Cleft closure for the treatment of unhealed perineal sinus

OBJECTIVE: Despite improvements in surgical practice, persistent perineal wound sinus is still a common complication after proctectomy. This study presents the success of a modified cleft closure technique in dealing with this problem. METHODS: From May 1997 patients with a persistent perineal sinus after surgery underwent a cleft closure - similar to that performed for patients with pilonidal sinus disease. RESULTS: Eight patients (6 male, 2 female) with an average age of 52 years underwent a cleft closure for a persistent perineal sinus after surgery. Four patients had undergone a proctocolectomy (ulcerative colitis), 2 an abdominoperineal excision of the rectum (adenocarcinoma) and 2 a proctectomy (1 Crohn's disease, 1 complication of diverticular disease). Symptoms had been present for an average of 41 months (range 5-152 months) and 3 patients had undergone other procedures attempted previously to deal with the problem. The first three patients had the procedure as an inpatient with an average stay of 4.7 days. The next 5 patients had the procedure as a day case (2 local anaesthetic, 3 general anaesthetic). Two patients developed a postoperative wound infection and all but one wound had healed completely by 8 weeks. In this patient the procedure was repeated to achieve healing. There was no other associated morbidity and no postoperative deaths. There have been no recurrences to date. CONCLUSION: Modified cleft closure for persistent perineal sinus is a simple procedure with low morbidity that can be performed under local anaesthetic in the day surgery unit.     

Depletion of neuropeptides during wound healing in rat skin

The peptides substance P, calcitonin gene-related peptide and somatostatin are present in nerve fibres in mammalian, including human, skin. There is evidence that in addition to having a putative neurotransmitter role, they may be trophic agents: a study was therefore undertaken of peptide changes during wound healing in rat skin. A significant depletion of the neuropeptides was found in the region of the wound within two days, and this persisted for two weeks. A smaller and delayed depletion also occurred in intact skin of the same dermatome, but not in an adjacent dermatome.     

Zinc depletion and complications of surgery

Zinc is essential for protein synthesis and reduced levels may impair recovery from surgery. To study this prospectively, clinical, anthropometric, haematological and biochemical indices of malnutrition were measured in 46 patients undergoing elective surgery and were related to the frequency and type of post-operative complications. In addition, leucocyte zinc levels, which are an estimate of tissue zinc levels, were measured. The diagnoses of the patients did not correlate with any of these parameters. Many patients were malnourished. 39% of the patients had a post-operative complication, of whom 8 had a wound complication. The frequency of complications as a whole was inversely related to serum albumin and transferrin levels, while wound complications were in addition associated with low leucocyte zinc levels. Malnutrition may therefore increase post-operative complications in general, but tissue zinc deficiency may contribute to wound problems.     

Successful in vitro fertilization in women with Fontan physiology

PurposePatients with single ventricle anatomy palliated with Fontan operation are at risk for thromboembolism, arrhythmia, and heart failure rendering pregnancy high risk or even contraindicated. Infertility and high rates of first trimester miscarriage are not uncommon. In vitro fertilization (IVF) with or without gestational surrogacy can be an option, but poses risks during ovarian stimulation, oocyte retrieval, and the post-procedural period. We present six cases of women with complex congenital heart disease status post Fontan operation who underwent successful IVF.MethodsCase series from a single-center tertiary care setting.ResultsIndications for referral were cardiac or fertility concerns for pregnancy of the congenital cardiologist. One woman had mild volume overload after oocyte retrieval requiring furosemide and one experienced post-operative colitis. There were no thrombotic complications.ConclusionsA multidisciplinary team-based approach can result in successful oocyte retrieval and IVF in women with complex congenital heart disease and Fontan physiology.     

GnRH agonist with low-dose hCG (dual trigger) is associated with higher risk of severe ovarian hyperstimulation syndrome compared to GnRH agonist alone

Purpose

The purpose of this study was to compare rates of ovarian hyperstimulation syndrome (OHSS) after using gonadotropin-releasing hormone agonists (GnRHa) alone and GnRHa in combination with low-dose human chorionic gonadotropin (hCG, dual trigger) for final oocyte maturation in women undergoing controlled ovarian hyperstimulation (COH).

Methods

A retrospective cohort study was conducted at an academic center. Study population included 108 women who received GnRHa trigger and 66 women who received dual trigger (GnRHa?+?low-dose [1000 IU] hCG trigger). The main outcome measure was OHSS. Secondary outcomes included total oocyte yield and oocyte maturity.

Results

The incidence of early OHSS was significantly higher after dual trigger than GnRHa trigger (8.6 vs 0 %). Moreover, four of the six patients that developed OHSS developed severe OHSS. Logistic modeling revealed that the combination of age, BMI, baseline AFC, and E2 >4000 pg/mL was predictive of OHSS with an area under the receiver operating characteristic curve of 0.84 and was superior to each factor alone. Adjusted analyses revealed that dual trigger was associated with a higher number of total oocytes (adjusted OR 1.27; 95 % confidence interval, 1.18, 1.38) and percentage of mature oocytes (AOR 1.10; 95 % confidence interval, 1.03, 1.17) obtained compared to GnRHa trigger alone.

Conclusions

Dual trigger for final oocyte maturation using GnRHa and low-dose hCG is associated with a significantly increased risk of severe OHSS compared to GnRH alone. However, dual trigger may be associated with a modest increase in oocyte yield, both in terms of number and maturity.

     

Interstitial pregnancy

A 20-year-old woman with an interstitial pregnancy who underwent ultrasonographic and laparoscopic imaging before surgical management is described.     

Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM)

BACKGROUND: The aim of the study was to develop a dedicated colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (CR-POSSUM) equation for predicting operative mortality, and to compare its performance with the Portsmouth (P)-POSSUM model. METHODS: Data were collected prospectively from 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001. After excluding missing data and 93 patients who did not satisfy the inclusion criteria, 4632 patients (68.2 per cent) underwent elective surgery and 2107 had an emergency operation (31.0 per cent); 2437 operations (35.9 per cent) for malignant and 4267 (62.8 per cent) for non-malignant diseases were scored. Stepwise logistic regression analysis was used to develop an age-adjusted POSSUM model and a dedicated CR-POSSUM model. A 60:40 per cent split-sample validation technique was adopted for model development and testing. Observed and expected mortality rates were compared. RESULTS: The operative mortality rate for the series was 5.7 per cent (387 of 6790 patients) (elective operations 2.8 per cent; emergency surgery 12.0 per cent). The CR-POSSUM, age-adjusted POSSUM and P-POSSUM models had similar areas under the receiver-operator characteristic curves. Model calibration was similar for CR-POSSUM and age-adjusted POSSUM models, and superior to that for the P-POSSUM model. The CR-POSSUM model offered the best overall accuracy, with an observed : expected ratio of 1.000, 0.998 and 0.911 respectively (test population). CONCLUSION: The CR-POSSUM model provided an accurate predictor of operative mortality. External validation is required in hospitals different from those in which the model was developed.