayed Healing of an Endovascular Access Site Related to an Unusual Etiology.

In this case report, the authors describe a patient who underwent an endovascular abdominal aortic aneurysm repair complicated by more than a 2-year delay in healing of the left inguinal fold access site. Providers initially suspected a chronic infection or foreign body reaction, but eventually the patient was diagnosed with superficial granulomatous pyoderma. Once the correct etiology was determined and appropriate treatment begun, the access site healed within 3 weeks.

Sternal Wound Complications: Objective Reclassification and Surgical Reconsideration.

Background: Sternal wound complications pose a tremendous challenge post-cardiac surgery. There's no consensus or clear guidelines to deal with them. We propose that simple and more objective classification helps to organize the range of sternal wound complications and suggest a relevant treatment strategy. Methods: One-hundred-sixteen cases of sternal wound complications retrospectively were reviewed out of 2,391 adult patients, who underwent full sternotomy during cardiac surgery from 2006 to 2018. Eighty-six cases conservatively were managed and the remaining 30 cases required surgical intervention. More objective classification was proposed and less invasive fasciocutaneous flap was considered for nearly all reconstructive procedures. Results: The incidence of sternal wound complications was 4.8%. Conservative management was adopted for 86 cases, mean duration was 11.19 ± 9.8 days. Surgical management was performed in 30 patients (25.86%); 28 (93.3%) of whom recovered with good outcomes with less invasive fasciocutaneous flap done for 13 cases. Two cases had recurrence; one conservatively was managed and other was reoperated and healed well. The most common organisms in recurrent infections were N. coagulase (29.8%), Klebsiella (12.5%), pseudomonas (10.5%), and MRSA (10.5%). We had 4 mortalities. None of the mortalities were related to sternal wound complications; one was related to the cardiac surgery. Conclusions: Sternal wound complications are grave events. Objective classification and proper management selection will gain better outcomes.

Anastomotic dehiscence following retroflexion in surveillance colonoscopy: a case report.

Anastomotic dehiscence following colonoscopy for routine surveillance after anterior resection for colorectal cancer is unreported in the English literature. It is a potentially fatal complication requiring awareness, quick recognition and management. We present the case of a 45-year-old woman who presented 12 hours after a routine follow-up colonoscopy with peritonitis due to anastomotic rupture diagnosed on computed tomography. The patient was taken to theatre for emergency laparotomy and formation of an end colostomy. Her postoperative recovery and follow-up were optimal.

Risk of Bronchial Dehiscence in Lung Transplant Recipients With Carbapenemase-producing Klebsiella.

BACKGROUND: Klebsiella pneumoniae is commonly isolated after lung transplantation. This study observed an increase in bronchial complications after an outbreak of Klebsiella pneumoniae carbapenemase-producing Klebsiella (KPC-KP). METHODS: The study enrolled 173 patients who had undergone bilateral lung transplantation between 2012 and 2018 to examine the association between bronchial complications after lung transplantation and KPC-KP. The KPC-KP group was defined as patients whose isolates from sputum or bronchoalveolar lavage fluid were positive for KPC-KP. The presence of bronchial complications was defined as a positive finding on bronchoscopy in accordance with the criteria of the International Society for Heart and Lung Transplantation. Risk factors for bronchial complications were analyzed. RESULTS: KPC-KP was identified in 29 patients (16.8%), and bronchial dehiscence was observed in 13 patients (7.5%). Smoking (odds ratio [OR], 5.690; 95% confidence interval [CI], 1.106- to 9.260; P = .037), the presence of KPC-KP (OR, 5.360; 95% CI, 1.380 to 20.810; P = .015), and bronchial necrosis (OR, 7.009; 95% CI, 1.811 to 27.124; P = .005) were associated with bronchial dehiscence in a multivariate logistic regression model. CONCLUSIONS: The presence of KPC-KP in lung-transplant recipients significantly increased the risk of bronchial dehiscence, independent of bronchial necrosis. Thus, patients with KPC-KP require greater surveillance and follow-up bronchoscopy, irrespective of the presence or absence of bronchial necrosis or the overall patient condition.