Burn wound depth assessment – is laser Doppler imaging the best measurement tool available?

Accurate early assessment of burn wound depth is increasingly important in clinical decision-making. Clinimetric principles are absolutely mandatory while developing a new test or tool for use in the clinical setting. This article critically evaluates the clinimetrics of a powerful tool for assessment of burn depth and whether Laser Doppler Imaging can meet those criteria by virtue of differentiation between superficial and deep burns.     

What is the best treatment of postpneumonectomy empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether an open surgical approach is superior to minimally invasive surgery in patients with postpneumonectomy empyema (PPE). Overall 171 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that open surgical approaches are superior to minimally invasive surgery in terms of empyema recurrence rate, mortality and reintervention rate. Minimally invasive surgery includes chest tube drainage with or without chemical irrigation and video-assisted thoracoscopic surgery debridement. Whereas open surgery includes open debridement, open window thoracostomy (OWT) and thoracomyoplasty. To allow for an accurate comparison, success of an intervention was defined as prevention of empyema recurrence. Two studies reported surgical outcomes of patients treated with minimally invasive treatment options. They found high mortality rates (17.1%) and low success rates (31%) in patients treated by chest tube drainage with chemical irrigation. Five studies treated PPE using a combination of minimally invasive and open surgical approaches and reported a high reintervention rate of 3.5 (range 3-5) and an empyema recurrence rate of 13.3%. Higher success rates (6.7 vs. 95%), lower mortality rates (33 vs. 0%) and shorter hospital stay (47.5 vs. 17.6?days) were all noted with thoracomyoplasty compared to chest tube drainage therapy. Five studies managed PPE using OWT or thoracomyoplasty. The time between empyema diagnosis to resolution (3 vs. 38?months) was much shorter with immediate OWT than with delayed OWT therapy. The Clagett procedure resulted in a mean hospital stay of 12.9?days, an operative mortality rate of 7.1% and an overall success rate of 81%. Thoracomyoplasty led to a mean hospital stay of 34?days with a mortality rate of 6%. The shorter hospital stay, lower empyema recurrence rates and lower mortality rates may make open surgical approaches a more effective treatment option to minimally invasive options.     

What is the best treatment for malignant pleural effusions?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether chemical pleurodesis is superior to catheter drainage or pleuroperitoneal shunts (PPS) in the management of patients with pleural effusions. Overall 161 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that chemical pleurodesis is superior to chronic catheter drainage and PPS in terms survival length and mortality rates but in patients with trapped lung syndrome chronic intrapleural catheter placement is indicated. Six studies reported patient outcomes after treatment with chemical pleurodesis. They report high success rates (89.4%) and low mortality rates (2%) without any need to convert to open thoracotomy. Mean hospital stay of 2.33 days, complication rates of 16.5% and mean survival length of 23.8 ± 16.3 months were observed. Five studies managed malignant pleural effusions (MPEs) using chronic indwelling catheters. They reported mean survival length of 126 days. Symptomatic relief was achieved in 94.2% of patients. There was a significant reduction in the Medical Research Council dyspnoea score (3.0-1.9, P < 0.001) and despite complication rates of 22%, comparable mortality rates (7.5%) were observed. Even in patients with trapped lung syndrome, mean survival length was 125 days with symptomatic improvement being achieved in 90.9% of patients. Three studies treated MPEs using PPSs. Mean hospital stay was 6.2 days (range 2-26) with a mean survival length of 11 months. Pleurodesis success rates varied from 57.1% to 95% with a complication rate of 14.8%. PPSs were shown to produce lower success rates (57.1% vs. 92.3%), shorter survival lengths (4.3 ± 1.9 vs. 6.7 ± 2.1 months) and higher complication rates (14.3% vs. 2.8%) than talc pleurodesis. Overall, chemical pleurodesis is the optimal treatment option for MPE with use of chronic intrapleural catheters reserved in cases where talc pleurodesis is not possible.     

Postanal repair – do the long‐term results justify the procedure?

Objective Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long‐term continence after PAR and relate this to patient satisfaction and quality of life. Method Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. Results One‐hundred one patients from four surgeons were identified. Fifty‐four patients were excluded because of loss to follow‐up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow‐up of 9.1 years (2.2–18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0–5), 26% moderate (CCS 6–12), and 48% (n = 27) severe incontinence (CCS 13–24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow‐up, and being able to distinguish flatus and stool. Conclusions In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long‐term subjective outcome, despite the fact that many patients have a high incontinence score.     

New biological temporary skin cover Xe-Derma(®) in the treatment of superficial scald burns in children

Background

Xe-Derma^® is a new dry sterile biological cover derived from acellular pig dermis. Hydrated Xe-Derma^® displays bio-mechanical features similar to the normal skin. The aim of the present study was to compare the efficacy of Xe-Derma^® with hydrocolloid dressing Askina THINSite^® for treatment of superficial burns in children in a prospective study.

Materials and methods

In a prospective study, 86 patients (5 months to 7 years of age) with superficial scald burns on a surface area of 1-35% BSA were enrolled. In the course of the study, 43 patients were treated with Xe-Derma^® and 43 patients with Askina THINSite^®. We collected data including the percentage of BSA covered with biological or synthetic material, epithelization time, the number of complete conversions (deepening of 100% of covered area into deep dermal wound) under each cover, the number and extent of partial conversions (deepening of less then 100% of covered area into deep dermal wound), infectious complications, the number of reapplications of the temporary cover and the extent in square centimetres of dressing material needed for successful healing of 1% BSA.

Results

No significant difference in the epithelization time, percentage of conversion from superficial to deep dermal burns and percentage of infectious complication was detected between the two groups. However, patients in the Xe-Derma^® group were burned on a more extensive burn surface area (p ≤ 0.028). Xe-Derma^® showed adherence to the wound and therefore there has been no need to be changed The number of reapplications and therefore also the number of square centimetres needed for successful healing of 1% BSA were statistically higher in the Askina THINSite^® group (p < 0.01) due to increased secretion and accumulation of fluid underneath this hydrocoloid cover. The minimal frequency of changes of this biological cover material brings a significant benefit to pediatric patients.

Conclusion

Acellular pig dermis Xe-Derma^® represents a reliable biological cover material. It is an advantageous alternative to synthetic temporary skin covers in the treatment of superficial scald burns in children.     

Endoscopic stapler‐assisted Zenker's diverticulotomy: Which is the best operative facility?

BACKGROUND: Despite great changes in treatment for Zenker's diverticulum, endoscopic stapler-assisted diverticulotomy (ESD) has not yet been included on the lists of possible day-case procedures, and determining the best operative facility is still a matter of debate. The aim of this article was to evaluate the safety and feasibility of endoscopic treatment for patients with Zenker's diverticulum on a planned 24-hour-stay basis. METHODS: We retrospectively reviewed cases in which patients were admitted to and operated on at the Department of Airway Endoscopic Surgery of the Padua University Hospital over a 5-year period (January 2000 to December 2004). RESULTS: We considered 106 consecutive ESDs performed on 86 patients (1.23 procedures/patient). All procedures were planned on a 24-hour-stay basis ("1-day surgery"). In no case was the endoscopic procedure aborted. The mean operative time was 14 minutes (range, 5-45 minutes). Neither perioperative mortality nor major complications occurred. Minor complications were noted in 3 cases (2.8%). The mean time taken to resume oral intake was 0.83 days (range, 0-1). The mean hospital stay was 1.06 days (range, 0-5). Ninety-nine patients (93.4%) were discharged within the 24 hours after surgery. In no case was readmission necessary. CONCLUSIONS: We believe that ESD is a suitable operation for 1-day surgery. This facility, in fact, ensures the same outcome and safety conditions as with the inpatient procedure, making it possible to rationalize health resource management, reduce hospital costs, and improve patient comfort. In selected cases, ESD could be performed on an outpatient basis.