Endobronchial valves for emphysema and persistent air-leak: 10-year experience in an Asian country.

BACKGROUND: Endobronchial valve (EBV) therapy, a validated method for bronchoscopic lung volume reduction (BLVR) in severe emphysema, has been explored for persistent air-leak (PAL) management. However, its effectiveness and safety in the Asian population require further real-world evaluation. In this study, we assessed the outcomes of treatment with EBV within this demographic. METHODS: We conducted a retrospective analysis of medical records from 11 Korean centers. For the emphysema cohort, inclusion criteria were patients diagnosed with emphysema who underwent bronchoscopy intended for BLVR. We assessed these patients for clinical outcomes of chronic obstructive pulmonary disease. All patients with PAL who underwent treatment with EBV were included. We identified the underlying causes of PAL and evaluated clinical outcomes after the procedure. RESULTS: The severe emphysema cohort comprised 192 patients with an average age of 70.3 years, and 95.8% of them were men. Ultimately, 137 underwent treatment with EBV. Three months after the procedure, the BLVR group demonstrated a significant improvement in forced expiratory volume in 1 s (+160 mL vs. +30 mL; P = 0.009). Radiographic evidence of lung volume reduction 6 months after BLVR was significantly associated with improved survival (adjusted hazard ratio 0.020; 95% confidence interval 0.038-0.650; P = 0.010). Although pneumothorax was more common in the BLVR group (18.9% vs. 3.8%; P = 0.018), death was higher in the no-BLVR group (38.5% vs. 54.5%, P = 0.001), whereas other adverse events were comparable between the groups. Within the subset of 18 patients with PAL, the predominant causes of air-leak included spontaneous secondary pneumothorax (44.0%), parapneumonic effusion/empyema (22.2%), and post-lung resection surgery (16.7%). Following the treatment, the majority (77.8%) successfully had their chest tubes removed. Post-procedural complications were minimal, with two incidences of hemoptysis and one of empyema, all of which were effectively managed. CONCLUSIONS: Treatment with EBV provides substantial clinical benefits in the management of emphysema and PAL in the Asian population, suggesting a favorable outcome for this therapeutic approach.

Value of preoperative evaluation of FEV1 in patients with destroyed lung undergoing pneumonectomy - a 20-year real-world study.

BACKGROUND: Clinical guidelines recommend a preoperative forced expiratory volume in one second (FEV1) of > 2 L as an indication for left or right pneumonectomy. This study compares the safety and long-term prognosis of pneumonectomy for destroyed lung (DL) patients with FEV1 ≤ 2 L or > 2 L. METHODS: A total of 123 DL patients who underwent pneumonectomy between November 2002 and February 2023 at the Department of Thoracic Surgery, Beijing Chest Hospital were included. Patients were sorted into two groups: the FEV1 > 2 L group (n = 30) or the FEV1 ≤ 2 L group (n = 96). Clinical characteristics and rates of mortality, complications within 30 days after surgery, long-term mortality, occurrence of residual lung infection/tuberculosis (TB), bronchopleural fistula/empyema, readmission by last follow-up visit, and modified Medical Research Council (mMRC) dyspnea scores were compared between groups. RESULTS: A total of 96.7% (119/123) of patients were successfully discharged, with 75.6% (93/123) in the FEV1 ≤ 2 L group. As compared to the FEV1 > 2 L group, the FEV1 ≤ 2 L group exhibited significantly lower proportions of males, patients with smoking histories, patients with lung cavities as revealed by chest imaging findings, and patients with lower forced vital capacity as a percentage of predicted values (FVC%pred) (P values of 0.001, 0.027, and 0.023, 0.003, respectively). No significant intergroup differences were observed in rates of mortality within 30 days after surgery, incidence of postoperative complications, long-term mortality, occurrence of residual lung infection/TB, bronchopleural fistula/empyema, mMRC ≥ 1 at the last follow-up visit, and postoperative readmission (P > 0.05). CONCLUSIONS: As most DL patients planning to undergo left/right pneumonectomy have a preoperative FEV1 ≤ 2 L, the procedure is generally safe with favourable short- and long-term prognoses for these patients. Consequently, the results of this study suggest that DL patient preoperative FEV1 > 2 L should not be utilised as an exclusion criterion for pneumonectomy.

Pharyngo-cervicospinal fistula with destructive osteomyelitis after laryngopharyngectomy and radiotherapy, managed successfully with a vascularized fibula free flap.

Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously.

[Management of Postoperative Surgical Site Infection and Empyema After Thoracic Surgery].

Surgical site infections (SSI)[wound infection, empyema] after thoracic surgery can lead to severe complications. Targeted antibiotic treatment and drainage are the keys. For the treatment of postoperative empyema without bronchopleural fistula, chest tube thoracostomy and irrigation with normal saline is effective. For postoperative empyema with bronchopleural fistula, open window thoracotomy is a good treatment option. Since the condition of empyema is different in each patient, treatment should be individualized depending on the patient's condition.

[Postoperative Complications of Open Window Thoracostomy:Report of a Case].

While open window thoracostomy is used to treat empyema with a high rate of infection control, it is an invasive procedure that leads to a decline in the quality of life. An 80-year-old man who had undergone wedge resection for pulmonary nodules subsequently developed postoperative empyema and underwent open window thoracostomy. After thoracostomy, the patient developed several complications, including bleeding from the lung surface and air leakage. Window closure was planned at this time;however, the plan was scuttled due to his low nutritional status and pulmonary air leakage. After the patient's condition improved with persistent conservative treatment, window closure was performed, and he overcame his complications. Patients with postoperative empyema requiring thoracostomy are at a high risk of developing postoperative complications. Therefore, it is important to manage the patients' condition persistently so that they can receive window closure at an appropriate time.

[Acute Empyema During Thoracic Drainage in a Pneumothorax Patient with Atopic Dermatitis:Report of a Case].

A 33-year-old man with atopic dermatitis underwent thoracic drainage was initiated for the right spontaneous pneumothorax. On the third hospital day, he developed acute empyema with pleural fluid opacity and elevated inflammatory reaction on blood test. For prolonged air leakage and acute empyema, thoracoscopic bullectomy and thoracic lavage and curettage were performed on the 6th hospital day. Because the preoperative cultural test of pleural effusion showed meticillin-resistant Staphylococcus aureus( MRSA), he was treated with vancomycin and ampicillin/sulbactam, and discharged on the 11th hospital day( the 5th postoperative day). Although spontaneous pneumothorax is rarely associated with empyema, patients with atopic dermatitis are prone to infections caused by Staphylococcus aureus, and the relation between atopic dermatitis and empyema was suspected in this case. As percutaneous medical procedures pose a risk of deep bacterial infection, when medical procedures including thoracic drainage is performed for patients with dermatosis, it is important to keep the possibility of bacterial infection in mind, and to quickly shift to treatment by detecting early signs of infection.

Intracranial Empyemas in the COVID-19 Era: A New Phenomenon? A Paediatric Case Series and Review of the Literature.

INTRODUCTION: We present the largest series of paediatric intracranial empyemas occurring after COVID-19 infection to date, and discuss the potential implications of the pandemic on this neurosurgical pathology. METHODS: Patients admitted to our centre between January 2016 and December 2021 with a confirmed radiological diagnosis of intracranial empyema were retrospectively reviewed, excluding non-otorhinological source cases. Patients were grouped according to onset before or after onset of the COVID-19 pandemic and COVID-19 status. A literature review of all post-COVID-19 intracranial empyemas was performed. SPSS v27 was used for statistical analysis. RESULTS: Sixteen patients were diagnosed with intracranial empyema: n = 5 prior to 2020 and n = 11 after, resulting in an average annual incidence of 0.3% prior to onset of the pandemic and 1.2% thereafter. Of those diagnosed since the pandemic, 4 (25%) were confirmed to have COVID-19 on recent PCR test. Time from COVID-19 infection until empyema diagnosis ranged from 15 days to 8 weeks. Mean age for post-COVID-19 cases was 8.5 years (range: 7-10 years) compared to 11 years in non-COVID cases (range: 3-14 years). Streptococcus intermedius was grown in all cases of post-COVID-19 empyema, and 3 of 4 (75%) post-COVID-19 cases developed cerebral sinus thromboses, compared to 3 of 12 (25%) non-COVID-19 cases. All cases were discharged home with no residual deficit. CONCLUSION: Our post-COVID-19 intracranial empyema series demonstrates a greater proportion of cerebral sinus thromboses than non-COVID-19 cases, potentially reflecting the thrombogenic effects of COVID-19. Incidence of intracranial empyema at our centre has increased since the start of the pandemic, causes of which require further investigation and multicentre collaboration.

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study.

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8 months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.

Modified Clagett procedure for acute pleural empyema.

Pleural empyema often requires surgical intervention; however, surgical invasiveness should be minimized. We utilized the modified Claget procedure as an alternative to thoracoplasty for acute pleural empyema with a dead space. The procedure was performed as follows: first, 500 mg of kanamycin and 500,000 units of polymyxin sulfate dissolved in 10-100 ml saline was instilled intrapleurally via tube thoracostomy. The chest tube was clamped overnight and then removed. The modified Clagett procedure might be effective for acute pleural empyema with a dead space without pulmonary or bronchopleural fistula. We report our successful experience of performing modified Clagett procedure for pleural empyema with a dead space, through a detailed case presentation.

Repair of pectus excavatum in a patient with an Eloesser thoracostomy window: sequential extrapleural Nuss procedure and modified Ravitch procedure.

A 28-year-old man with a history of tuberculous empyema and pectus excavatum visited our hospital for progressive dyspnea and leg edema. The patient had undergone an Eloesser window operation for repetitive pleuro-cutaneous fistula due to chronic tuberculous empyema in the left thorax one year prior. Chest computed tomography demonstrated severe compression of the right ventricle and inferior vena cava and chronic empyema with the Eloesser window in the left thorax. Because conservative treatment had failed, the patient underwent a total extrapleural Nuss procedure, resulting in marked relief of compression and complete resolution of leg edema and congestive hepatopathy. However, he required ventilation support due to carbon dioxide retention. Therefore, the patient underwent a modified Ravitch procedure and was weaned off ventilation support. Herein, we represent the first report of a sequential extrapleural Nuss procedure and a modified Ravitch procedure in a patient with chronic tuberculous empyema with an Eloesser window.

Risk factors for posttraumatic empyema in diaphragmatic injuries.

BACKGROUND: Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center. METHODS: This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors. RESULTS: We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22-35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18-44) and 17 (10-27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77-23. 43), and visible contamination (OR 5.13, 95% IC 1.26-20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema. CONCLUSION: The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

Minimally Invasive Surgical Treatment of Hepatic Hydrothorax Complicated by Empyema: A Case Report.

Hepatic hydrothorax complicated by empyema is difficult to manage. A 53-year-old man with liver cirrhosis was admitted for refractory right pleural effusion. He had a pleural catheter inserted 2 months prior. Pleural fluid appeared as exudate, and bacteria were identified in the pleural fluid culture. After confirming full ipsilateral lung expansion, minimally invasive surgery was performed. A diaphragmatic defect found by creating a pneumoperitoneum was closed, followed by talc pleurodesis. Postoperatively, overnight positive-pressure ventilation and 5-day peritoneal drainage were performed; chest tube drainage dramatically reduced over this time. At the 10-month follow-up, no recurrence of pleural effusion or signs of infection were observed.

Spinal epidural empyema concurrent with sequestrum in a cat: a case report.

A 5-month-old intact female mixed cat presented with repetitive paraplegia and drainage of pus from the back despite continuous antibiotic medication. Neurologic examination was consistent with below T3-L3 myelopathy. Computed tomography and magnetic resonance imaging revealed a contrast-enhanced mass in the L1-3 spinal canal, and bone fragments in the T13 and L1 spinal canal. Spinal epidural empyema was suspected, and hemilaminectomy was performed for T12-L2 on the right side and T11-12 on the left side. Bone fragments were diagnosed as sequestrum infected with Bacteroides sp. The cat recovered enough to ambulate next day. One month after surgery, there was no deficit in neurological function. This is the first report of spinal epidural empyema concurrent with sequestrum in a cat.

[Effective Treatment for Empyema with Fistula by Negative Pressure Wound Therapy:Report of a Case].

A 54-year-old male with alcoholic cirrhosis and diabetes mellitus was referred to our hospital for the treatment of right pleural empyema with fistula. Despite performing a simple suture closure of the pulmonary fistula, air leakage occurred one week after surgery. Hence, we covered the fistula with a pediculed muscle flap associated with an open window thoracostomy. After 32 days of gauze drainage, negative pressure wound therapy( NPWT) was introduced for reducing the residual pleural space. A chest computed tomography( CT) scan showed almost the full expansion of the lung after undergoing 98 days of NPWT. The patient was discharged from the hospital four months after thoracostomy.

Lung Resection in Children with Necrotizing Pneumonia: Outcome and Follow-up.

INTRODUCTION: The number of patients with necrotizing pneumonia has increased in recent years. The aim of this study is to review the incidence, management, and outcome of pediatric necrotizing pneumonia requiring surgical therapy and to prove that lung resection results in favorable development of patients. We hypothesize that overall lung function in children after lung resection does not differ from that of the healthy population. MATERIALS AND METHODS: A retrospective tertiary referral center study with a prospective follow-up spirometric study of patients with necrotizing pneumonia managed between January 2010 and December 2019 was performed. RESULTS: The study cohort consisted of 1,295 patients admitted to the pediatric department for community-acquired pneumonia; 47 patients developed necrotizing pneumonia, 36 of whom underwent parenchymal lung resection. A 5-year rise in the occurrence of necrotizing pneumonia requiring resection was 77%, with a significant increase in the last 3 years (p < 0.05). The median age at the time of surgery was 32.5 (interquartile range [IQR]: 32.25) months. Streptococcus pneumoniae was the most prevalent pathogen (83%), although 53.3% of these patients were vaccinated against the agent. In 67% of patients, preresection procedures were performed: drainage of pneumothorax (17%), drainage of empyema (46%), drainage of empyema with use of alteplase (25%), and thoracoscopic decortication (12%). Surgical procedures included lobectomy (72.2%), wedge resection (13.9%), bilobectomy (8.3%), and pneumonectomy (5.6%). The postoperative complication was bronchopleural fistula in three patients. There were two (5.5%) postoperative deaths due to multiple organ failure. The follow-up spirometry was performed 43.3 (median, IQR 23.8-66.7) months after surgical intervention. Normal lung function was detected in 35 (64.8%) patients, restrictive pattern in 6 (11.1%) patients, obstructive pattern in 11 (20.4%) patients, and combined in 2 (3.7%) patients. CONCLUSION: The number of patients with necrotizing pneumonia requiring resection has increased significantly in the last 3 years (p < 0.05). Aggressive surgical treatment results in significant clinical improvement in most cases and favorable lung function outcome. Long-term follow-up showed normal spirometry in 64.8% of cases.

Assessment of Intraoperative Microbiological Culture in Patients with Empyema: Comparison with Preoperative Microbiological Culture.

PURPOSE: Assessing microbiological culture results is essential in the diagnosis of empyema and appropriate antibiotic selection; however, the guidelines for the management of empyema do not mention assessing microbiological culture intraoperatively. Therefore, we tested the hypothesis that intraoperative microbiological culture may improve the management of empyema. METHODS: We performed a retrospective analysis of 47 patients who underwent surgery for stage II/III empyema from January 2011 to May 2019. We compared the positivity of microbiological culture assessed preoperatively at empyema diagnosis versus intraoperatively. We further investigated the clinical characteristics and postoperative outcomes of patients whose intraoperative microbiological culture results were positive. RESULTS: The positive rates of preoperative and intraoperative microbiological cultures were 27.7% (13/47) and 36.2% (17/47), respectively. Among 34 patients who were culture-negative preoperatively, eight patients (23.5%) were culture-positive intraoperatively. Intraoperative positive culture was significantly associated with a shorter duration of preoperative antibiotic treatment (p = 0.002). There was no significant difference between intraoperative culture-positive and -negative results regarding postoperative complications. CONCLUSIONS: Intraoperative microbiological culture may help detect bacteria in patients whose microbiological culture results were negative at empyema diagnosis. Assessing microbiological culture should be recommended intraoperatively as well as preoperatively, for the appropriate management of empyema.

[Descending Necrotizing Mediastinitis with Empyema Necessitated Two Performances of Surgical Drainage for Successful Treatment:Report of a Case].

The case was a 57-year-old woman. She visited a local doctor with a chief complaint of sore throat. A retropharyngeal abscess was suspected, and she was referred to our otolaryngology. Contrast-enhanced computed tomography(CT) scan revealed continuous fluid retention from the retropharyngeal space to the neck and the superior and posterior mediastinum with bilateral pleural effusion. The patient was diagnosed with descending necrotizing mediastinitis with empyema, and on the same day cervical drainage, thoracoscopic bilateral mediastinal drainage, empyema curettage and tracheostomy was performed. Postoperative contrast-enhanced CT scan revealed a widespread residual mediastinal abscess and thoracoscopic bilateral mediastinal drainage was performed again on the 11th postoperative day. After reoperation, the inflammation gradually subsided and she was discharged 47 days after reoperation.

Immediate replacement of bone flap after craniotomy for empyema in children.

PURPOSE: Optimal management of the bone flap after craniotomy for intracranial infection has not been well defined in the pediatric population. This study reviewed the outcomes of a single Canadian center where immediate replacement of the bone flap was standard practice. METHODS: This is a retrospective study of all patients who underwent craniotomies for evacuation of epidural or subdural empyema at a single center from 1982 to 2018. Patients were identified using the prospective surgical database maintained by the Division of Pediatric Neurosurgery at BC Children's Hospital. Primary outcome was treatment failure, defined as reoperation at the site of initial surgery for removal of an infected bone flap or repeat drainage of empyema under the replaced bone flap. Secondary outcome was any reoperation for recurrent infection at any site. RESULTS: Twenty-four patients met the inclusion criteria with a minimum of 3-month follow-up from the index intervention. Treatment failure occurred in four patients (17%), all of whom required repeat surgery for further drainage of pus underlying the bone flap. Mean time to repeat surgery was 13 days. Any reoperation for recurrent infection at any site occurred in three patients. Seven out of 24 patients required a second surgery to evacuate empyema (29.2%). Age, sex, epidural or subdural location, osteomyelitis, and bone flap wash were not associated with the primary outcome of treatment failure. CONCLUSION: Immediate replacement of the bone flap in the surgical management of pediatric subdural or epidural empyema is reasonable. Replacing the flap at the time of first surgery avoids the morbidity and costs of a subsequent reconstructive operation.

Uncommon Presentation of Severe Empyema of the Gallbladder: Case Report and Literature Review.

BACKGROUND Empyema of the gallbladder is a complication of cholecystitis that can develop into sepsis if not treated promptly. Signs and symptoms of gallstone disease are nausea/vomiting, right upper quadrant tenderness, and a history of gallstone disease. With persistence of the obstruction, inflammation and bacterial overgrowth within the gallbladder lumen and tissue may lead to eventual venous congestion, pressure necrosis and even empyema of the gallbladder. CASE REPORT A 60-year old male presented with complaints of mild mid-epigastric pain radiating to the back. He denied previous similar history. CT and ultrasound of the abdomen revealed acute cholecystitis. During surgery, it was clear that the imaging did not accurately represent the severity of the infection and he was diagnosed with gallbladder empyema. Surgery was difficult but was successfully finished. The patient's symptoms and laboratory results normalized by post-operative day 3 and he was discharged. He had no further complications during 2-week follow up. CONCLUSIONS Physicians should keep the abnormal presentations of gallbladder empyema in mind and prepare themselves for a presentation different from imaging during surgery. Several prognostic factors including gallbladder wall thickness, gender, white cell count and diabetes mellitus have been associated with severe complicated cholecystitis and empyema of the gallbladder.

Muscle Flap Transposition for the Management of Intrathoracic Fistulas.

BACKGROUND: Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas. METHODS: A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed. RESULTS: A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment. CONCLUSIONS: Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.