Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial.

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms achieved similar reductions in wound area, non-viable tissue area and wound healing scores during the debridement period. There were no significant differences between the arms in the incidence of complete wound closure (41% in the EsxcharEx arm vs. 53% in the gel vehicle arm) and in the mean time to complete wound closure (70.0 ± 32.8 days in the EsxcharEx arm vs. 65.7 ± 38.4 days in gel vehicle arm). There were no significant safety issues and EscharEx demonstrated a favourable benefit to risk profile.

[DOES NEOADJUVANT CHEMOTHERAPY AFFECT THE IMMEDIATE POSTOPERATIVE COMPLICATION RATE AFTER BREAST RECONSTRUCTION?]

BACKGROUND: Neoadjuvant chemotherapy (NAC) before breast cancer surgery is safe and effective. By reducing the tumor burden, women can achieve complete resections with less extensive operations. Both surgeons and patients share concerns that NAC increases the risk for infection after immediate breast reconstruction, due to its effect on the immune system and the relatively short duration between chemotherapy and surgery. While breast reconstruction plays an increasingly significant role in the treatment of breast cancer, little has been written about the effect of NAC and its impact on post-operative complications. METHODS: We identified 158 patients (205 breasts) who underwent surgery for breast cancer with immediate reconstruction between the years 2013-2017 at the Kaplan Medical Center. Using univariate and multivariate statistics, we compared our patient characteristics according to our main predictor of interest: receiving NAC. We focused on the immediate post-operative complications: infection, skin necrosis, wound dehiscence, hematoma, seroma and implant explantation. RESULTS: Fifty-two patients received NAC and 106 did not. The neoadjuvant group was found to be younger (45 years old vs. 51, P<0.05). The overall complication rate was 30.3%, with a trend towards a lower complication rate in the NAC group, though not statistically significant (23% vs. 34% P=0.2). The overall infection rate was 8.8%, again with a trend towards a lower infection rate among the NAC group (3.8% vs. 11.3% P=0.12). Mastectomy (P=0.02), implant reconstruction (P=0.05) and diabetes (P<0.05) were associated with a higher complication rate. CONCLUSIONS: Our data indicates that NAC is not associated with an increased rate of immediate post-operative complications in women undergoing breast surgery and reconstruction. Therefore, receiving NAC should not be considered a reason to avoid immediate breast reconstruction.

An engineered muscle flap for reconstruction of large soft tissue defects.

Large soft tissue defects involve significant tissue loss, requiring surgical reconstruction. Autologous flaps are occasionally scant, demand prolonged transfer surgery, and induce donor site morbidity. The present work set out to fabricate an engineered muscle flap bearing its own functional vascular pedicle for repair of a large soft tissue defect in mice. Full-thickness abdominal wall defect was reconstructed using this engineered vascular muscle flap. A 3D engineered tissue constructed of a porous, biodegradable polymer scaffold embedded with endothelial cells, fibroblasts, and/or myoblasts was cultured in vitro and then implanted around the femoral artery and veins before being transferred, as an axial flap, with its vascular pedicle to reconstruct a full-thickness abdominal wall defect in the same mouse. Within 1 wk of implantation, scaffolds showed extensive functional vascular density and perfusion and anastomosis with host vessels. At 1 wk posttransfer, the engineered muscle flaps were highly vascularized, were well-integrated within the surrounding tissue, and featured sufficient mechanical strength to support the abdominal viscera. Thus, the described engineered muscle flap, equipped with an autologous vascular pedicle, constitutes an effective tool for reconstruction of large defects, thereby circumventing the need for both harvesting autologous flaps and postoperative scarification.

[REVIEW OF COMMON PATHOGENS IN THE BONE AND BLOOD CULTURES AND ANTIBIOTIC TREATMENT IN PATIENTS WITH STERNAL OSTEOMYELITIS].

AIMS: This study concentrates on microbiological data collection of deep sternal wounds to delineate early and correct antibiotic therapy. BACKGROUND: Deep sternal wound infection, mediastinitis and sternal osteomyelitis are devastating and life-threatening complications of median-sternotomy incisions after cardiac surgical procedures. The incidence of surgical wound infection in sternotomies should be similar to that in any clean surgical procedure (i.e. approximately 2%). Nonetheless, the infection rates are higher among heart disease patients, due to the fact that these patients are burdened with a high number of risk factors in comparison with the general population. RESULTS: In line with other publications, the most commonly cultured organism from deep sternal wound and blood cultures was found to be Staphylococcus. In comparison, the most commonly cultured Gram-negative organisms were Pseudomonas and all gram-negative organisms combined together represented approximately 50% of all cultures. Three dominant organisms were isolated from wound and blood cultures: Staphylococcus, Pseudomonas and Acinetobacter. We found that 40% of blood cultures were identical to prior wound cultures, in comparison to 30% of bone cultures. Furthermore, 20% of the organisms isolated from the wound and 13% of the organisms isolated from the bone later on cross over to involve the blood. CONCLUSIONS: Empiric antibiotic regimen should be broad spectrum and cover both gram-positive as well as gramnegative organisms. We demonstrate that antibiotic regimen during sepsis may rely partially on preliminary wound cultures. Furthermore, antibiotic treatment for a relatively short period of two weeks is adequate, alongside thorough surgical revision with debridement of all foreign bodies, and reconstruction with vascularized soft tissue flap (pectoral major).

A method for constructing vascularized muscle flap.

Abdominal wall reconstruction following extensive tissue loss is essential and can be achieved using autologous flaps. However, their use is limited due to their inadequate availability and due to post-operative donor site scarification. This work presents a step-by-step technique for fabrication of a vascularized muscle flap, to be applied in full-thickness abdominal wall defect reconstruction. Poly L-lactic acid/poly lactic-co-glycolic acid scaffolds, prepared using a salt leaching technique, were used as the supporting matrix in vitro for simultaneously seeded endothelial cells, fibroblasts and myoblasts. The cell-embedded graft was then implanted around femoral artery and vein vessels, which provided a central blood supply. Vascularization and perfusion were achieved by capillary sprouting from the main host vessel into the graft. A thick and vascularized tissue was formed within one week, and was then transferred as an autologous flap together with its main vessels, to a full-thickness abdominal wall defect. The flap remained viable after transfer and featured sufficient mechanical strength to support the abdominal viscera. Thus, this engineered muscle flap can be used as an alternative source for autologous flaps to reconstruct full-thickness abdominal wall defects.

Do Wound Cultures Give Information About the Microbiology of Blood Cultures in Severe Burn Patients?

BACKGROUND: Blood stream infection (BSI) and the subsequent development of sepsis are among the most common infection complications occurring in severe burn patients. This study was designed to evaluate the relationship between the burn wound flora and BSI pathogens. METHODS: Documentation of all bacterial and fungal wound and blood isolates from severe burn patients hospitalized in the burn unit and intensive care unit was obtained from medical records retrieved retrospectively from a computerized, hospital-wide database over a 13-year period. All data were recorded in relation to the Ryan score. RESULTS: Of 195 severe burn patients, 88 had at least 1 BSI episode. Transmission of the same pathogen from wound to blood was documented in 30% of the patients, with a rising BSI frequency as the Ryan score increased. There were a total of 263 bacteremic episodes in 88 study patients, 44% of blood isolates were documented previously in wound cultures, and transmission of the same pathogen from wound to blood was noted in 65% of bacteremic patients. CONCLUSIONS: When there is clinical suspicion of sepsis, appropriate empirical systemic antibiotic therapy should be broad spectrum and should rely on the susceptibility of the organisms from recent cultures of the burn wound surface, until the blood cultures results are completed.

[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Improved vascular organization enhances functional integration of engineered skeletal muscle grafts.

Severe traumatic events such as burns, and cancer therapy, often involve a significant loss of tissue, requiring surgical reconstruction by means of autologous muscle flaps. The scant availability of quality vascularized flaps and donor site morbidity often limit their use. Engineered vascularized grafts provide an alternative for this need. This work describes a first-time analysis, of the degree of in vitro vascularization and tissue organization, required to enhance the pace and efficacy of vascularized muscle graft integration in vivo. While one-day in vitro was sufficient for graft integration, a three-week culturing period, yielding semiorganized vessel structures and muscle fibers, significantly improved grafting efficacy. Implanted vessel networks were gradually replaced by host vessels, coupled with enhanced perfusion and capillary density. Upregulation of key graft angiogenic factors suggest its active role in promoting the angiogenic response. Transition from satellite cells to mature fibers was indicated by increased gene expression, increased capillary to fiber ratio, and similar morphology to normal muscle. We suggest a "relay" approach in which extended in vitro incubation, enabling the formation of a more structured vascular bed, allows for graft-host angiogenic collaboration that promotes anastomosis and vascular integration. The enhanced angiogenic response supports enhanced muscle regeneration, maturation, and integration.

Cartilage-sparing otoplasty - 288 ears in 3 years.

BACKGROUND: Standard methods of otoplasty may risk anatomical distortion. Previous work showcased a novel, cartilage-sparing technique. This study aimed to confirm the safety and effectiveness of the method in a larger cohort. METHODS: This retrospective study included patients undergoing otoplasty by a single surgeon using a single technique between January 2021 and December 2023. Eligible patients were aged >5 years and had prominent or constricted or cup ears, forming a 2 cm distance from the mastoid. Surgical techniques included novel key-point sutures. Minimum follow-up was 6 months. Data on demographics, risk factors, perioperative management, and complications were collected from patient records. RESULTS: A total of 288 operated ears (147 patients) were included. The mean age was 17 years, and 91 (61.9%) were female. The mean duration of follow-up was 24.3 months. Postoperative complications were generally minor and included Polydioxanone (PDS) suture exposure (n = 16, 5.5%), manageable postoperative pain (n = 8, 2.7%), self-resolving swelling (n = 8, 2.7%), minor bleeding (n = 7, 2.4%), and superficial skin complications (n = 4, 1.3%). Infections occurred in 4 ears (1.3%) and were treated effectively with topical/oral antibiotics. Cases of partial release of the ear resolved without intervention (n = 4, 1.3%). Only 4 (1.3%) ears experienced loss of correction, with options for reoperation available as needed. Analysis showed no significant age differences in postoperative complications and a nonsignificant trend towards higher postoperative swelling in males than in females (10.7% vs 2.2%; P = 0.054). CONCLUSIONS: The data confirms that this technique offers safe and rapid cartilage-sparing otoplasty with minimal complications and low recurrence rates. It ensures long-lasting and aesthetically pleasing results for prominent ear deformities. LEVEL OF EVIDENCE: Level III.

Cartilage-Sparing Otoplasty: A New Approach.

SUMMARY: Ear protrusion is the primary indication for otoplasty. Many methods have been developed for addressing this defect, based on cartilage-scoring and excision and suture-fixation techniques. Disadvantages include irreversible distortion of the anatomy, irregularities, or overcorrection, or forward bulging of the conchal bowl. One of the most common long-term sequelae of otoplasty is an unsatisfactory result. A novel, cartilage-sparing, suture-based technique has been developed that aims to minimize the risk of complications and provide a natural-appearing aesthetic result. The method is based on two to three key sutures that shape the concha into the desired natural appearance while preventing a conchal bulge, which otherwise could appear if no cartilage is removed. Furthermore, these sutures support the neo-antihelix created by four further sutures anchored to the mastoid fascia, thus achieving the two main goals of otoplasty. The sparing of cartilaginous tissue means that the procedure is reversible if needed. In addition, permanent postoperative stigmata, pathologic scarring, and anatomical deformity can be avoided. This technique was used on 91 ears in 2020 and 2021, with only one ear (1.1%) requiring revision. Rates of complications or recurrence were low. The presented technique appears to be a rapid and safe method for treating the prominent ear deformity, providing aesthetically pleasing results.

Preoperative planning using virtual reality and computed tomography angiogram in deep inferior epigastric perforator flap breast reconstruction.

The gold standard for preoperative planning of deep inferior epigastric perforator (DIEP) flap breast reconstruction uses computed tomography angiography (CTA). Virtual reality (VR) circumnavigates the limitations of CTA by reconstructing a fully immersive and interactive 3D representation of the scan. Scans of 44 patients who underwent DIEP flap breast reconstruction were retrospectively reviewed and compared using CTA and VR imaging modalities. The objective of this research was to compare perforators found using VR to the ones identified using conventional CTA. A correlation was found between the imaging modalities for unilateral (R = 0.96 (CI = 0.92, 0.98)) and bilateral (R = 0.93, (CI = 0.83, 0.97)) DIEP flap surgeries when comparing perforator location related to the umbilicus. Multivariable ordinal logistic regression found that higher intramuscular course length (IMC) is associated with the number of perforators found per side (OR = 1.79 (CI = 1.24, 2.6)), and medial location (OR = 2.85 (CI = 1.38, 5.87)). Larger vessel caliber (VC) is associated with shorter IMC (T2 vs. T3, OR = 3.34 (CI = 1.49, 7.49)), and branching in adipose tissue (AB) is associated with higher VC (T1 vs. T3, OR = 0.02 (CI = 0.007, 0.08); T2 vs. T3, OR = 0.24 (CI = 0.11, 0.55)). Overall, preoperative planning using VR was easy to use, safe, more intuitive, and provided in a time-efficient manner, more information about perforant characteristics. VR can improve the surgeon's decision accuracy, relating to the best perforators for harvesting, in a shorter time period.

Surgical site infection in reconstructive and aesthetic breast surgery: A single center retrospective analysis of the association between healthcare workers and infections.

BACKGROUND: Reconstructive and aesthetic breast surgeries are frequently performed procedures, and the consequences of a postoperative infection are devastating both for the patient and the healthcare (HC) system. Over the years, there has been heightened interest in the physical and mental well-being of physicians and HC workers. Little is known about the relationship between HC workers and surgical site infections (SSI), and whether HC workers are at an increased risk for SSI. The aim of this study was to investigate whether women working in the HC system have an increased risk for SSI following reconstructive and aesthetic breast surgery. MATERIALS AND METHODS: We conducted a retrospective analysis of all patients who underwent aesthetic and reconstructive breast surgery at our institution between the years 2013-2020. Women who were recognized as HC workers were analyzed in a separate group and compared to those who were not. RESULTS: Records of 378 patients were reviewed, of whom 53 (14%) were identified as HC workers. The overall infection rate was 17.4%. HC workers manifested a higher infection rate than the other group (32% vs. 15.1%, p<0.05) and a significantly higher relative risk for SSI (RR 2.12, p<0.01). CONCLUSIONS: Women working in the HC system may have an increased risk of developing postoperative infectious complications following aesthetic and reconstructive breast-related surgery. Further research is needed to corroborate these findings and elucidate the causes.

Techniques and Innovations in Flap Engineering: A Review.

Currently, the gold standard for complex defect reconstruction is autologous tissue flaps, with vascularized composite allografts as its highest level. Good clinical results are obtained despite considerable obstacles, such as limited donor sites, donor site morbidity, and complex operations. Researchers in the field of tissue engineering are trying to generate novel tissue flaps requiring small or no donor site sacrifice. At the base of existing technologies is the tissue's potential for regeneration and neovascularization. Methods: A review was conducted identifying relevant published articles in PubMed on the subject of flap engineering, with the focus on plastic surgery. This review article surveys contemporary technologies in flap engineering, including cell sheet technology, prefabricated flaps, and tissue engineering chambers. Conclusions: Some of the described procedures, though not yet ready for clinical use, are certainly ready for trial in large animal models and even human studies. Tissue engineering is a promising field for the handling of large and complex tissue defects.

Microcomputed Tomography-Based Analysis of Neovascularization within Bioengineered Vascularized Tissues.

In the field of tissue engineering, evaluating newly formed vascular networks is considered a fundamental step in deciphering the processes underlying tissue development. Several common modalities exist to study vessel network formation and function. However, a proper methodology that allows through three-dimensional visualization of neovessels in a reproducible manner is required. Here, we describe in-depth exploration, visualization, and analysis of vessels within newly formed tissues by utilizing a contrast agent perfusion protocol and high-resolution microcomputed tomography. Bioengineered constructs consisting of porous, biocompatible, and biodegradable scaffolds are loaded with cocultures of adipose-derived microvascular endothelial cells (HAMECs) and dental pulp stem cells (DPSCs) and implanted in a rat femoral bundle model. After 14 days of in vivo maturation, we performed the optimized perfusion protocol to allow host penetrating vascular visualization and assessment within neotissues. Following high-resolution microCT scanning of DPSC:HAMEC explants, we performed the volumetric and spatial analysis of neovasculature. Eventually, the process was repeated with a previously published coculture system for prevascularization based on adipose-derived mesenchymal stromal cells (MSCs) and HAMECs. Overall, our approach allows a comprehensive understanding of vessel organization during engraftment and development of neotissues.

In vivo study of the efficacy of bupivacaine-eluting novel soy protein wound dressings in a rat burn model.

Dealing with wound related pain is an integral part of treatment. Systemic administration of analgesic and anesthetic agents is a common solution for providing pain relief to patients but comes at a risk of severe side effects as well as addiction. To overcome these issues, research efforts were madeto provide a platform for local controlled release of pain killers. We have developed a bilayer soy protein-based wound dressing for the controlled local release of bupivacaine to the wound site. The combination of a dense and a porous layer provides a platform for cell growth and proliferation as well as physical protection to the wound site. The current study focuses on the in vitro bupivacaine release profile from the dressing and the corresponding in vivo results of pain levels in a second-degree burn model on rats. The Rat Grimace Scale method and the Von Frey filaments method were used to quantify both, spontaneous pain and mechanically induced pain. A high burst release of 61.8 ± 1.9% of the loaded drug was obtained during the initial hour, followed by a slower release rate during the following day. The animal trials show that the RGS scores of the bupivacaine-treated group were significantly lower than these of the untreated group, proving a decrease of 51-68% in pain levels during days 1-3 after burn. Hence, successful pain reduction of spontaneous pain as well as mechanically induced pain, for at least three days after burn was achieved. It is concluded that our novel bupivacaine eluting soy protein wound dressings are a promising new concept in the field of local controlled drug release for pain management.

Advances in the Use of Electrospun Nanofibrous Polymeric Matrix for Dermal Healing at the Donor Site After the Split-Thickness Skin Graft Excision: A Prospective, Randomized, Controlled, Open-Label, Multicenter Study.

Dressings used to manage donor site wounds (DSWs) have up to 40% of patients experiencing complications that may cause suboptimal scarring. We evaluated the efficacy and safety of a portable electrospun nanofibrous matrix that provides contactless management of DSWs compared with standard dressing techniques. This study included adult patients who underwent an excised split-thickness skin graft (STSG) with a DSW area of 10 to 200 cm2. Patients were allocated into two groups; ie, the nanofiber group managed with a nanofibrous polymer-based matrix, and the control group managed using the standard of care such as Jelonet® or Biatain® Ibu dressing. Primary outcomes were postoperative dermal healing efficacy assessed by Draize scores. The time to complete re-epithelialization was also recorded. Secondary outcomes included postoperative adverse events, pain, and infections during the first 21 days and extended 12-month follow-up. The itching and scarring were recorded during the extended follow-up (months 1, 3, 6, 9, and 12) using Numerical-Analogue-Score and Vancouver scores, respectively. The nanofiber and control groups included 21 and 20 patients, respectively. The Draize dermal irritation scores were significantly lower in the nanofiber vs control group (Z = -2.509; P = .028) on the first postoperative day but became similar afterward (Z ≥ -1.62; P ≥ .198). In addition, the average time to re-epithelialization was similar in the nanofiber (17.9 ± 4.4 days) and control group (18.3 ± 4.5 days; Z = -0.299; P = .764), so were postoperative adverse events, pain, and infection incidence, itching and scarring. The safety and efficacy of electrospun nanofibrous matrix are similar to standard wound care allowing its use as an alternative donor site dressing following the STSG excision.

Large leg ulcers due to autoimmune diseases.

BACKGROUND: Large leg ulcers (LLU) may complicate autoimmune diseases. They pose a therapeutic challenge and are often resistant to treatment. To report three cases of autoimmune diseases complicated with LLU. CASE REPORT: Case 1. A 55-year old woman presented with long-standing painful LLU due to mixed connective tissue disease (MCTD). Biopsy from the ulcer edge showed small vessel vasculitis. IV methylprednisolone (MethP) 1 G/day, prednisolone (PR) 1mg/kg, monthly IV cyclophosphamide (CYC), cyclosporine (CyA) 100mg/day, IVIG 125G, ciprofloxacin+IV Iloprost+enoxaparin+aspirin (AAVAA), hyperbaric oxygen therapy (HO), maggot debridement and autologous skin transplantation were performed and the LLU healed. Case 2. A 45-year old women with MCTD developed multiple LLU's with non-specific inflammation by biopsy. MethP, PR, hydroxychloroquine (HCQ), azathioprine (AZA), CYC, IVIG, AAVAA failed. Treatment for underlying the LLU tibial osteomyelitis and addition of CyA was followed by the LLU healing. Case 3. A 20-year-old man with history of polyarteritis nodosa (PAN) developed painful LLU's due to small vessel vasculitis (biopsy). MethP, PR 1 mg/kg, CYC, CyA 100 mg/d, AAVAA failed. MRSA sepsis and relapse of systemic PAN developed. IV vancomycin, followed by ciprofloxacin, monthly IVIG (150 g/for 5 days) and infliximab (5 mg/kg) were instituted and the LLU's healed. CONCLUSIONS: LLU are extremely resistant to therapy. Combined use of multiple medications and services are needed for healing of LLU due to autoimmune diseases.

Salivary monitoring related to major surgery.

BACKGROUND: Prolonged surgical procedures involving stress, extended general anaesthesia and a long pre-surgical fasting period may have systemic effects such as alterations in saliva flow rate and composition. These may compromise the patient's electrolytes and fluid balance and cause dehydration, systemic stress and oxidative changes. PATIENTS AND METHODS: Saliva was collected prior and following surgery from 20 patients and 20 control subjects. The saliva samples were analysed for flow rates and levels of the following: calcium (Ca), magnesium (Mg), total protein, albumin and lactate dehydrogenase (LDH), total antioxidant status (TAS), uric acid (UA), superoxide dismutase (SOD), carbonyls, matrix metalloproteinases (MMPs) -2, -3 and -9 and heat shock proteins (HSPs) 70 and 90. RESULTS: Salivary levels of Ca, Mg, protein, albumin and LDH were higher in post-surgical patients by 70% (P = 0·002), 88% (P = 0·0001), 120% (P = 0·13), 111% (P = 0·039) and 492% (P = 0·006) respectively than that in healthy controls. Salivary antioxidants in the surgical patients were higher while salivary carbonyls remained unchanged. Salivary TAS levels in pre- and post-surgical patients were higher by 63% (P = 0·001) and 85% (P = 0·0001) respectively, UA concentrations by 92% (P = 0·014) and 81% (P = 0·036) respectively and SOD values by 47% (P = 0·61) and 112% (P = 0·049) respectively. Salivary concentrations of MMP3 were higher in pre- and post-surgical patients by 23% (P = 0·067) and 30% (P = 0·044) respectively. CONCLUSIONS: Local salivary, oral and systemic-induced alterations should be prevented. Moreover, salivary collection and analysis may be a new, efficient tool in the monitoring of patients undergoing major surgery. Further related research is necessary.