HB-107, a nonbacteriostatic fragment of the antimicrobial peptide cecropin B, accelerates murine wound repair

Antimicrobial peptides are essential to innate host defense as effectors of pathogen clearance and can modify host cell behaviors to promote wound repair. While these two functions appear interrelated, it is unclear whether the ability to aid in wound repair requires inherent antimicrobial function. We hypothesized that the influence of antimicrobial peptides on wound repair is not dependent on antimicrobial function. To explore this, we analyzed the microbial killing activity of peptide fragments and correlated this with the ability to influence wound repair in mice. HB-107, a peptide lacking antimicrobial activity and originally derived from the antimicrobial cecropin B, showed up to 64 percent improvement in wound repair compared to scrambled peptide and vehicle controls, an effect comparable to treatment with recombinant human platelet-derived growth factor-BB (formulated as Regranex). Wounds treated with HB-107 showed keratinocyte hyperplasia and increased leukocyte infiltration. Furthermore, HB-107 stimulated interleukin-8 secretion from cultured endothelial cells, an effect that may explain the increase in leukocyte migration. These findings confirm that antimicrobial peptides can function as effectors of cutaneous wound repair. Moreover, this study furthers our understanding of antimicrobial peptides by showing that their wound repair properties can be independent of antimicrobial function.     

First Hungarian, internet-based prospective, multicenter study: the hernia-project

In inguinal hernia repair, different laparoscopic and open techniques of tension-free repair using synthetic meshes have been reported to result in better patient comfort and lower recurrence rates compared with conventional procedures like Shouldice's or Bassini's operation. In comparison with the laparoscopic procedure, open tension-free repair can be performed under local anaesthesia and is less expensive. For these reasons, the recent trend in inguinal hernia surgery, has been towards using an open, mesh-based tensionless repair (Lichtenstein technique). To evaluate and support the widespread use of this technique in Hungary a large, prospective multicentre trial was initiated at 15 March 1999. Prospective registration of 1500 hernia operation using Lichtenstein technique is undertaken that is carried out in 15 hospitals. Postoperative outcome, complications and recurrence is recorded through a five years period. The case presentation and data collection is internet based. Each center participating in the study is connected by internet to the coordinating center and all information concerning this study is sent by this way. This system is able to generate actual statistical data in every moment of the study.     

Rapid two-stage repair of S,L,L, ventricular septal defect, pulmonary atresia, Ebstein anomaly of the tricuspid valve, and stenotic pulmonary arteries.

The repair of a corrected transposition of the great arteries, ventricular septal defect, and pulmonary atresia is presented. An Ebstein anomaly of the tricuspid valve, dextrocardia, and severe distortion of the pulmonary arteries complicated the surgical procedure, which was performed in two stages. Reconstruction of the pulmonary arteries and a bidirectional cavopulmonary anastomosis were performed first; Rastelli and hemi-Mustard procedures completed the correction. The rationale and the possible indications of this "one and a half ventricle" repair are discussed.     

Mitral valve repair for broad, asymmetrical prolapse in the posterior mitral leaflet

We designed a mitral valve repair and successfully performed this repair for a case of broad, asymmetrical prolapse in the middle scallop of the posterior mitral leaflet. The repair procedure consists of making a fan-shaped leaflet by resecting the prolapsed portion in a trapezoid shape with detachment of the leaflet along the annulus and leaflet reapproximation by rotating this fan-shaped leaflet. This technique can utilize more leaflet tissue for filling the gap made by leaflet resection than the quadrangular resection and suture technique. As a result, it helps reduce tension on the suture lines, avoids the need for extensive annular plication, and also avoids leaflet distortion while making it easier to adjust the height of the leaflets that should be reapproximated. The essence of this mitral valve repair exists in the “resecting line of the leaflet,” which has not yet been reported.     

The role of cytokines, coagulation, and fibrinolysis in peritoneal tissue repair.

Peritoneal tissue repair is a distinct entity. Regardless of the type of injury, a common series of events follows, culminating in inflammation and restoration. Molecular actors interact in a series of events in which the balance of fibrin deposition and degradation is vital. Although the complexity of the repair is illustrated by the multitude of effects and the overlap of molecular mediators involved, a framework is emerging. In this context, the overall role of cytokines is to shift the balance of fibrin deposition and degradation in favour of fibrin residues. Coagulation, as well as generating fibrin, is probably of importance in stimulating remesothelialisation, and fibrinolysis is instrumental in the degradation of fibrin deposits. As far as wound healing in concerned, we propose that the ultimate goal may not be to prevent adhesions, but rather to control their formation. To attain this, site-specific modulation of the repair process is essential. The new insights in mediators and modulators reviewed in this paper may provide means for site-specific modulation of peritoneal tissue repair as well as constituting molecular markers of the repair process.     

Patient perception of laparoscopic versus open mesh repair of inguinal hernia, the hard sell

Background

Inguinal hernia repairs are one of the most commonly performed procedures in the UK. This study examined the adequacy of the consent process for inguinal hernia repair focusing on the patients’ understanding of the relative risks and benefits of laparoscopic versus open repair.

Methods

The study consisted of a retrospective postal questionnaire poll of 200 patients (162 males and 38 females) aged between 42 and 85 who had been assessed in the surgical outpatients (within the last 12?months) and received counselling regarding their inguinal hernia repair. Patient perception regarding the risks and merit of laparoscopic versus open repair was surveyed using a multiple-choice questionnaire.

Results

One hundred and twenty patients (60?%) returned their questionnaires, after excluding recurrent and bilateral hernias; 97 patients were entered into the study. The majority of patients reported a perception that a laparoscopic repair was safer and quicker than open (61.5 and 75.4?%, respectively); 29.2?% of patients felt that the recurrence rate was lower with a laparoscopic repair with 50.8?% of patients expressing that open repair had a higher complication rate than laparoscopic treatment; 81.5?% of patients correctly appreciated that laparoscopic repair had a quicker return to work; and 76.9?% of patients felt that laparoscopic repair was the only method, which could be undertaken as a day case procedure.

Conclusion

The results show that many patients have an incorrect perception of laparoscopic inguinal hernia repair, which may reflect an inadequate consent and counselling process. No definitive evidence exists regarding the superior safety and efficacy of one method over another, but it would appear that a significant number of patients are unaware of this.     

Survival after ruptured abdominal aortic aneurysm: effect of patient, surgeon, and hospital factors

OBJECTIVE: The purpose of this study was to determine the effects of patient, surgeon, and hospital factors on survival after repair of ruptured abdominal aortic aneurysm (AAA) and to compare them with risk factors for survival after elective AAA repair. It was hypothesized that patients operated on by high-volume surgeons with subspecialty training would have better outcomes, which might argue for regionalization of AAA surgery. METHODS: In this population-based retrospective cohort study, surgeon billing and administrative data were used to identify all patients who had undergone AAA repair between April 1, 1992, and March 31, 2001, in Ontario, Canada. Demographic information was collected for each patient, as well as numerous variables related to the surgeons and hospitals. RESULTS: There were 2601 patients with ruptured AAA repair, with an average 30-day mortality rate of 40.8%. Significant independent predictors of lower survival were older age, female gender, lower patient income quintile, performance of surgery at night or on weekends, repair in larger cities, surgeons with lower annual volume of ruptured AAA operations, and surgeons without vascular or cardiothoracic fellowship training. There were 13,701 patients with elective AAA repair, with an average 30-day mortality rate of 4.5%. Significant independent predictors of lower survival were similar, except gender was not significant, but the Charlson Comorbidity Index was. When the hazard ratios associated with predictive factors were compared, surgeon factors appeared to be more important in ruptured AAA repair, and patient factors appeared more important in elective AAA repair. CONCLUSION: For elective AAA repair, and even more so for ruptured AAA repair, high-volume surgeons with subspecialty training conferred a significant survival benefit for patients. Although this would seem to argue in favor of regionalization, decisions should await a more complete understanding of the relationship between transfer time, delay in treatment, and outcome.     

Repair of hypospadias complications using the tubularized, incised plate urethroplasty

BACKGROUND/PURPOSE: Secondary procedures to correct complications after hypospadias repair remain challenging especially for "hypospadias cripples." The tubularized, incised plate urethroplasty was first introduced by Snodgrass for the repair of primary hypospadias in 1993. The authors used this procedure to correct the complications after hypospadias repair in patients who had no abundant local skin flaps to be used for a neourethra. METHODS: Six patients underwent tubularized, incised plate urethroplasty for the correction of complications of hypospadias repair performed the previous year, including a large urethrocutaneous fistula (n = 1) and disruption of the neourethra (n = 5). Prior surgical procedures included transverse island tube urethroplasty in 4 cases and 2-stage urethroplasty in 2 cases. The average patient age at the time of secondary procedure was 4.6 years (range, 1 to 12 years). RESULTS: The mean follow-up period was 6 months (range, 2 months to 1 year). All the patients obtained a functional neourethra with a vertical, slitlike meatus. A small fistula developed in one child and mild meatal retraction in another. CONCLUSIONS: The tubularized, incised plate urethroplasty offers few complications and good cosmetic results. The authors recommend its use for patients who have had repeated surgeries for hypospadias repair, especially those in whom only limited local skin flaps can be utilized for a neourethra.     

Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome

The purpose of this study was to document the diagnosis, surgical treatment, and functional outcome in patients with subscapularis ruptures after shoulder arthroplasty. Prospective objective and subjective data were collected on 7 patients with symptomatic rupture of the subscapularis tendon after shoulder arthroplasty. Presenting signs and symptoms included pain, weakness in internal rotation, increased external rotation, and anterior instability. All patients were treated with surgical repair of the ruptured tendon. Four required repair augmentation with a transfer of the pectoralis major tendon. After subscapularis repair and pectoralis transfer, 2 patients continued to have anterior instability and required an additional operation to address the instability. At a mean follow-up of 2.3 years (range, 18-55 months), the mean American Shoulder and Elbow Surgeons shoulder score in this study group was 63.2. The mean patient satisfaction rating, on a 10-point scale, was 6.2. Factors associated with post-arthroplasty subscapularis ruptures included subscapularis lengthening techniques used to address internal rotation contracture and previous surgery that violated the subscapularis tendon. Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation after arthroplasty. Although symptoms were adequately addressed with appropriate surgical treatment, decreased functional outcomes were observed.     

Endoscopic extraperitoneal inguinal hernia repair with double mesh: indications, technique, complications, and results

Although totally extraperitoneal laparoscopic hernia repair has the same benefits attributed to the traditional preperitoneal prosthetic surgical repair, this procedure is not used widely because of perceived difficulty in dissection. Since one of the most common causes of hernia recurrence in this procedure is inadequate lateral inferior and medial inferior mesh fixation, we have introduced a double-mesh technique in an effort to reduce the rate of recurrence. Our procedure is a variation of the totally extraperitoneal laparoscopic inguinal hernia repair and provides a more secure inguinal floor by adjusting the second mesh to the area of weakness. We describe the laparoscopic inguinal hernia repair by the extraperitoneal double-mesh technique performed in 53 selected patients with very large indirect hernias and extremely large bilateral or recurrent hernias. The mean operative time was 74 minutes for unilateral hernias and 110 minutes for bilateral hernias. The median follow-up time was 65 months (range, 9-97 months) with no recurrences, neuralgia, or bleeding complications. We believe that this technique offers perfect positioning of the meshes and provides the most secure inguinal floor. Therefore, the method is presented for consideration in the laparoscopic repair of large indirect, direct, or recurrent hernias.     

Surgical repair of inguinal hernia in the adult Clinical, functional, and economic outcomes of surgical practices

Inguinal hernia repair is the most commonly performed surgical procedure. Nearly one out of three men between 20 and 60 years of age will undergo hernia repair. Multiple surgical techniques are available which have comparable clinical outcomes but which differ in their functional results and economic impact. Despite an extensive surgical literature, no consensus exists regarding an optimal technique. This review aims to compare the indications for the three most common techniques: 1) the Shouldice repair, 2) the Lichtenstein repair, and 3) the laparoscopic hernia repair. To begin with, we present the operative principals of each repair along with criteria for evaluation of outcomes. Evidence-based outcomes data are then presented. We then address the choice of a surgical technique for everyday practice based on these factors. Finally, we propose avenues for future clinical research which may improve clinical, functional, and economic results in the repair of inguinal hernia of the adult.     

Laser, fibrin glue, or suture repair of peripheral nerves: a comparative functional, histological, and morphometric study in the rat sciatic nerve

OBJECT: This study was undertaken to evaluate CO2 laser-assisted nerve repair and compare it with nerve repair performed with fibrin glue or absorbable sutures. METHODS: In eight rats, the sciatic nerve was sharply transected and approximated using two 10-0 absorbable sutures and then fused by means of CO2 milliwatt laser welding (power 100 mW, exposure time 1 second per pulse, spot size 320 microm), with the addition of a protein solder (bovine albumin) to reinforce the repair site. The control groups consisted of eight rats in which the nerves were approximated with two 10-0 absorbable sutures and subsequently glued using a fibrin sealant (Tissucol), and eight rats in which the nerves were repaired using conventional microsurgical sutures (four to six 10-0 sutures in the perineurium or epineurium). Evaluation was performed 16 weeks postsurgery and included the toe-spreading test and light microscopy and morphometric assessment. The motor function of the nerves in all groups showed gradual improvement with time. At 16 weeks, the motor function was approximately 60% of the normal function, and there were no significant differences among the groups. On histological studies, all nerves revealed various degrees of axonal regeneration, with myelinated fibers in the distal nerve segments. There were slight differences in favor of the group treated with laser repair, in terms of wound healing at the repair site. In all groups, the number of axons distal to the repair site was higher compared with those proximal, but the axon diameter was significantly less than that in control nerves (p < 0.05). There were no significant differences in the number, density, or diameter of the axons in the proximal or distal nerve segments among the three nerve repair groups (p < 0.05), although there was a trend toward more and thicker myelinated axons in the distal segments of the laser-repaired nerves. CONCLUSIONS: It was found that CO2 laser-assisted nerve repair with soldering is at least equal to fibrin glue and suture repair in effectiveness in a rodent model of sciatic nerve repair.     

The 30-day mortality of ruptured abdominal aortic aneurysms: influence of gender, age, diameter and comorbidities

AIM: The aim of this study was to determine the influence of gender, age, the aneurysm diameter and comorbidity on the 30-day mortality after open repair of ruptured abdominal aortic aneurysms (AAA). METHODS: Between January 1, 1993, and December 31, 2006 all consecutive patients who underwent open repair for a ruptured AAA at the tertiary care of Catharina teaching Hospital were included in this study (N=186). Patients who underwent endovascular repair of their ruptured abdominal aortic aneurysms were excluded from this study. Patient and procedure characteristics were collected and analyzed in relation to 30-day mortality. The association between age, gender, diameter of AAA and comorbidity with 30-day mortality was analyzed with c2 are and logistic regression; a P value <0.05 was considered significant. RESULTS: In this study there were 186 patients with ruptured AAA repair with an 30-day mortality of 36.6% (68/186). Among female patient 30-day mortality was 45.8% (11/24) compared with 35.2% (57/162) among male patients (P=0.31). Patients of 80 years and older had a 61.3% (19/31) 30-day mortality where younger patients had 33% (51/155) 30-day mortality (P=0.02). Thirty-day mortality was 47.2% (17/36) for patients with an AAA less than 65 mm compared with 34% (36/104) for patients with an AAA of 65 mm or larger (P=0.16). Multivariate analysis demonstrated age was a significant predictor of ruptured AAA repair mortality (P=0.017). CONCLUSION: In this study, age was the only significant risk factor of 30-day mortality after open repair in patients with ruptured AAA.     

Cells, matrix, growth factors, and the surgeon. The biology of scarless fetal wound repair.

OBJECTIVE: This review updates the surgeon about the cellular, matrix, and growth factor components of scarless fetal wound repair. SUMMARY BACKGROUND DATA: Fetal skin wound healing is characterized by the absence of scar tissue formation. This unique repair process is not dependent on the sterile, aqueous intrauterine environment. The differences between fetal and adult skin wound healing appear to reflect processes intrinsic to fetal tissue, such as the unique fetal fibroblasts, a more rapid and ordered deposition and turnover of tissue components, and, particularly, a markedly reduced inflammatory infiltrate and cytokine profile. Scarless fetal wounds are relatively deficient in the inflammatory cytokine, transforming growth factor beta (TGF-beta). In contrast, the fibrosis characteristic of adult wound repair may be associated with TGF-beta excess. Recent experimental studies suggest that specific anti-TGF-beta therapeutic strategies can ameliorate scar formation in adult wound repair and fibrotic diseases. Inhibitors of TGF-beta may be important future drugs to control scar. CONCLUSIONS: Based on the scarless fetal wound repair model, a number of ways in which the matrix and cellular response of the healing adult wound might be manipulated to reduce scarring are reviewed.     

Embryology, anatomy, and surgical applications of the preperitoneal space

The preperitoneal space is presented from an embryologic, anatomic, and surgical standpoint in detail. Because this space is one of the most used areas for the repair of groin hernias, knowledge of its embryology and anatomy is essential.     

A new, easy, and safe suturing technique for laparoscopic repair of Morgagni hernias

Laparoscopic repair is gaining attention as a minimally invasive surgical option for children with Morgagni hernias. There are very few reports in the literature in which different suturing techniques are described. In this report, the authors detail a new, easy, and safe suturing technique used in the laparoscopic repair of a Morgagni hernia in a five-and-a-half-month-old baby.     

Advances in aortic valve repair: focus on functional approach, clinical outcomes, and central role of echocardiography

The surgical classification of aortic regurgitation (AR) is based on cusp mobility. Based on this classification, there are 3 classes of AR: type I is defined as normal cusp mobility, type II is defined as excessive cusp mobility, and type III is defined as restricted cusp mobility. Patients often have multiple coexisting mechanisms. Because aortic valve (AV) repair is safe, effective, and durable, it likely will become a mainstream surgical option for the management of significant AR, even in the setting of a bicuspid valve. Intraoperative transesophageal echocardiography has a central role at all stages in AV repair. Before cardiopulmonary bypass, it can accurately diagnose the mechanism of AR to guide operative strategy for successful repair. After separation from cardiopulmonary bypass, it can comprehensively evaluate the AV repair, including the likelihood that the repair will be durable in the long-term. Important echocardiographic predictors of a durable AV repair include the absence of AR, cusp coaptation above the annular plane, a coaptation length >4 mm, and an effective cusp height >8 mm. The clinical applicability of AV repair continues to expand and likely will evolve into a mainstream surgical therapy for AR, including minimally invasive techniques.     

Nerve repair,grafting, and nerve transfers

Advances in the field of peripheral nerve surgery have increased our understanding of the complex cellular and molecular events involved in nerve injury and repair. Application of these important discoveries has led to important developments in the techniques of nerve repair, nerve grafting, nerve allografts, end-to-side repairs, and nerve-to-nerve transfers. As our understanding of this dynamic field increases, further improvement in functional outcomes after nerve injury and repair can be expected.     

Intraluminal pressure, transmucosal potential difference, and pH studies in the oesophagus of patients before and after Collis repair of a hiatal hernia

Intraluminal pressure, transmucosal potential difference, and endo-oesophageal pH measurements were studied in patients with hiatal hernia—before and after a hiatal repair. The operation employed is the Collis (1968) repair for uncomplicated hiatal hernia and does not refer to gastroplasty as recommended for peptic stricture (Collis, 1961). Postoperative studies show that the repair approximates the inferior oesophageal sphincter to the hiatus with the production of a single band of raised pressure at the lower end of the oesophagus. This band is similar to that seen in normal subjects and its appearance was associated with cure of the symptoms, abolition of the gastro-oesophageal reflux, and improvement in the function of the inferior oesophageal sphincter and the musculature of the body of the oesophagus. Certain physiological implications of this study are discussed.