Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma.

BACKGROUND: Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. METHODS: The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). RESULTS: From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. CONCLUSION: The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.

A new technique for emergency cerclage: Guard suture method.

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes. Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns. Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively). Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

A Comparative Study Between Different Surgical Techniques For Left Atrial Exclusion in Patients Undergoing Concomitant Cardiac Surgery.

OBJECTIVES: To find out the most successful surgical technique to obliterate left atrial appendage (LAA) in atrial fibrillation (AF) patients who had undergone concomitant cardiac surgery. BACKGROUND: About 10%-65% of patients develop AF following cardiac surgery [Rho 2009; Mathew 2004; Maesen 2012]. Cerebral cardio-embolic stroke remains the most serious complication in AF patients. LAA is the main anatomical source for thromboembolic events. The use of oral anticoagulants (OAG) is considered to be an effective method for reduction of thromboembolic complications [Johnson 2000]. The use of oral anticoagulants is faced by two important facts which are the therapy duration is still unknown [Kirchhof 2017] and importantly that between 30-50% of patients are not candidates for oral anticoagulants due to the high bleeding risk or other contraindications [Johnson 2000; Kirchhof 2017; Kirchhof 2014]. In such patients, LAA obliteration would be an optimal alternative technique as it will reduce the stroke risk by 50% [Go 2014]. Several surgical techniques with variable degrees of success rates have been used.  It still is unclear which surgical technique is optimum to achieve a successful obliteration of the LAA and a considerable reduction of the postoperative stroke events in AF patients. PATIENTS AND METHODS: A total of 100 patients have been subjected to surgical LAA exclusion from April 2017 to April 2019 in two different centers. All patients had postoperative transesophageal echo (TEE) examination to confirm the success of LAA occlusion. All patients included in our study suffered from AF at the time of surgery or in past history, which was confirmed by ECG examination in their previous medical files. A variety of surgical techniques to close the LAA have been utilized, including surgical excision by means of scissors, patch exclusion by means of an endocardial patch, suture exclusion and finally stapler exclusion. TEE examination 16 months postoperatively divided our patients into four groups as follows: successful LAA occlusion, Patent LAA, excluded LAA with persistent flow into LAA, and remnant LAA with a stump connection with LAA more than 1 cm. RESULTS: Out of 100 patients, 30 patients (30%) underwent surgical LAA excision, 24 patients (24%) underwent surgical epicardial suture ligation, eight patients (8%) underwent patch exclusion using autologous pericardial patch, 33 patients (33%) underwent LAA internal orifice purse string suture obliteration, and five patients (5%) underwent stapler exclusion. Forty-two patients out of 100 (42%) showed successful LAA closure. The successful LAA occlusion occurred mostly in LAA excision patients 87%, 24% in LAA internal orifice purse string suture obliteration patients, 21% in epicardial suture ligation patients, and 37.5% in patch exclusion patients. The stapler exclusion was very disappointing as we did not record a single case out of the five patients who showed a successful LAA occlusion. Stroke events were recorded in all surgical techniques except the LAA excision technique. The stroke rate after two years follow up was zero in the surgical excision group, 49% in the suture exclusion group, 20% in the patch exclusion group, and 40% in stapler exclusion group. CONCLUSION: Surgical LAA excision is the most successful technique for LAA occlusion and represents a promising technique for the reduction of thromboembolic events in AF patients who undergo a concomitant cardiac surgery.

Online survey on uterotomy closure techniques in caesarean section.

OBJECTIVES: Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. METHODS: The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. RESULTS: The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. CONCLUSIONS: There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications.

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Effective, simple and fast procedure for laparoscopic port-sites wounds closure.

The closure of port-sites wounds, as the ultimate step of surgical laparoscopic procedures, can be allowed by threads, staples, surgical glue or adhesive sutures. We describe a simple and easy skin suturing technique which saves time and provides significant surgical ergonomics.

Influence of instructor-to-student ratio for teaching suturing skills with models.

OBJECTIVE: To evaluate the influence of instructor to student ratio on the effectiveness and efficiency of teaching suturing skills to veterinary students. STUDY DESIGN: Prospective randomized study. SAMPLE POPULATION: Second-year veterinary students (N = 121). METHODS: Students were randomly divided into three groups to participate in four 2-hour skills laboratory sessions in which suturing of the subcutaneous tissue was taught by using a simple continuous pattern, suturing of the skin was taught by using continuous patterns, suturing of the skin was taught by using interrupted patterns, and suturing of hollow organs was taught by using inverting patterns. For each laboratory, the groups were taught by using instructor-to-student ratios of 1:6, 1:8, and 1:10 on a rotating basis. Students were surveyed at the end of each laboratory, and underwent individual performance assessments at the end of each laboratory session and again at the end of the semester in an objective structured clinical examination (OSCE). RESULTS: For each of the four in-laboratory assessments and the OSCE, no difference in performance was detected between groups. When they were surveyed, students in all groups reported that there was an adequate number of instructors in the laboratory and that they received help in a timely fashion when help was requested (median for all groups = agree). CONCLUSION: For students with prior surgical skills education and with the use of prelaboratory instructional videos, teaching at the 1:10 instructor-to-student ratio was efficient and effective. CLINICAL SIGNIFICANCE: Good educational outcomes may be reached with a 1:10 instructor-to-student ratio or, potentially, fewer instructors, depending on the educational aids present in the laboratory and students' prior level of experience.

Randomized controlled trial comparing the effectiveness of mass and spaced learning in microsurgical procedures using computer aided assessment.

Spaced-learning refers to teaching spread over time, compared to mass-learning where the same duration of teaching is completed in one session. Our hypothesis is that spaced-learning is better than mass-learning in retaining microsurgical suturing skills. Medical students were randomized into mass-learning (single 8-h session) and spaced-learning (2-h weekly sessions over 4 weeks) groups. They were taught to place 9 sutures in a 4 mm-wide elastic strip. The primary outcome was precision of suture placement during a test conducted 1 month after completion of sessions. Secondary outcomes were time taken, cumulative performance, and participant satisfaction. 42 students (24 in the mass-learning group; 18 in spaced-learning group) participated. 3 students in the spaced-learning group were later excluded as they did not complete all sessions. Both groups had comparable baseline suturing skills but at 1 month after completion of teaching, the total score for suture placement were higher in spaced-learning group (27.63 vs 31.60,p = 0.04). There was no statistical difference for duration and satisfaction in either group. Both groups showed an improvement in technical performance over the sessions, but this did not differ between both groups. Microsurgical courses are often conducted in mass-learning format so spaced learning offers an alternative that enhances retention of complex surgical skills.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis.

INTRODUCTION: Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery. MATERIAL AND METHODS: MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859. RESULTS: The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results. CONCLUSIONS: Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

Patients who have undergone rotator cuff repair experience around 75% functional recovery at 6 months after surgery.

PURPOSE: The purposes of this study were to (1) evaluate changes in recovery patterns [i.e., clinical outcomes, range of motion (ROM)] in the first 12 months following surgery, (2) identify potential prognostic factors of early clinical outcomes after rotator cuff repair (RCR). METHODS: The study cohort included 344 consecutive patients treated with RCR. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariate linear regression analyses for various parameters including demographics, pre- and perioperative variables were used to predict shoulder function at 12-month follow-up, as measured by clinical outcomes and ROM. RESULTS: Significant improvement in all clinical scores and ROM were noted during serial follow-ups after RCR (all p < 0.001). Multivariate analysis revealed that female sex, older age, more anchors, diabetes mellitus, and preoperative stiffness were independently associated with worse shoulder function 3 months after RCR. Including the 3 months factors, heavy labor, use of the suture-bridge technique, and large tears were also independently associated with worse outcomes 6 months after surgery. Heavy labor, suture-bridge technique, diabetes mellitus, and preoperative stiffness were associated with significantly worse functional outcomes at 12 months after surgery (all p < 0.05). CONCLUSION: Functional recovery based on clinical outcomes (i.e., UCLA, ASES scores) showed approximately 60% of ultimate recovery at 3 months and approximately 75% recovery at 6 months after RCR. Female sex, diabetes mellitus, preoperative stiffness, a larger number of anchors, suture bridge technique, heavy labor, old age and, larger tears were prognostic factors of poor clinical results or ROM in the short-term follow-up intervals. Knowledge of these prognostic factors may lead to improved insight for physicians to predict the pattern of the recovery and patient expectations accordingly. LEVEL OF EVIDENCE: III, A cohort study.

Comparison of fertility outcomes after laparoscopic myomectomy for barbed versus nonbarbed sutures.

OBJECTIVE: To assess the impact on women's reproductive outcomes of barbed sutures to repair uterine breaches during laparoscopic myomectomy compared with traditional smooth sutures. DESIGN: Retrospective, monocentric cohort study, with information on subsequent pregnancies prospectively acquired for some women. SETTING: Tertiary-level academic referral center. PATIENT(S): Women older than 18 years who had undergone a laparoscopic myomectomy and had sought pregnancy afterward, divided into two groups based on type of suture used to repair the uterine wall: group A (nonbarbed) and group B (barbed). INTERVENTION(S): Laparoscopic removal of FIGO types 3, 4, 5, and 6 uterine leiomyomas by use of either only barbed sutures or only traditional smooth sutures to reconstruct the uterine defect. MAIN OUTCOME MEASURE(S): Pregnancy achievement rates, delivery modes, main pregnancy complications, perioperative complications for both kinds of suture, and the trend of the use of barbed sutures over time at our center. RESULT(S): Of 164 patients included, 83 were in group A and 81 in group B. Ninety-one patients (55.5%) experienced at least one postoperative pregnancy, with no differences between the groups (group A 60.5%; group B 50.6%). Of the 103 recorded postoperative pregnancies, 70 (68%) resulted in live births, 29 (28.1%) in first-trimester miscarriages, and 4 (3.9%) were ongoing. CONCLUSION(S): Barbed sutures have a similar impact on reproductive outcomes as smooth conventional threads, both in terms of pregnancy and obstetric complication rates, after laparoscopic myomectomy.

Obstetric vesico-vaginal fistulas: Midvaginal and juxtacervical fistula repair outcomes in the Democratic Republic of Congo.

OBJECTIVE: This study aims to establish the postoperative success rates of midvaginal versus juxtacervical obstetric vesicovaginal fistula (VVF) repairs. In addition, we aim to quantify the impact of patient sociodemographic variables, fistula classification, and surgical repair techniques associated with postoperative outcomes. METHODS: A retrospective cohort study was conducted involving 420 women who had undergone a primary obstetric VVF repair. All data were collected from the Panzi Hospital, Democratic Republic of Congo between 2015 and 2017. Patient notes were analyzed to determine sociodemographic variables, symptoms, fistula classification, surgical repair techniques, and postoperative follow up. Binary logistic regression presented as χ2 for trend was used to establish P values. RESULTS: Overall, 95.6% and 96.2% of midvaginal and juxtacervical VVF, respectively, underwent a successful repair. The principal prognostic factor associated with a statistically significant likelihood of a successful repair was the degree of fibrosis noted preoperatively (P =0.004, 95% confidence interval [CI] 2.38-94.61). Furthermore, VVF were more likely to have a successful repair if they were closed in two layers (P = 0.004, 95% CI 1.86-25.81) and sutured vertically (P = 0.005, 95% CI 1.16-2.52). CONCLUSION: Overall, high postoperative success rates of obstetric VVF repair can be expected among well-trained surgeons but a complex interplay of factors means that the ability to preoperatively foreshadow individual outcomes remains difficult.

Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. DATA SOURCES: PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. METHODS OF STUDY SELECTION: The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. TABULATION, INTEGRATION, AND RESULTS: A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88). CONCLUSION: There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.

Scalp wound closures in mohs micrographic surgery: a survey of staples vs sutures.

Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.

Incidence of Surgical Site Infections in Second Intention Healing After Dermatologic Surgery.

BACKGROUND: There are few studies analyzing the surgical site infection (SSI) rate of second intention wounds after dermatologic surgery, and the results are inconclusive. Yet, the current dogma in dermatologic surgery is that wounds healed by second intention have lower infection rates. OBJECTIVE: To determine the rate of SSI and associated pathogenic organisms of second intention wounds compared with sutured wounds after skin cancer extirpation. MATERIALS AND METHODS: This was a retrospective cohort study of patients who had either Mohs micrographic surgery or wide local excision (WLE) for skin cancer extirpation between 2012 and 2016. Wounds were stratified by closure type, location, and associated organisms. Infection was diagnosed by a positive wound culture. RESULTS: The overall infection rate was 3.9%. The infection rate for sutured and second intention wounds was 3.2% and 6.8%, respectively. Second intention wounds were associated with a significantly higher risk of infection compared with sutured wounds (odds ratio = 2.22, 95% confidence interval 1.63-2.99). The lower extremity (LE) had the highest overall infection rate (10.5%). The face had the lowest overall infection rate (2.5%). CONCLUSION: Mohs micrographic surgery or WLE performed on the LE or lesions allowed to heal by second intention has an increased risk of SSI.

Evaluation of the Possible Risk Factors on Bronchial Closure Techniques for Bronchopleural Fistula after Lung Resection.

BACKGROUND: Broncho-pleural fistula (BPF) can occur after pulmonary resections as a complication with high morbidity and mortality rates. AIM: In the present study, we analyzed the relation between the possible risk factors and the two major bronchial closure techniques for BPF after lung resections, and the management methods of BPF. MATERIALS AND METHODS: A total of 26 cases detected and managed with BPF diagnosis in our clinic between September 2005 and September 2017 were evaluated retrospectively. The cases were divided into two groups: Group 1 (n=14); bronchial closure performed manually and Group 2 (n=12) bronchial closure with stapler. We analyzed cases for age, gender, body mass index, pulmonary function tests, time to fistula, total protein/albumin level, length of hospital stay, bronchial stump distance, presence of bronchial stump coverage, and the mean survivals. RESULTS: Twenty-three of the cases were males (88.5%) with a mean age of 60.03±8.7 years (range 38-73). While BPF was detected in twenty-three (88.5%) of the cases after pneumonectomy, three (11.5%) of them were after lobectomy. There was no statistically significant correlation between the two groups in gender, age, BMI, preoperative FEV1, time to fistula, total protein/albumin level, length of hospital stay, bronchial stump distance, and presence of bronchial stump coverage (chi-square test, p>0.05). As a result of the applied Kaplan-Meier analysis, we found no statistically significant difference in the mean survival rates between the two groups (p>0.05). CONCLUSIONS: Broncho-pleural fistulas still remains a major challenge. Although there is no statistical relationship between bronchial closure techniques and possible risk factors in our study, patients should be assessed in terms of possible risk factors. The management strategy for BPF varies according to individual patients' clinical condition, the size of the fistula, and development time.

Temporary Abdominal Closure Is Associated with Increased Risk for Fungal Intra-Abdominal Infections in Trauma Patients.

Background: Fungal infections are associated with increased morbidity and death. Few studies have examined risk factors associated with post-operative fungal intra-abdominal infections (FIAIs) in trauma patients after exploratory laparotomy. In this study, we evaluated potential risk factors for acquiring post-operative FIAIs and their impact on clinical outcomes. Methods: This was a retrospective analysis of trauma patients admitted from 2005 to 2018 who underwent exploratory laparotomy and subsequently had development of intra-abdominal infection (IAI). Demographics, comorbidities, culture data, antimicrobial usage, Injury Severity Scores (ISS), and clinical outcomes were abstracted. All post-operative IAIs were evaluated and stratified as either bacterial, fungal, combined, and with or without colonization. All groups were compared. Risk factors for the development of post-operative IAI and clinical outcomes were analyzed by Student t test and chi-square test. Multi-variable logistic regression was used to determine independent predictors of post-operative FIAIs. Results: There were 1675 patients identified as having undergone exploratory laparotomy in the setting of traumatic injury, 161 of whom were suspected of having IAI. A total of 105 (6.2%) patients had a diagnosis of IAI. Of these patients, 40 (38%) received a diagnosis of FIAI. The most common fungal pathogens were unspeciated yeast (48.3%), followed by Candida albicans (42.7%), C. glabrata (4.5%), C. dubliniensis (2.25%), and C. tropicalis (2.25%). There were no significant differences in demographics, comorbidities, and percentage of gastric perforations between FIAI and bacterial IAI (BIAI) groups. Patients with FIAIs, however, had a 75% temporary abdominal closure (TAC) rate compared with 51% in BIAIs (p = 0.01). The FIAI group had higher ISS (27 vs. 22, p = 0.03), longer hospital days (34 vs. 25, p = 0.02), and longer intensive care unit (ICU) days (17 vs. 9, p = 0.006) when compared with BIAI. The FIAI group also had a five-fold greater mortality rate. Logistic regression identified TAC as an independent risk factor for the development of post-operative FIAIs (odds ratio [OR] 6.16, confidence interval [CI] 1.14-28.0, p = 0.02). Conclusions: An FIAI after exploratory laparotomy was associated with greater morbidity and death. A TAC was associated independently with increased risk of FIAI after exploratory laparotomy in the setting of traumatic injury. Clinicians should suspect fungal infections in trauma patients in whom post-operative IAI develops after undergoing exploratory laparotomy using TAC techniques.

Arthroscopic repair of partial-thickness articular surface rotator cuff tears: single-row transtendon technique versus double-row suture bridge (transosseous equivalent) fixation: results from a prospective randomized study.

BACKGROUND: The purpose of this prospective study was to compare the clinical and structural findings following the arthroscopic repair of partial-thickness (exceeding 50%) articular-sided rotator cuff tears using either a single-row or a double-row suture bridge fixation. MATERIALS AND METHODS: Fifty patients were included in this study. The patients were randomly placed into two groups: 25 underwent the single-row (Group I) and 25 a double-row suture bridge fixation (Group II). The clinical outcomes were assessed using ASES and Constant shoulder scores, both preoperatively and at the end of follow-up. The pain level was evaluated using the visual analogue scale (VAS), preoperatively, at 6 months and at the end of follow-up. All patients underwent preoperative MRI to identify the rotator cuff tear, and postoperatively at 12 months to evaluate tendon integrity. RESULTS: The average follow-up was 32.5 months. The mean ASES scores increased from 35.9 to 96.7 in Group I and from 35.3 to 93.4 in Group II; the mean Constant shoulder scores increased from 55.6 to 97.8 in Group I and from 57.5 to 97.3 in Group II. There were no significant differences between the two groups. The average preoperative pain level decreased from 7.4 to 3 at 6 months and to 0.4 at the end of the Group I; and from 7.6 to 3 at 6 months and 0.8 in Group II. There was no significant difference between the two groups. At 12 months, the MRI assessments showed two retears in Group I (8%) and one retear in Group II (4%). CONCLUSION: Arthroscopic repair of partial-thickness articular rotator cuff tears that exceed 50% of tendon thickness with a single-row transtendon repair or double-row suture bridge provides functional improvement and pain relief regardless of the repair technique used. There were no differences in clinical results between both techniques. LEVEL OF EVIDENCE: Level II; prospective comparative study.