Use of tissue expanders in the repair of complex abdominal wall defects

Background/Purpose

Closure of abdominal wall defects in children poses a challenge for pediatric surgeons. We describe a technique using tissue expanders placed either intraperitoneally or in the abdominal wall to aid in the reconstruction of a variety of complex abdominal wall defects.

Methods

The tissue expanders are inserted under general anesthesia. Initial expansion is done in the operating room with attention to peak airway pressure, urine output, and end-tidal carbon dioxide. The expanders are inflated in the outpatient setting via percutaneous access until the calculated inflation volume is achieved. They are then removed; and definitive closure is accomplished using a combination of native tissue flaps, abdominal component separation techniques, biomaterials, and synthetic material.

Results

Six children underwent tissue expansion for treatment of abdominal wall defects (omphalocele, n = 3), trauma (n = 1), and thoracopagus twins (n = 1 pair). One to 4 expanders were used per patient, with all having a successful reconstruction of their abdominal walls. Two to 3 operations were required to restore abdominal domain and consisted of expander insertion, removal with reconstruction, and possible revision of the reconstruction.

Conclusions

Tissue expanders possess a broad range of applications for abdominal wall reconstruction and can be used in patients of all ages.     

Management of burn deformities using tissue expanders: a retrospective comparative analysis between tissue expansion in limb and non-limb sites

The tissue expansion technique is in the armamentaria in reconstructive surgery. It provides donor skin that is an optimal match in terms of skin color, texture, sensation and hair-bearing characteristics. Literature shows its applications in all regions from the head to the feet. Tissue expansion in extremities, however, carries a high rate of complications. Fortunately, not every complication in tissue expansion means failure.

Objective

A retrospective comparative analysis between tissue expansion in limb and non-limb sites in burn deformities.

Materials and methods

Sixty expanders in 53 patients were included. These constitute the experience of a single surgeon. Forty expanders (66.6%) were applied to non-limb sites and 20 expanders (33.3%) to limb sites. Indications of tissue expansion were burn alopecia, scarring and contracture. Complications and failures were recorded.

Results

Non-limb expanders had 10% rate of complications and 2.5% of failure. Limb expanders showed 30% complications and 15% failure. Statistical analysis showed that the difference was non-significant at this statistical power.

Conclusion

The non-significant difference regarding complication and failure rates between limb and non-limb expanders in this study encourages the use of tissue expanders in extremities. Close follow-up of patients will prevent many expanders that develop complications from becoming failures.     

The use of intraabdominal tissue expanders as a primary strategy for closure of giant omphaloceles

Background

Giant omphaloceles present a unique challenge to pediatric surgeons because of the difficulty in obtaining timely, tension-free closure of tissues over the defect. Reports of the use of tissue expanders in the subcutaneous space, intramuscular space, or intraabdominal cavity have illustrated the usefulness of this technique to provide biologic closure of abdominal wall defects. However, these reports have focused on use of tissue expanders as a second-line treatment after other options, such as silastic silos or attempted primary closure, have failed.

Methods

We report 2 cases in which intraabdominal tissue expanders were used as a primary strategy to obtain closure of giant omphalocele defects.

Case Reports

The first patient was a baby boy born at 36 weeks by date who was prenatally diagnosed with a giant omphalocele. An intraabdominal tissue expander was placed at 2 weeks of age. The tissue expander was removed and his abdomen was primarily closed at 8 weeks of age. The second patient was born at 25 weeks gestation as part of a twin gestation with severe intrauterine growth retardation (600 g birth weight). Bedside reduction was not attempted because of severe pulmonary hypertension and significant loss of abdominal domain because of herniated liver and bowel. At 8 months of age, she underwent laparoscopically assisted placement of an intraabdominal tissue expander. At 9 months of age, the tissue expander was removed, all abdominal viscera were reduced, and the defect was closed using only an 8 × 8-cm piece of AlloDerm (LifeCell, Branchburg, NJ). Both children are currently at home and doing well.

Conclusions

We believe that early use of intraabdominal tissue expanders provides a more expedient method of obtaining closure of the defect in giant omphaloceles.     

Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Cesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation

Study Objective

To determine if prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia.

Design

Prospective, randomized, double-blinded, placebo-controlled study.

Setting

Large university-affiliated community hospital.

Patients

81 consecutive term parturients (not in active labor) who were scheduled for elective Cesarean section.

Interventions

Parturients received 1.0 to 1.5 L of intravenous Ringer's lactate and either glycopyrrolate 0.4 mg or an equal volume of saline, with caregivers blinded to the immediate sequelae of study drug. Each patient received intrathecal bupivacaine (12 to 14 mg) with morphine sulfate (0.1 to 0.2 mg).

Measurements

Continuous heart rate (HR) and blood pressure monitoring occurred for 20 minutes, with the minimum HR recorded for each 5-minute epoch. Heart rates < 60 beats per minute defined bradycardia. Heart rate variability (HRV) analysis occurred offline.

Main Results

None of 34 patients administered glycopyrrolate and 6 of 35 (17%) patients receiving saline experienced bradycardia (P = 0.02476). Time domain, frequency domain, and nonlinear and embedded spectrum entropy analyses all reflected the decrease in HRV accompanying administration of glycopyrrolate.

Conclusion

Bradycardia after spinal anesthesia occurs commonly. Prophylactic glycopyrrolate may prevent the bradycardia, but not necessarily the hypotension.     

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement

Background/Purpose

Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines.

Methods

This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases.

Results

A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance.

Conclusions

Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.     

Advantages of minimally invasive, balloon-dissector-assisted tissue expander placement: a clinical and experimental study

BACKGROUND: Tissue expansion has been dependent upon healing the access incision after placement. Delay can be reduced with minimally placed expanders. Smaller, remote incisions allow for earlier expansion. METHODS: Balloon-assisted tissue expander placement was evaluated in a pig model and compared with open placement. Open placement with delayed expansion versus minimally invasive placement with immediate expansion, and open placement with immediate expansion versus balloon dissection with delayed expansion were compared. Our clinical series with balloon dissector tissue-expander placement was reviewed. Fifty-two tissue expanders were placed minimally invasively and successfully expanded. RESULTS: Use of balloon dissector in the pig model yielded a shorter reconstructive period, faster expansion, and greater flap advancement. Clinical results revealed no infections, dehiscence, extrusion, or hematomas. All cases had expansion begun intraoperatively and were successfully expanded. CONCLUSIONS: Minimally invasively placed expanders resulted in shorter expansion times, the ability to institute immediate expansion, and improved expansion compared with open placement.     

The use of a powdered polysaccharide hemostat (HemoStase) in live donor nephrectomies controls bleeding and reduces postoperative complications

Objective

This study assesses the use of microporous hemospheres (hemoStase) procedures to control bleeding and reduce associated unfavorable sequelae in live donor nephrectomy (LDN).

Methods

Forty-four consecutive patients who underwent LDN between January 2009 and August 2009 were included in this prospective study. HemoStase (CryoLife, Inc), Kennesaw, Georgia) was used topically in the kidney bed to avoid bleeding. We recorded intraoperative and postoperative bleeding control, re-exploration to control bleeding, surgical site fluid collection, infection, and postoperative wound complications.

Results

Hemostasis was achieved in all 44 (100%) patients, none of whom experienced postoperative bleeding, fluid collection, infection or required re-exploration of the surgical site.

Conclusion

HemoStase is a safe, facile hemostatic agent that effectively controls bleeding and reduces associated postoperative complications in LDN cases.     

Epidemiology and risk factors for corneal graft rejection

Objective

The aim of this study was to evaluate the frequency and main risk factors for corneal graft rejection.

Patients and Methods

This retrospective study included 285 eyes in 256 patients who underwent a penetrating keratoplasty (KPT) from January 1995 to December 2004. The minimum follow-up was 12 months to evaluate graft evolution. Except for complications, the follow-up was weekly, then monthly for 6 months, and ultimately quarterly during the first year. Thereafter the follow-up was performed semi-annually. Patients were informed about the functional signs for which they have to urgently consult.

Results

Immunologic rejection of the corneal graft occurred in 128 KPT in 112 patients (rejection frequency = 41%). The identified main risk factors were new vascularization of the recipient cornea over 2 or more quadrants, corneal opacity due to an infectious origin, posttraumatic corneal opacity or congenital glaucoma, graft diameter >8 mm, and therapeutic KPT.

Conclusions

Rejection of the corneal graft is the primary cause of KPT failure. One out of 2 graft failures was due to rejection. Two criteria are unanimously recognized as risk factors for rejection: neovascularization of recipient cornea and antecedents of corneal rejection. The rejection must be treated early to not endanger graft success, which imposes a close follow-up for grafted patients.     

Outcomes of surgical and radiologic placed implantable central venous access ports

Background

Recent literature suggests implantable central venous access ports (ICVAPs) can be placed by interventional radiologists with fewer complications and lower expenses when compared with surgeons. An analysis of outcomes and expenses of ICVAP placement by service was conducted.

Methods

Three hundred sixty-eight ICVAPs were placed over 3 years at a 230-bed community teaching hospital. A retrospective review of these procedures was conducted. Data recorded for each procedure included patient demographics, reason for placement, indwelling port days, complications, billed charges, and reimbursement.

Results

Two hundred seventy-six (75%) ICVAPs were placed by interventional radiologists, while surgeons placed the remaining 92 ports (25%). Short-term complications were identified in 7 interventional radiologist-placed ports (2.5%) and 1 surgically placed port (1.1%), P = .42. Billed charges were greater for interventional radiologist-placed ports ($5,301 vs $4,552, P = .0001). In contrast, reimbursement was greater for surgically placed ports: interventional radiologist 31.3% of charges, surgery 42.8%, P = .049.

Conclusion

Reimbursement and charges demonstrated significant differences between surgeons and interventional radiologists. Prior assertions that ports placed by interventional radiologists are less expensive with fewer complications may no longer be valid.     

Management of giant omphalocele with rapid creation of abdominal domain

Background

The management of giant omphaloceles (GO) can be quite difficult when there is absence of abdominal domain. Coverage with delayed closure has been described. We present a technique to create an adequate peritoneal domain.

Methods

This is a retrospective review of our experience using an intraperitoneal tissue expander (IPTE) to create adequate abdominal domain in 2 patients with GO.

Results

In 2 children with unrepaired GO, an IPTE was placed into the pelvis and was inflated to the target volume over 3 to 4 weeks. At the definitive operation for the closure of the abdominal defect, the IPTE was removed, allowing reduction of all the viscera into the peritoneal cavity and achieving complete abdominal wall closure. The patients are now 1 year postoperative, each having a normal abdomen and enjoying normal growth and development.

Conclusion

Intraperitoneal tissue expander placement can create the needed domain over several weeks in GO. Its use in 2 cases was associated with satisfactory complete abdominal wall closure in short order. This technique should be considered as a treatment option.     

MANOS: colecistectomías transvaginales. Reporte preliminar

Objective

To present the first transvaginal cholecystectomies performed in Cuba.

Methods

This is a study involving 7 female patients. The ages of the patients varied from 33 to 62 years of age, with an average age of 47.7. All of them had symptomatic cholelithiasis performed between March 11, 2008 and May 7, 2008. The operation performed in each case was a transvaginal cholecystectomy assisted with minilaparoscopy. Inclusion criteria: Females between 18 and 65 years old; diagnosis of disease which requires cholecystectomy. The exclusion criteria included ASA III and IV, morbidly obese patients (BMI >35), venereal diseases, acute and chronic pelvic inflammatory diseases, virgins and pregnant patients. The operations were performed by general surgeons using rigid laparoscopic instruments. Studied: operating room time; analgesia required and post-operative complications

Results

The operating room time was between 61 and 86 min, with an average of 72.4 min. Patients required no analgesia during the post-operative period. They were discharged in less than 24 h following surgery. We found no complications in follow-up visits for up to one month after surgery.

Conclusions

Minilaparoscopic-assisted transvaginal cholecystectomy is a feasible and safe method for expert laparoscopic surgeons. This technique was, and could be, performed using rigid, currently available laparoscopic instruments. Minilaparoscopic- assisted natural orifice surgery (MANOS) could be an intermediate step between Laparoscopic surgery and NOTES.     

Racial disparities in motorcycle-related mortality: an analysis of the National Trauma Data Bank

Background

Studies have shown racial disparities in outcomes after motor vehicle crashes; however, it is currently unknown if race impacts the likelihood of mortality after a motorcycle crash (MCC). The primary objective of this study was to determine if race is associated with MCC mortality.

Methods

We performed a retrospective cross-sectional analysis of MCCs included in the National Trauma Data Bank between 2002 and 2006. Multiple logistic regression was used to adjust for age, sex, insurance status, year, helmet use, and injury severity characteristics.

Results

Black patients had a 1.58 (95% confidence interval, 1.28-1.97) increased odds of mortality after a MCC, but were more likely to use a helmet (1.30; 95% confidence interval, 1.19-1.43) compared with their white counterparts (n = 62,840).

Conclusions

Black motorcyclists appear more likely to die after a MCC compared with whites. Although the reasons for this disparity are unclear, these data suggest that resources beyond encouraging helmet use are necessary to reduce fatalities among black motorcyclists.     

Conjoined twins--past, present, and future

Background/Purpose

Conjoined twins are rare and complex anomalies of the newborn. They require a highly experienced team and a center equipped to deal with such challenging anatomy.

Method

A review of 31 sets of conjoined twins was managed by one team over a 15-year period. The spectrum of the anomalies, management strategies, and outcomes will be analyzed with future recommendations.

Results

Ten sets of complete conjoined twins and two sets of parasitic conjoined twins were successfully separated. Tissue expanders and prosthetic meshes were not required. A separation of one set of craniopagus parasiticus conjoined twins was attempted, but abandoned owing to major vascular and brain sharing. The remaining 18 sets were not separable owing to major cardiac anomalies and/or sharing, and all died within several weeks of birth.

Conclusion

Careful planning, a multidisciplinary approach, rehearsal, and experience are important factors in dealing with conjoined twins. Tissue expanders and prosthetic meshes are not required in most cases. Selective abortion or fetal intervention may play a role in the future.     

Risk factors for early peritoneal dialysis catheter failure in children

Background

There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan.

Methods

A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or χ² analysis.

Results

There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 ± 7 years) were younger than patients with a functioning catheter at 2 months (12 ± 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type.

Conclusion

Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.     

Thoracoscopy using a substernal handport for palpation

Background

A substernal handport allows palpation of the lung and thus circumvents one of the major limitations of thoracoscopy.

Methods

This approach has been used in 24 consecutive patients, primarily during planned metastasectomy or when palpation was needed for deeper or smaller lesions that were difficult to find.

Results

No long-term complications from this procedure were noted, and the 3 early complications were either minor or unrelated to the procedure. This approach allowed adequate resection to be accomplished by a less invasive approach in 67% of patients, although conversion to an open procedure was necessary in 33% of patients for anatomic and technical reasons. Among the 16 patients who underwent this procedure alone, the median length of stay in the hospital was 3 days. The rate of incomplete resection and of recurrence after metastasectomy was comparable to that for an open approach.

Conclusions

Our experience documents that a substernal handport is safe, does not compromise the ability to perform an adequate metastasectomy, and allows biopsy of lesions that are otherwise not amenable to a minimally invasive approach. This technique should be included in the standard armamentarium of approaches for thoracic surgery.     

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

Background

Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver.

Methods

To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients.

Results

In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months.

Conclusions

This procedure could represent a useful method for preventing postoperative venous congestion.     

Bronchial Complications Following Lung Transplantation

Introduction

Bronchial complications owing to the airway anastomosis in lung transplantation are important causes of morbidity and mortality. They occur in up to 27% of cases as defined by stenosis, necrosis, and dehiscence. Treatment depends on the type of complication.

Objective

To report our experience to treat this complication.

Methods

Between 2000 and 2007, we performed 71 lung transplants of which 36 were bilateral. The total number of anastomoses was 107:52 to the right and 55 to the left. The telescoping technique was initially used (14 initial unilateral transplants), and after October, 2003 it was changed to an end-to-end anastomosis (57 transplants and 93 anastomoses).

Results

Eight patients developed bronchial complications including two that were bilateral. There were 4 stenosis, 3 dehiscences, and 3 necrosis complications (9.4%). The complication rate for telescoping anastomosis was 21.4%, and for the end-to-end technique, 7.5%. The treatment of the stenosis used metallic or plastic self-expandable stents. Two bronchial dehiscences resulted in case of bronchopleural fistulae, empyema, and death; the other patient experienced spontaneous resolution. Concerning bronchial necrosis, 1 patient developed fistulization to the pulmonary artery and massive hemoptysis, and the other with bilateral necrosis, a spontaneous resolution.

Conclusion

Our bronchial anastomosis complication rate was comparable with that in other reports. The rate for the telescoping technique was greater compared with the end-to-end technique. The treatment of bronchial stenosis with a self-expandable prosthesis showed good results.     

The effect of timing of postmastectomy radiation on implant-based breast reconstruction: a retrospective comparison of complication outcomes

Background

The optimal timing of postmastectomy radiation for women undergoing delayed permanent implant exchange continues to remain controversial. The objective of our study is to compare complication rates when tissue expanders are exchanged for permanent implants pre- vs postradiation.

Methods

A retrospective review of 54 consecutive patients who underwent implant-based breast reconstruction and received postmastectomy radiation was conducted. Complications including infection, implant loss, and capsular contracture (measured in Baker score) were compared between the 2 groups.

Results

Of the patients studied, 32 patients had radiation before placement of permanent implants, whereas 22 patients received radiation after implant placement. There was no difference in individual complication rates between the 2 groups.

Conclusions

In our study of 54 patients, the timing of radiation did not affect individual complication rates for patients who underwent implant-based breast reconstruction after immediate tissue expander placement.     

AVAS Best Clinical Resident Award (Tied): Management and outcomes of the open abdomen in nontrauma patients

Background

Little is known regarding the morbidity and mortality of the open abdomen technique in older nontrauma patients.

Methods

A retrospective chart review identified cases of emergency laparotomy in which open abdomens were used.

Results

Eighty-eight patients with open Acute Physiology and Chronic Health Evaluation (APACHE) abdomens were identified. An overall mortality rate of 34%, consistent with mortality predicted by APACHE IV score, was seen. Common complications included ventilator-associated pneumonia (30%) and acute renal failure (22%). A perioperative APACHE IV score of greater than 65 and an albumin level less than 2.5 g/dL were found to predict an increased likelihood of long-term assisted care placement after discharge from the acute care setting.

Conclusions

The use of the open abdomen technique in older nontrauma patients carries acceptable morbidity and mortality given the acuity of disease. Focus on ventilator-associated pneumonia prevention and aggressive fluid resuscitation to avoid acute renal failure may improve outcomes. Need for long-term assisted care placement can be predicted early after admission based on the APACHE IV score or albumin level.