Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature.

PURPOSE: Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material. METHODS: A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations. RESULTS: The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days. CONCLUSIONS: The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.

Conservative Measures for Managing Constipation in Patients Living With a Colostomy.

PURPOSE: The purpose of this study was to determine the effect of a conservative regimen for the treatment of constipation in persons living with a colostomy. DESIGN: Prospective, noncontrolled, single-center study. SUBJECTS AND SETTING: The study sample comprised 35 patients with a colostomy who were diagnosed with constipation. Subjects with morphologic changes causing constipation such as stomal stenosis and neoplastic and inflammatory changes were excluded. The study was conducted in the Proctology and Stoma Outpatient Clinic at Poznan University of Medical Sciences. METHODS: Patients at our Stoma Outpatient Clinic underwent baseline evaluation, and those with symptoms of constipation (prolonged periods between bowel movements, passage of pasty or hardened fecal effluent, and associated symptoms such as abdominal discomfort or bloating, flatulence, and pain with passage of effluent into the stoma) received individualized dietary recommendations that typically included an increase in dietary fiber and fluid intake, along with increased fluid intake. The outcomes of dietary changes were evaluated during a follow-up visit 3 months later. If dietary changes alone did not improve constipation symptoms, we prescribed a psyllium-based bulk-forming agent, an osmotic stool softener, and a probiotic, with or without a prokinetic agent such as metoclopramide taken 3 times daily. RESULTS: Dietary interventions alone were deemed successful in 60% of study subjects (n = 21); the remaining 14 patients required additional treatment. CONCLUSIONS: Dietary modifications alone relieved constipation in more than half of a group of 35 patients with constipation. We therefore recommend a trial of dietary modifications prior to the initiation of pharmacotherapy in patients with a colostomy.

Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis.

BACKGROUND: Chronic anal fissure (CAF) is a linear split of the anoderm. The minimally invasive management of CAF such as botulinum toxin (BT) injection is recommended. However, the exact efficient dose of BT, number of injections per session and the injection sites are still debatable. The aim of this analysis was to assess the dose-dependent efficiency of botulinum toxin injection for CAF. METHODS: PubMed and Web of Science databases were searched for terms: "anal fissure" AND "botulinum toxin." Studies published between October 1993 and May 2015 were included and had to meet the following criteria: (1) chronic anal fissure, (2) prospective character of the study, (3) used simple BT injection without any other interventions and (4) no previous treatment with BT. RESULTS: A total of 1577 patients from 34 prospective studies used either Botox or Dysport formulations were qualified for this meta-analysis. A total number of BT units per session ranged from 5 to 150 IU, whereas the efficiency across analyzed studies ranged from 33 to 96 %. Surprisingly, we did not observe a dose-dependent efficiency (Spearman's rank correlation coefficient, ρ = 0.060; p = 0.0708). Moreover, there were no BT dose-dependent postoperative complications or fecal incontinence and significant difference in healing rates compared BT injection into the anal sphincter muscles. CONCLUSIONS: BT injection has been an accepted method for the management of CAF. Surprisingly, there is no dose-dependent efficiency, and the postoperative incontinence rate is not related to the BT dosage regardless the type of formulation of botulinum neurotoxin used. Moreover, no difference in healing rate has been observed in regard to the site and number of injections per session.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis.

PURPOSE: Restorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia. METHODS: A total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients' records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis. RESULTS: Analyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001). CONCLUSIONS: Neoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

In Vitro Studies of Antibacterial and Antifungal Wound Dressings Comprising H2TiO3 and SiO2 Nanoparticles.

The incidence rate of the infected and complex wound is established at approximately 40,000/1 million of the world's adult population. The aim of this study was to assess the efficiency of three novel types of wound dressings comprising sodium chloride, metatitanic acid and silicon dioxide nanoparticles. The study design was to prove their antimicrobial properties against the microorganisms most commonly causing wound infections. The study evaluated the antimicrobial effect of tested dressings on referenced strains of bacteria (ATCC collection, Argenta, Poland) and strains of fungi species (our own collection of fungi cultured from patients). The dressings were tested with both bacterial and fungal strains on solid media (Mueller-Hinton, Sobouraud, bioMerieux, France) in the standard method. The results confirmed the inhibition of growth of bacteria and revealed zones of inhibition for Escherichia coli, Staphylococcus aureus and Enterococcus faecalis. Significant zones of inhibition were established for Staphylococcus aureus and for fungi species of the Candida sp. These results would be crucial due to the fact of the low availability of antifungal therapeutics for both systemic and topical usage. Moreover, the current standard of antifungal treatment is associated with high costs and high toxicity in general. The preliminary results are very promising but further studies are necessary. Based on the obtained results, the tested dressings may contribute to the development of the surgical armamentarium of complex wound management in the near future.

Cell-based Hyper-interleukin 6 or Hyper-interleukin 11 secreting vaccines combined with low dose cyclophosphamide in an orthotopic murine prostate cancer model.

BACKGROUND: Cell based vaccines encoding Hyper-IL-6 (H6) and Hyper-IL-11 (H11) present high activity in murine melanoma and renal cancer model. We evaluated the efficacy of cellular vaccines modified with H6 or H11 combined with cyclophosphamide in orthotopic murine prostate cancer model. MATERIAL AND METHODS: TRAMP cells were transduced with H6 and H11 cDNA (TRAMP-H6 and TRAMP-H11). An orthotopic TRAMP model based on the implantation of TRAMP cells into the dorsolateral lobe of the prostate of C57BL6/J mice was employed. The efficacy of TRAMP-H6 and TRAMP-H11 vaccines evaluated in the therapeutic setting was compared with the TRAMP cells modified with a mock transduced E1-deleted adenoviral vector (TRAMP-AdV) and non-modified irradiated TRAMP cells (TRAMP IRR) in relation to naive (non-immunized) mice. In the next experimental groups mice vaccinated with TRAMP-H6 and TRAMP-H11 received cyclophosphamide (CY). Detection of immune cells in the spleen in mice receiving vaccines combined with CY was evaluated. RESULTS: Modification of TRAMP cells with H6 increased the efficacy of TRAMP-based whole-cell vaccine. The highest response rate was observed in mice receiving TRAMP-H6 alone and combined with CY. Vaccination with TRAMP-H6 alone and combined with CY and TRAMP H11 combined with CY extended median OS of mice bearing orthotopic TRAMP tumors in therapeutic setting. Low dose CY administered alone demonstrated some antitumor activity in employed model. TRAMP-H6 or TRAMP-H11 combined with CY strongly augmented generation of CD8+, CD4+ T lymphocytes and memory T cells. Immunization with TRAMP combined with or without CY suppressed generation of T regulatory cells. CONSLUSIONS: Prostate cancer vaccines modified with H6 or H11 induce prostate tumour regression and increase mice survival by stimulating the immune system. Cyclophosphamide added to modified TRAMP vaccines demonstrated clinical benefit of treated mice and enhanced anti-tumour immune response.

Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis--a prospective randomized study.

BACKGROUND: Microencapsulated sodium butyrate (MSB) has been previously associated with anti-inflammatory and regenerative properties regarding large bowel mucosa. We aimed to examine a role of MSB in patients with diverticulosis, hypothesizing its potential for reduction of diverticulitis episodes and diverticulitis prevention. METHODS: Seventy-three patients with diverticulosis (diagnosed in colonoscopy or/and barium enema or/and CT colography) were recruited for the study and randomized. The investigated group was administered MSB 300 mg daily; the control group was administered placebo. After 12 months, a total of 52 patients completed the study and were subject to analysis (30 subjects and 22 controls). During the study, the number of episodes of diverticulitis (symptomatic diagnosis with acute pain, fever, and leukocytosis), hospitalizations, and surgery performed for diverticulitis were recorded. Additionally, a question regarding subjective improvement of symptoms reflected changes in quality of life during the analysis. RESULTS: After 12 months, the study group noted a significantly decreased number of diverticulitis episodes in comparison to the control group. The subjective quality of life in the study group was higher than in the control group. There were no side effects of the MSB during the therapy. CONCLUSIONS: MSB reduces the frequency of diverticulitis episodes, is safe, and improves the quality of life. It can play a role in the prevention of diverticulitis.

Negative Pressure Level and Effects on Bacterial Growth Kinetics in an in vitro Wound Model.

Negative Pressure Wound Therapy (NPWT) has been widely adopted in wound healing strategies due to its multimodal mechanism of action. While NPWT's positive impression on wound healing is well-established, its effect on bacterial load reduction remains equivocal. This study investigates NPWT's efficacy in reducing bioburden using an in vitro porcine skin model, focusing on the impact of Staphylococcus aureus and Staphylococcus epidermidis. Custom-made negative pressure chambers were employed to apply varying negative pressures. Porcine skin was cut into 5 × 5 cm squares and three standardized wounds of 6 mm each were created using a biopsy punch. Then, wounds were infected with S. aureus and S. epidermidis bacterial suspensions diluted 1:10,000 to obtain a final concentration of 1.5 × 104 CFU/ml and were placed in negative pressure chambers. After incubation, bacterial counts were expressed as colony-forming units (CFU) per ml. For S. aureus at 120 hours, the median CFU, mean area per colony, and total growth area were notably lower at -80 mmHg when compared to -250 mmHg and -50 mmHg, suggesting an optimal negative pressure for the pressure-dependent inhibition of the bacterial proliferation. While analyzing S. epidermidis at 120 hours, the response to the negative pressure was similar but less clear, with the minor CFU at -100 mmHg. The influence of intermittent negative pressure on the S. epidermidis growth showed notably lower median CFU with the interval therapy every hour compared to the S. aureus control group. This study contributes valuable insights into NPWT's influence on the bacterial load, emphasizing the need for further research to reformulate its role in managing contaminated wounds.

Pre- and postischemic pulsed acoustic cellular expression conditioning modulates expression of inflammation factors in cremaster ischemia/reperfusion injury model.

Pulsed acoustic cellular expression (PACE) is a treatment that applies focused acoustic shock waves to promote tissue healing. The aim of this study was to assess the effect of PACE treatment on inflammatory responses in a cremaster muscle ischemia/reperfusion injury model. Seventeen cremaster muscle flaps were evaluated in four groups: nonischemic controls (n = 5), 5-hour ischemia controls (n = 4), preischemic (5-hour) PACE conditioning (n = 4), and postischemic (5-hour) PACE conditioning (n = 4). The expression of proinflammatory cytokines (TNFα, IL-6, IL-1α, IL-1ß, GM-CSF) and chemokines (CCL3, CCL4, CXCL4) was assessed using TaqMan® real-time PCR. Expression of ELAM-1, VCAM-1, and ICAM-1 was assessed by immunostaining. Preischemic PACE conditioning upregulated expression of IL-6, CCL3, CCL4, and CXCL4, and downregulated expression of TNFα, GM-CSF, and IL-1α. Postischemic PACE conditioning significantly decreased expression of all evaluated genes. Pre- and postischemic PACE conditioning decreased expression of ELAM-1 and ICAM-1. Results of the study indicate that application of PACE conditioning may have a beneficial effect on the recovery of tissues subjected to the ischemia/reperfusion injury. Postischemic PACE conditioning revealed anti-inflammatory effect as confirmed by decreased expression of inflammatory cytokines, chemokines, and cell adhesion molecules (ELAM-1 and ICAM-1) that are responsible for leukocyte recruitment into ischemic tissues. Hence, PACE therapy may be used effectively in clinical practice as a convenient therapeutic strategy to protect tissues against ischemia/reperfusion related injury after microsurgical procedures of free tissue transfers.

Composite osseomusculocutaneous sternum, ribs, thymus, pectoralis muscles, and skin allotransplantation model of bone marrow transplantation.

Cellular and vascularized bone marrow cells have been used to induce donor-specific chimerism in various models of composite tissue allotransplantation. Although thymus transplantation has been reported in the literature, the effect of thymus transplantation on chimerism levels in vascularized bone containing composite tissue allotransplantation has not been reported. In this study, a new method for composite vascularized sternal bone marrow transplant model is descried that can be applied to augment chimerism after transplantation. A total of seven composite osseomusculocutaneous sternum, ribs, thymus, pectoralis muscles, and skin transplantations were performed in two groups. The first group (n = 5) was designed as an allotransplantation group and the second group (n = 2) was designed as an isotransplantation group. Composite osseomusculocutaneous sternum, ribs, thymus, and pectoralis muscles allografts were harvested on the common carotid artery and external jugular vein and a heterotopic transplantation was performed to the inguinal region of the recipient rat. Cyclosporine A monotherapy was administered in order to prevent acute and chronic allograft rejection. Animals sacrificed when any sign of rejection occurred. The longest survival was 156 day post-transplant. Assessment of bone marrow cells within sternum bone component and flow cytometry analysis of donor-specific chimerism in the peripheral blood of recipients were evaluated. Our results showed that this composite allograft carried 7.5 × 10(6) of viable hematopoietic cells within the sternum component. At day 7 post-transplant chimerism was developed in T-cell population and mean level was assessed at 2.65% for RT1(n) /CD4 and at 1.0% for RT1(n) /CD8. In this study, a new osseomusculocutaneous sternum, ribs, thymus, pectoralis muscle, and skin allotransplantation model is reported which can be used to augment hematopoietic activity for chimerism induction after transplantation.

Stoma close to the abdominal wound: a real technical problem. A description of a novel care strategy.

IntroductionIn some clinical scenarios, stoma site may be located close to the abdominal wound edge impeding optimal wound management and stoma care. We present a novel strategy of utility NPWT for management of simultaneous abdominal wound healing with stoma presence. Material and methodsRetrospective analysis of seventeen patients treated with a novel wound care strategy was conducted. Application of NPWT within wound bed, around stoma site and skin between allows for: 1) separating wound from stoma site, 2) maintaining the optimal environment for wound healing, 3) protecting peristomal skin and 4) facilitating application of ostomy appliances.ResultsThe study group comprised of twelve female (70,6 %) and five male (29,4%) with the mean age of 49.1 18.4 years The most common underlying pathology was Crohn s disease (n-5; 29,4%). Since NPWT was implemented, patients had undergone from 1 to 13 surgeries. Thirteen patients (76,5%) required intensive care unit admission. The mean time of hospital stay was 65,3 28,6 days (range: 36 134). The mean session of NPWT was 10.8 5.2 (range: 5 - 24) per patient. The range of the level of negative pressure was from -80 to 125 mmHg. In all patients, progress in wound healing was achieved resulting in granulation tissue formation, minimizing wound retraction and thus reduction of the wound area. As a result of NPWT, wound was granulated entirely, tertiary intension closure were achieved or patients were qualified for reconstructive surgery.DiscussionNPWT is safe and useful therapy for complicated abdominal wounds with the presence of stoma close to wounds edges. A novel care strategy allows for simultaneous technical opportunity to separate stoma from wound bed and facilitate wound healing.

Challenges in restoring bowel continuity: An analysis of 91 patients undergoing a reversal procedure

Introduction: The restoration of bowel continuity is associated with significant postoperative morbidity. Aim: The aim of the study was to report the outcomes of restoring intestinal continuity in a large patient cohort. Material and methods: A retrospective analysis was conducted on 91 patients with terminal stoma who were qualified for restoration of GI tract continuity between January 2015 and March 2020. The following demographic and clinical characteristics were analyzed: age, gender, BMI, comorbidities, indication for stoma creation, operative time, the need for blood replacement, the site and type of the anastomosis, and complication and mortality rates. Results: The study group was comprised of 40 women (44%) and 51 men (56%). The mean BMI was 26.8 ±4.9 kg/m2. Only 29.7% of the patients (n = 27) were at normal weight (BMI: 18.5­24.9) and only 11% (n = 10) did not suffer from any comorbidities. The most common indications for index surgery were complicated diverticulitis (37.4%) and colorectal cancer (21.9%). The stapled technique was used in the majority of patients (n = 79, 87%). The mean operative time was 191.7 ±71.4 min. Nine patients (9.9%) required blood replacement peri- or postoperatively, whereas 3 patients (3.3%) required intensive care unit admission. The overall surgical complication rate was 36.2% (n = 33) and the mortality rate was 1.1% (n = 1). Discussion: Restoration of bowel continuity is quite a demanding and complex procedure and thus should be performed by an experienced surgical team. In the majority of patients, the complication rate represents only minor complications. The morbidity and mortality rates are acceptable and comparable to other publications.

Analysis of risk factors for conversion in laparoscopic adrenalectomy: a single-institution series of 256 patients.

Introduction: Although introduction of the laparoscopic approach for adrenal gland surgery revolutionized the strategy in management of adrenal gland tumors, open surgery is still a method of choice in some clinical scenarios. Moreover, laparoscopy may have limitations resulting in conversion. Aim: To assess risk factors predisposing for conversion based on our own material, including 256 laparoscopic adrenalectomies performed in 2009-2016. Material and methods: A retrospective analysis of patients who underwent adrenalectomies between 2009 and 2016 was conducted. Patients were analyzed for sex, body mass index (BMI), size of the adrenal gland lesion, final histopathological diagnosis and operated side of the adrenal gland, its impact on conversion rate. Results: A total of 256 patients underwent laparoscopic adrenalectomy. The reported study comprised of 94 (36.7%) men and 162 (63.3%) women. The most common indication for adrenalectomy were adrenal cortex adenoma (n = 149; 58.2%) and pheochromocytoma (n = 48; 18.75%). The conversion rate was 3.91% (n = 10 patients). Mean BMI of patients without conversion was 27.6 kg/m2, whereas in the group of patients with conversion, BMI was 29.7 kg/m2 (p > 0.05). The conversion rate was precisely the same when comparing the right (5/126; 3.9%) and left (5/126; 3.9%) adrenal gland. There was no correlation between the size of the adrenal lesion and the risk of conversion. Conclusions: The laparoscopic approach remains an efficient and safe procedure for adrenal gland tumors. Based on our study, obese patients and those with pheochromocytoma are associated with a higher risk of conversion but without any statistical significance. There was no difference in the conversion rate when analyzing the size of the adrenal gland tumor. No difference was also revealed in the conversion rate when comparing both sides of laparoscopic adrenalectomy.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects.

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Pulsed acoustic cellular expression as a protective therapy against I/R injury in a cremaster muscle flap model.

BACKGROUND: Tissue ischemia and reperfusion (I/R) affects blood flow restoration and oxygen delivery to the damaged tissues contributing to tissue morbidity and microcirculatory compromise. Pulsed acoustic cellular expression (PACE) technology is known to support tissue neovascularization. The aim of this study was to test PACE conditioning mechanism of action on microcirculatory hemodynamics in ischemia-reperfusion injury model. METHODS: 34 rat cremaster muscle flaps were monitored under intravital microscopy system in 4 experimental groups: 1) non-ischemic controls (n=10), 2) 5h ischemia without conditioning (n=8), 3) pre-ischemic (5h) PACE conditioning (n=8), 4) post-ischemic (5h) PACE conditioning (n=8). Standard microcirculatory hemodynamics of RBC velocity, vessel diameters and functional capillary perfusion were recorded for 2h after I/R. Immunohistochemistry assessed expression of proangiogenic factors: VEGF and vWF, whereas real-time PCR assessed proangiogenic (VEGF, eNOS) and proinflammatory factors (iNOS; chemokines: CCL2, CXCL5 and chemokine receptor CCR2). RESULTS: Pre-ischemic PACE conditioning (group 3) resulted in increased RBC velocity of second (A-2) and third order arterioles (A-3) and venule (V-1) by 40%, 15% and 24% respectively comparing to ischemic group without conditioning (p<0.05). Post-ischemic PACE conditioning (group 4) revealed: 1) increase in RBC velocity in second (A-2) and third order arterioles (A-3) by 65% and 31% respectively comparing to ischemia without conditioning (group 2), 2) 33% increase in first order arterioles diameter (A-1) (p<0.05) compared to ischemic controls, 3) 21% increase in number of functional capillaries compared to ischemia without conditioning (group 2) (P<0.05). Immunostaining assays showed that PACE postconditioning up-regulated proangiogenic factors vWF and VEGF protein expression. This correlated with increased gene expression of VEGF (up to 180%). In contrast, gene expression of proinflammatory factors (iNOS, CCL2, CXCL5) decreased compared to ischemic controls. Pre-ischemic PACE conditioning decreased gene expression of proinflammatory chemokines (CCL2 and CXCL5), compared to ischemic controls without conditioning. CONCLUSIONS: As expected 5h ischemia resulted in deterioration of microcirculatory hemodynamics confirmed by decreased vessels diameters and RBC velocities. This was alleviated by pre- and post-ischemic PACE conditioning which improved functional capillary density and stimulated angiogenesis as confirmed by up-regulated VEGF expression. Furthermore, post-ischemic PACE conditioning correlated with decreased expression of early proinflammatory factors (iNOS, CCL2, CXCL5). Both types of PACE conditioning ameliorated deleterious effect of ischemia-reperfusion injury on microcirculatory hemodynamics of muscle flaps.

Anatomic survey of arachnoid foveolae and the clinical correlation to cranial bone grafting.

INTRODUCTION: When performing in situ harvesting of cranial bone grafts, there is a risk of entering the pericranial-intracranial venous system, either directly or indirectly through the arachnoid foveolae. The aims of this study were to investigate the size and location of arachnoid foveolae and to provide an anatomic road map to prevent penetrating these structures. METHODS: Three hundred dry skulls were selected from the Hamann-Todd osteological collection (Cleveland, OH); skulls were collected between 1912 and 1938. Our study skulls were limited to whites or African American adults. Exclusion criteria included children (<18 y), ethnic groups other than African Americans and whites, skulls demonstrating fracture or craniofacial abnormalities, or any skull whose age, ethnicity, and sex could not be confirmed. From the 300 skulls in the collection, 200 met the criteria and were included in our review. The mean age of these 200 individuals was 43.86 years, with a male-to-female proportion of 100:100, and a white-to-African American proportion of 144:56. A 500-W candescent light was used to transilluminate the arachnoid foveola, and digital photographs with scale were obtained. The location and diameters of foveolae for arachnoid granulations relative to the coronal and sagittal suture were measured. CONCLUSIONS: Approximately 90% of major arachnoid foveolae are located within 2.5 cm of the coronal and 1.5 cm of the sagittal suture for the left and right parietal bones. Major arachnoid foveolae are located at closer distances to the superior sagittal suture and the coronal suture in the right and left parietal bone than minor foveolae. The results of this study imply that potential complications can be minimized by avoiding these areas and by harvesting in situ bone grafts from the absolute and relative safe zones described in this study.

Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study.

INTRODUCTION: The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI. AIM: To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery. MATERIAL AND METHODS: As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed. RESULTS: The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03-3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group. CONCLUSIONS: CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.

Pulsed acoustic cellular treatment induces expression of proangiogenic factors and chemokines in muscle flaps.

BACKGROUND: Pulsed Acoustic Cellular Expression (PACE) treatment is a novel technology with potential to improve tissue perfusion, but the mechanism of this action is unknown. We assessed in vivo the effect of PACE therapy on muscle microcirculatory hemodynamics, neovascularization, and proangiogenic and proinflammatory gene expression. METHODS: Cremaster muscles were prepared for standard intravital microscopy in 42 Lewis rats divided into five groups: (1) control (n = 10); acute PACE treatment 15 minutes before surgery with (2) 200 impulses (n = 8) and (3) 500 impulses (n = 8); and PACE treatment 24 hours before surgery with (4) 200 impulses (n = 8) and (5) 500 impulses (n = 8).Microcirculatory hemodynamics of red blood cell velocity and capillary perfusion were recorded for 4 hours. Gene expression levels of proinflammatory (inductible nitric oxide synthase [iNOS]) and proangiogenic factors (endothelial nitric oxide synthase [eNOS], vascular endothelial growth factor [VEGF], chemokine (C-X-C motif) ligand 5 [CXCL5], chemokine (C-C motif) ligand 2 [CCL2], and chemokine (C-C motif) receptor 2 [CCR2] were measured using Taqman real-time Polymerase Chain Reaction (PCR). Immunohistochemistry assessed expression of proangiogenic factors: VEGF, von Willebrand factor (vWF), and vessel density by CD31. RESULTS: PACE treatment resulted in an increase of arteriolar diameters in acute groups 2 and 3 (p < 0.05). In group 5, vessel densities assessed by CD31, VEGF, and vWF expression increased significantly 24 hours after PACE treatment compared with control (p < 0.05). PACE application downregulated proinflammatory iNOS gene expression and upregulated proangiogenic genes expression of eNOS, VEGF, CXCL5, and CCL2. CONCLUSIONS: Application of PACE treatment, applied as short time acting preconditioning and conditioning treatment, resulted in upregulation of proangiogenic chemokines gene expression in the muscle and showed upregulation of expression of proangiogenic factors such as VEGF and vWF on the vessel endothelium.