Patience is a virtue: Multiple preoperative visits are associated with decreased recurrence in pediatric pilonidal disease

Background/PurposeThis study aimed to compare preoperative management strategies for patients undergoing trephination for pilonidal disease and evaluate risk factors for recurrence.MethodsA retrospective review was performed of children undergoing index surgical treatment with trephination for pilonidal disease between September 2017 and April 2019. Intraoperative and postoperative management were standardized. Demographic and perioperative data were collected and analyzed.ResultsOne-hundred twenty patients were identified with a median follow-up time of 7.5 months (interquartile range 4.1–13.2 months). Overall, 24 (20%) patients had a postoperative recurrence of pilonidal disease. Patients with multiple preoperative surgery clinic visits were less likely to have recurrent disease compared to those seen only once preoperatively (11% vs 26%, p = 0.040). Compared to patients without recurrence, those who recurred went to the operating room sooner from the time of initial surgical consultation (32 days vs 54 days, p < 0.001). Perioperative antibiotics, history of acute infection, and prior drainage procedures were not risk factors for recurrence.ConclusionsMultiple preoperative clinic visits are associated with a lower recurrence rate in children undergoing trephination for pilonidal disease. An increased duration of preoperative medical management may be responsible for this finding. Prospective study is needed to confirm these findings and identify additional factors that influence recurrence.Type of StudyTreatment Study.Level of EvidenceIII (Retrospective Comparative).     

IFATS collection: Adipose stromal cells adopt a proangiogenic phenotype under the influence of hypoxia

Evolving evidence suggests a possible role for adipose stromal cells (ASCs) in adult neovascularization, although the specific cues that stimulate their angiogenic behavior are poorly understood. We evaluated the effect of hypoxia, a central mediator of new blood vessel development within ischemic tissue, on proneovascular ASC functions. Murine ASCs were exposed to normoxia (21% oxygen) or hypoxia (5%, 1% oxygen) for varying lengths of time. Vascular endothelial growth factor (VEGF) secretion by ASCs increased as an inverse function of oxygen tension, with progressively higher VEGF expression at 21%, 5%, and 1% oxygen, respectively. Greater VEGF levels were also associated with longer periods in culture. ASCs were able to migrate towards stromal cell-derived factor (SDF)-1, a chemokine expressed by ischemic tissue, with hypoxia augmenting ASC expression of the SDF-1 receptor (CXCR4) and potentiating ASC migration. In vivo, ASCs demonstrated the capacity to proliferate in response to a hypoxic insult remote from their resident niche, and this was supported by in vitro studies showing increasing ASC proliferation with greater degrees of hypoxia. Hypoxia did not significantly alter the expression of endothelial surface markers by ASCs. However, these cells did assume an endothelial phenotype as evidenced by their ability to tubularize when seeded with differentiated endothelial cells on Matrigel. Taken together, these data suggest that ASCs upregulate their proneovascular activity in response to hypoxia, and may harbor the capacity to home to ischemic tissue and function cooperatively with existing vasculature to promote angiogenesis.     

Akt‐mediated mechanotransduction in murine fibroblasts during hypertrophic scar formation

Although numerous factors are implicated in skin fibrosis, the exact pathophysiology of hypertrophic scarring remains unknown. We recently demonstrated that mechanical force initiates hypertrophic scar formation in a murine model, potentially enhancing cellular survival through Akt. Here, we specifically examined Akt‐mediated mechanotransduction in fibroblasts using both strain culture systems and our murine scar model. In vitro, static strain increased fibroblast motility, an effect blocked by wortmannin (a phosphoinositide‐3‐kinase/Akt inhibitor). We also demonstrated that high‐frequency cyclic strain was more effective at inducing Akt phosphorylation than low frequency or static strain. In vivo, Akt phosphorylation was induced by mechanical loading of dermal fibroblasts in both unwounded and wounded murine skin. Mechanically loaded scars also exhibited strong expression of α‐smooth muscle actin, a putative marker of pathologic scar formation. In vivo inhibition of Akt increased apoptosis but did not significantly abrogate hypertrophic scar development. These data suggest that although Akt signaling is activated in fibroblasts during mechanical loading of skin, this is not the critical pathway in hypertrophic scar formation. Future studies are needed to fully elucidate the critical mechanotransduction components and pathways which activate skin fibrosis.     

Today or tomorrow? A retrospective analysis of the clinical indications used to request urgent magnetic resonance imaging of the spine

INTRODUCTION

The finite resources available to National Health Service institutions require clinicians to order investigations that are not readily available appropriately. This is particularly true for the radiological assessment of patients presenting with features pertaining to acute spinal cord dysfunction. Such cases conventionally require urgent magnetic resonance imaging (MRI) which is sometimes performed ‘out-of-hours’. There is evidence to suggest, however, that a high proportion of patients do not have a structural abnormality on MRI to account for their clinical findings, and consequently the majority of scans that are requested urgently are normal. The primary aim of this study was to determine whether any clinical feature(s) could accurately predict the presence of a structural abnormality on MRI. As a secondary objective, the ability of such features to predict the need for spinal surgery was assessed.

PATIENTS AND METHODS

A retrospective analysis of consecutive patients who warranted urgent MRI was conducted. Eighty-one patients were eligible for study. The Fisher’s test was used for statistical analysis of all data. A P-value of less than 0.05 was considered to be significant.

RESULTS

MRI was performed within 24 h of admission in 16 patients, and of these, seven had surgery within 24–48 h. Only two patients were found to have significant neurological compromise. Despite both a history and examination suggesting otherwise, MRI was normal in 10 patients (12%).

CONCLUSIONS

We were unable to elucidate any clinical features that were able to predict the presence of an abnormal MRI. We did find, however, that patients with a combination of both subjective neurological findings and positive neurological signs (P = 0.02), saddle anaesthesia and/or decreased anal tone (P = 0.03) or sciatica (P = 0.02) had pathology on MRI that warranted surgical intervention. The authors recommend that the aforementioned features formulate the basis of guidelines used to request and/or perform MRI urgently since they are highly suggestive of surgical intervention. Conversely, patients who do not exhibit the above examination findings might not require either an urgent or ‘out-of-hours’ scan, but could potentially be investigated less expediently and/or wait until ‘normal working hours’.     

Breast conserving surgery in combination with intraoperative radiotherapy after previous external beam therapy: an option to avoid mastectomy

Purpose

Mastectomy is the standard procedure in patients with in-breast tumor recurrence (IBTR) or breast cancer after irradiation of the chest due to Hodgkin’s disease. In certain cases a second breast conserving surgery (BCS) in combination with intraoperative radiotherapy (IORT) is possible. To date, data concerning BCS in combination with IORT in pre-irradiated patients are limited. This is the first pooled analysis of this special indication with a mature follow-up of 5 years.

Methods

Patients with IBTR after external beam radiotherapy (EBRT; treated in two centers) for breast cancer were included. Patients with previous EBRT including the breast tissue due to other diseases were also included. IORT was performed with the Intrabeam?-device using low kV X-rays. Clinical data including outcome for all patients and toxicity for a representative cohort (LENT-SOMA scales) were obtained. Statistical analyses were done including Kaplan–Meier estimates for local recurrence, distant metastasis and overall survival.

Results

A total of 41 patients were identified (39 patients with IBTR, 2 with Hodgkin`s disease in previous medical history). Median follow-up was 58 months (range 4–170). No grade 3/4 acute toxicity occurred within 9 weeks. Local recurrence-free survival rate was 89.9% and overall survival was 82.7% at 5 years. Seven patients developed metastasis within the whole follow-up.

Conclusions

BCS in combination with IORT in IBTR in pre-irradiated patients is a feasible method to avoid mastectomy with a low risk of side effects and an excellent local control and good overall survival.

     

Operative treatment for intussusception: Should an incidental appendectomy be performed?

Background/objectives

An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA).

Tibial component overhang in total knee replacement: incidence and functional outcomes

The aim of this study was to quantify the incidence and severity of tibial component overhang in total knee replacement and find any relationship between overhang and functional outcome. 532 anteroposterior radiographs of total knee replacements were reviewed retrospectively to identify medial or lateral overhang of the tibial component. Patients completed an Oxford knee score (OKS) questionnaire at mean follow-up of 36 months. Overhang of the tibial component was noted in 13.4% of patients with a mean OKS of 353. Severity of overhang did not correlate with OKS. Overhang of the tibial component is common. However, in this study it was not associated with a worse than expected outcome and increasing severity did not correlate with worse functional scores.