BIOMIMETIC DERMOID GRAFTS WITH ALLOGENIC BIOACTIVITY: AN INNOVATIVE APPROACH FOR HERNIA REPAIR IN BUFFALOES

Background/Aim: Abdominal wall defects may result from trauma, burn, necrotizing soft tissue infection or complications of abdominal surgeries. Reconstruction poses a great challenge for the surgeon in cases of large abdominal wall defects with lack of surrounding tissue. Abdominal wall defects lack a good functional and aesthetic impact and early reconstruction is prudent for better outcomes. This study evaluates the results of Vacuum assisted wound closure (VAC) therapy in patients with large anterior abdominal wall tissue defect which could not be closed primarily otherwise.Methods: This case series included 20 patients with partial thickness, anterior abdominal wall tissue defects. All patients had suffered an acute trauma. Wound debridement was done and VAC therapy dressing was applied in systematic manner. Dressing was changed every 3 or 4 days and continued up to 9-14 days.Results: Twenty patients underwent VAC therapy with an average age of 32 years (range, 25-52 years). Indications comprised tissue loss after acute trauma due to road traffic accident, burn and other trauma leading to anterior abdominal wall soft tissue defect. VAC was used for an average of 12 days, with an average negative pressure of 125 mm Hg. Healthy granulation tissue was formed in all patients. Subsequently split thickness skin grafts were applied in these patients. This results in early recovery as well as decreased morbidity in all patients.Conclusions: All patients had good tolerance to Vacuum-assisted closure. It offers many benefits comprising fewer dressing changes and an earlier return to daily activities. Patients with large abdominal defects can benefit from this procedure.

INTRODUCTION: A pedicled or free tissue thigh flap has been used for large abdominal wall defect reconstruction.1, 2 Anterolateral thigh flaps, tensor fascia lata musculocutaneous flaps, and their combination are reliable and are often used.3, 4 Despite the reported efficacy, it is unclear how large an abdominal defect can be closed with a single thigh flap. The objective of this study was to compare the length of the abdomen and thigh, and to determine whether a thigh flap is suitable for all abdominal wall reconstruction procedures. METHODS: A total of 100 adult Japanese subjects (men: 50, women: 50) with no medical history of musculoskeletal disease or injury were recruited. The length from the xiphoid process to the pubic tubercle was defined as the length of the abdomen (AL). The length of the thigh (TL) was defined as the distance from the anterior superior iliac spine to the upper lateral edge of the ipsilateral patella. The height of each subject and the difference between the TL and AL (TL – AL) were recorded. Statistical analysis was performed. RESULTS: The average age was 42.6 years in men and 41.8 years in women. The average height and standard deviation was 172.65 ± 6.53 cm in men and 158.00 ± 5.14 cm in women. The averages and standard deviations of the TL, AL, and TL – AL were 45.26 ± 3.20 cm, 32.70 ± 2.78 cm, and 12.57 ± 3.73 cm in men, and 40..82 ± 1.68 cm, 32.69 ± 2.93 cm, and 7.91 ± 3.17 cm in women, respectively. The height showed no correlation with AL in female subjects. AL showed no correlation between the male and female subjects. A height of less than 170 cm in males showed a clear correlation with TL – AL. CONCLUSION: Since the TL was larger than the AL in all subjects, a thigh flap is suitable for abdominal wall reconstruction in most cases. AL was consistent according to height in female subjects. In female and male subjects less than 170 cm in height, the thigh flap may be too short for abdominal wall reconstruction. Reference Citations: 1. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg. 1999; 103: 1191–1197. 2. Williams JK, Carlson GW, Howell RL, Wagner JD. The tensor fascia lata free flap in abdominal-wall reconstruction. J Reconstr Microsurg. 1997; 13: 83–90. 3. Lv Y, Cao D, Guo F, Qian Y. Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients. Am J Surg. 2015; 210: 365–373. 4. Sasaki K, Nozaki K, Nakazawa H, Kukuchi Y. Reconstruction of a large abdominal wall defect using combined free tensor fasciae lata musculocutaneous flap and anterolateral thigh flap. Plast Reconstr Surg. 1998; 102: 2244–2252.

The pedicled anterolateral thigh (ALT) flap is safe and reliable for repairing abdominal wall defects. This flap has a long pedicle and a wide arc of rotation, and it can extend from above the umbilicus and the lower back to the upper thigh, including the groin and perineum. The ALT flap is a technically simple muscle flap that permits primary closure and minimal morbidity of the donor site. We report a case of successful reconstruction of a large abdominal defect after tumor resection by using a pedicled vastus lateralis muscle flap. Literature review on the clinical applications of the ALT and pedicled vastus lateralis muscle flap for reconstruction of soft tissue defects were performed.

ABSTRACTINTRODUCTIONGastroschisis is almost always a small, right-sided, periumbilical, abdominal wall defect, and its occurrence on the left side of the umbilicus is extremely rare. Furthermore, omphaloceles and gastroschisis usually do not co-occur. The present report is the 2nd worldwide to describe the co-occurrence of an omphalocele and left gastroschisis-like abdominal wall defect.CASE PRESENTATIONA 32-year-old pregnant woman (gravidity 2 and parity 1) was referred to our center because gastroschisis was detected in her fetus at 15 weeks and 3 days of gestational age. At 33 weeks and 3 days of gestational age, cesarean section was performed to deliver the female infant after a premature rupture of membranes. Her birth weight was 1368 g, and her Apgar scores were 8 at 1 min and 9 at 5 min. At birth, a macroscopic examination revealed an omphalocele with liver prolapse and a large, left-sided, epigastric, abdominal defect with an associated prolapse of the liver, spleen, stomach, and intestine. The patient had 2 very challenging conditions, namely, an early delivery with immature lung function and 2 large abdominal defects, for which a staged operation was performed using a combination of techniques involving the application of an artificial patch to close the abdominal wall temporarily, a hydro-fiber dressing to promote epithelization, and component separation to close the rather large defect permanently. Contrast CT revealed a defect in the lower costal cartilage and hypoplasia of the upper left abdominal wall. The peripheral part of the left superior epigastric artery was unclear in the imaging study.CONCLUSIONSThe abdominal wall defect might have differed from other cases of left-sided gastroschisis in terms of its pathogenesis in the upper left abdomen. The presence of lower left hypoplastic thorax strongly suggested that dysfunction of the left superior epigastric artery had caused the abdominal wall defect. There is no standard treatment for this extremely rare, congenital malformation. Thus, its treatment requires the application of several techniques, each to address different aspects of the condition at the corresponding, surgical stage.

Management of neonates with large abdominal wall defects and undescended testis

Closure of large abdominal defects after extensive abdominal surgery is a major technical surgical problem. Failure to close the abdomen leaves the patient at risk for grave complications. Full-thickness abdominal wall skin transplantation appears to solve this problem. This is the first time that detailed histopathologic features of skin abdominal wall transplantation from cadaver donors are described. Five adults and four children underwent 10 transplants because of large abdominal wall defects. Twenty-two posttransplantation skin specimens were evaluated during a mean follow-up of 23.5 weeks, and the findings were compared with the clinical appearance of the skin. Rejection was manifested as a maculopapular rash. The histologic features were categorized as perivascular infiltrates, epidermal changes, and stromal changes. A grading system is proposed based on the number of cases encountered: No rejection, grade 0 (n = 9): No perivascular infiltrates. Indeterminate for rejection, grade 1 (n = 2): Up to 10% of vessels show infiltrates of small lymphocytes. No eosinophils, large lymphocytes, spongiosis, epidermal, or stromal inflammation are seen. Mild rejection, grade 2 (n = 5): 11% to 50% of vessels are infiltrated by small lymphocytes. Eosinophils and mild spongiosis may or may not be present. No epidermal infiltrates, stromal infiltrates, or large lymphocytes are seen. Moderate rejection, grade 3 (n = 4): Greater than 50% of vessels show lymphocytic infiltrates that may be accompanied by epidermal and stromal inflammation. Spongiosis is absent or mild. Endothelial plumping, eosinophils, and large lymphocytes may be seen. Severe rejection, grade 4 (n = 2): Greater than 50% of vessels show infiltrates, but different from moderate rejection, there is dyskeratosis and the epidermis shows heavier lymphocytic infiltrates and moderate to severe spongiosis. The stroma shows infiltrates extending into the base of the epidermis. Endothelial plumping, eosinophils, and large lymphocytes are present. The mean number of weeks after transplantation for the development of clearcut rejection (grades 2-4) was 8.36. Among the 9 nonrejection cases, 4 specimens from 3 patients had thrombosis of the vessels feeding the graft. A grading system serves to better assess skin allograft rejection.

Reconstruction of large abdominal wall defects with conventional reconstruction including the component separation technique is difficult because of strong transverse tension and loss or weakness of the rectus abdominis muscle. To overcome this problem, dynamic reconstruction of the abdominal wall using a free innervated rectus femoris musculocutaneous flap was performed for large defects with separation of the bilateral rectus abdominis muscles. The intact motor nerve of the rectus femoris muscle was transferred without transection, and only the pedicle vessels were anastomosed to the omental vessels. Four and one-half years after surgery, the rectus femoris muscle had voluntary strong muscle contraction and there was no abdominal protrusion, herniation, or donor morbidity. This new method with dynamic function can replace conventional techniques for large abdominal defects without rectus muscle function.

A premature newborn was found to have a previously unknown lower abdominal defect. ### Prenatal and Birth Histories: ### Presentation: The infant had no respiratory effort at birth and was intubated in the delivery room. A large abdominal defect was noted, and stool was seen passing from a patent anus. Initial heart rate was 55 beats per minute. Positive pressure ventilation, surfactant, and chest compressions were administered without result. An emergency umbilical venous catheter was inserted, and the infant received 5 rounds of epinephrine and empiric bilateral thoracenteses before resuscitation was discontinued because of lack of response. The parents declined autopsy. ### Physical Examination: Postresuscitation examination revealed redundant skin over the scalp and neck. There was a 5-cm-long, transverse, full-thickness infraumbilical abdominal defect with liver and gallbladder exposed. The small intestine was completely eviscerated. Bilateral, symmetrical, 3-cm-long skin defects …

To explore the effectiveness of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection. Between September 2010 and December 2017, 18 patients with abdominal wall tumors were collected. There were 11 males and 7 females, with an average age of 45.2 years (range, 29-68 years). Histologic diagnosis included desmoid tumor in 8 cases, sarcomas in 6 cases, malignant teratoma in 2 cases, and colon adenocarcinoma in 2 cases. All abdominal wall defects were full-thickness defects. Peritoneum continuity was reconstructed with mesh; the lateral vastus muscular flaps were used to fill the dead space and rebuild the abdominal wall strength; the abdominal wall soft tissue defects were repaired with pedicled anterolateral thigh flaps. The size of abdominal wall defects ranged from 15 cm×6 cm to 25 cm×22 cm; the size of lateral vastus muscular flap ranged from 10 cm×8 cm to 22 cm×10 cm; the size of anterolateral thigh flap ranged from 14.0 cm×8.0 cm to 21.0 cm×8.5 cm. The bilateral pedicled anterolateral thigh myocutaneous flaps were harvested to repair the extensive abdominal wall defects in 2 cases. All donor sites were sutured directly. All wounds healed smoothly and all flaps survived totally. All donor sites healed smoothly. The mean follow-up time was 22.5 months (range, 11-56 months). No tumor recurrence occurred, the abdominal function and appearance were satisfactory, no abdominal hernia was noted. Only linear scar left at the donor sites. Pedicled anterolateral thigh myocutaneous flap combined with mesh is fit for large full-thickness abdominal defect reconstruction.

Background: Closure of large abdominal-wall defects after abdominal trauma usually requires the employment of the components separation method. We discuss a case where the separation of the external and internal oblique muscles was difficult on the right side due to severe scarring and adhesion. Both components separation and multiple partitioning were performed for the reconstruction of the abdominal wall defect. Aim and objectives: This method allows bilateral fascia mobilization over a greater distance when it is difficult to achieve separation of the external and internal oblique muscles on both sides to the level of the mid-axillary line. Materials and Methods: A 60-year-old man underwent exploratory laparotomy at China Medical University Hospital for injuries sustained after a motor vehicle accident. The large abdominal fascia defect following laparotomy was corrected by using a combined approach of both components separation and multiple partitioning and primary fascia closure was achieved. Results: Eight months after abdominal wall reconstruction, the incision was well healed, there was no evidence of hernia, and the bowel functions were normal. Conclusion: The combined use of the components separation and multiple partitioning methods may be viable choice for abdominal fascia reconstruction in cases with severe scarring and adhesion between the external and internal oblique muscles.

Short-course antibiotic therapy could enhance adherence and reduce adverse drug effects and costs. However, based on sparse evidence, most guidelines recommend a longer course of antibiotics for nonsevere childhood community-acquired pneumonia (CAP). To determine whether a shorter course of antibiotics was noninferior to a longer course for childhood nonsevere CAP. MEDLINE, Embase, Web of Science, the Cochrane Library, and 3 Chinese databases from inception to March 31, 2022, as well as clinical trial registries and Google.com. Randomized clinical trials comparing a shorter- vs longer-course therapy using the same oral antibiotic for children with nonsevere CAP were included. Random-effects models were used to pool the data, which were analyzed from April 15, 2022, to May 15, 2022. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence. Treatment failure, defined by persistence of pneumonia or the new appearance of any general danger signs of CAP (eg, lethargy, unconsciousness, seizures, or inability to drink), elevated temperature (>38 °C) after completion of treatment, change of antibiotic, hospitalization, death, missing more than 3 study drug doses, loss to follow-up, or withdrawal of informed consent. Nine randomized clinical trials including 11 143 participants were included in this meta-analysis. A total of 98% of the participants were aged 2 to 59 months, and 58% were male. Eight studies with 10 662 patients reported treatment failure. Treatment failure occurred in 12.8% vs 12.6% of participants randomized to a shorter vs a longer course of antibiotics. High-quality evidence showed that a shorter course of oral antibiotic was noninferior to a longer course with respect to treatment failure for children with nonsevere CAP (risk ratio, 1.01; 95% CI, 0.92-1.11; risk difference, 0.00; 95% CI, -0.01 to 0.01; I2 = 0%). A 3-day course of antibiotic treatment was noninferior to a 5-day course for the outcome of treatment failure (risk ratio, 1.01; 95% CI, 0.91-1.12; I2 = 0%), and a 5-day course was noninferior to a 10-day course (risk ratio, 0.87; 95% CI, 0.50-1.53; I2 = 0%). A shorter course of antibiotics was associated with fewer reports of gastroenteritis (risk ratio, 0.79; 95% CI, 0.66-0.95) and lower caregiver absenteeism (incident rate ratio, 0.74; 95% CI, 0.65-0.84). Results of this meta-analysis suggest that a shorter course of antibiotics was noninferior to a longer course in children aged 2 to 59 months with nonsevere CAP. Clinicians should consider prescribing a shorter course of antibiotics for the management of pediatric nonsevere CAP.

Pneumonia is the leading cause of mortality in young children in developing countries. A short course of antibiotics in the treatment of nonsevere pneumonia has been suggested as feasible and could lead to decreased costs, risk of adverse events, and development of antimicrobial resistance. This review evaluates the evidence regarding the duration of antibiotic treatment in this population. The PubMed, EMBASE, Cochrane Library, and other databases were searched. Studies were selected for inclusion if they enrolled patients in developing countries between the ages of 2 months to 18 years clinically diagnosed with nonsevere pneumonia, and compared the clinical outcomes of a short course of oral antibiotics with a long course. The outcomes of interest included failure rate, relapse rate, and safety. Four randomized controlled trials were identified, which enrolled 9235 patients cumulatively. All patients were aged between 2 to 59 months and diagnosed using World Health Organization defined criteria. All four trials showed no significant difference in relapse rates between 3-day and 5-day courses. In one study, the 3-day course was associated with higher rates of treatment failure and adverse events, with no adverse event classified as severe. Overall, short and long courses of antibiotics produce similar outcomes treating clinically diagnosed, nonsevere pneumonia in children in developing countries between the ages of 2 to 59 months. Three out of four studies in this review, representing two-thirds of the patients in aggregate, showed no significant difference in treatment failure or relapse rates between a 3-day and 5-day course of antibiotics.

An experimental study was conducted to determine the end-results of two different defects on the anterior abdominal wall: an abdominal wall defect (AWD) versus an umbilical cord defect (UCD) using chick embryos. The AWD was created by leaving an intact skin bridge between the defect and the umbilical cord in group l; the UCD was created on the umbilical cord near the junction of the skin in group 2. At the end of incubation, the intestines appeared hemorrhagic in the AWD group, but not in the UCD group. During microscopic examination, hemorrhagic areas were observed in the bowel wall and mucosal villi in the AWD group but not in the UCD group. The end-result of the defect causing the physiological umbilical hernia resulted in bowel damage resembling the classic picture of gastroschisis (GS). We conclude that the site of the defect in GS is not the abdominal wall itself, but the physiological umbilical hernia.

An experimental study was conducted to determine the end-results of two different defects on the anterior abdominal wall: an abdominal wall defect (AWD) versus an umbilical cord defect (UCD) using chick embryos. The AWD was created by leaving an intact skin bridge between the defect and the umbilical cord in group 1; the UCD was created on the umbilical cord near the junction of the skin in group 2. At the end of incubation, the intestines appeared hemorrhagic in the AWD group, but not in the UCD group. During microscopic examination, hemorrhagic areas were observed in the bowel wall and mucosal villi in the AWD group but not in the UCD group. The end-result of the defect causing the physiological umbilical hernia resulted in bowel damage resembling the classic picture of gastroschisis (GS). We conclude that the site of the defect in GS is not the abdominal wall itself, but the physiological umbilical hernia.

Azithromycin has become a frequent choice for the treatment of group A streptococcal (GAS) tonsillopharyngitis. In this study, our objective was to determine the optimal dose of azithromycin for treatment of GAS tonsillopharyngitis in children and adults by analyzing trials that used different dose regimens. We performed a meta-analysis of randomized, controlled trials that involved bacteriological confirmation of GAS tonsillopharyngitis, random assignment to receive either azithromycin or a 10-day comparator antibiotic, and assessment of bacteriological eradication by throat culture after therapy. The primary outcomes of interest were bacteriological and clinical cure rates. Nineteen trials involving 4626 patients were included in the analysis. One trial used 10-day course of 2 different comparator antibiotics, and 2 trials compared 2 dose regimens of azithromycin with a 10-day course of comparator antibiotic; all other trials compared 1 dose regimen of azithromycin with a single 10-day course of comparator antibiotic. In children, azithromycin administered at 60 mg/kg per course was superior to the 10-day courses of comparators (P < .00001), with bacterial failure occurring 5 times more often in patients receiving the 10-day courses of antibiotics. Azithromycin administered at 30 mg/kg per course was inferior to the 10-day courses of comparators (P = .02), with bacterial failure occurring 3 times more frequently in patients receiving azithromycin. Three-day regimens were inferior to 5-day regimens (P = .002). In adults, no studies compared dosages by weight. Three-day regimens of 500 mg/day showed a trend favoring azithromycin over the 10-day courses of comparators (P = .14); 5-day regimens were inferior to 3-day regimens (P = .006). Clinical cure rates were significantly different for the different azithromycin regimens, with differences that resembled those for bacterial cure rate. This analysis suggests that azithromycin administered at a dosage of 60 mg/kg in children or administered for 3 days at a dosage of 500 mg/day in adults is more effective than other treatment regimens in producing eradication and clinical cure of GAS tonsillopharyngitis.