Closure Group Research Articles

On the Aspects of Enriched Lattice-valued Topological Groups and Closure of Lattice-valued Subgroups

Starting with L as an enriched cl-premonoid, in this paper, we explore some categorical connections between L-valued topological groups and Kent convergence groups, where it is shown that every L-valued topological group determines a well-known Kent convergence group, and conversely, every Kent convergence group induces an L-valued topological group. Considering an L-valued subgroup of a group, we show that the category of L-valued groups, L-GRP has initial structure. Furthermore, we consider a category L-CLS of L-valued closure spaces, obtaining its relation with L-valued Moore closure, and provide examples in relation to L-valued subgroups that produce Moore collection. Here we look at a category of L-valued closure groups, L-CLGRP proving that it is a topological category. Finally, we obtain a relationship between L-GRP and L-TransTOLGRP, the category of L-transitive tolerance groups besides adding some properties of L-valued closures of L-valued subgroups on L-valued topological groups.

Primary versus modified secondary closure techniques for persistent tracheocutaneous fistula in pediatric patients.

This study aimed at compating two closure techniques for tracheocutaneous fistulas (TCFs) in pediatric patients. A total of 106 consecutive pediatric patients who underwent closure of a persistent TCF between April 2007 and February 2021 at a tertiary pediatric hospital were evaluated, and 103 pediatric patients aged between 12months and 18years were included. The clinical characteristics, perioperative outcomes, and postoperative outcomes were compared between TCF closure by primary closure (Group 1) and a modified secondary healing technique (Group 2). Of the 103 patients, 58 were classified into Group 1, and 45 into Group 2. The mean age at tracheostomy and TCF closure was significantly younger in Group 2, and the interval between decannulation to TCF closure was significantly shorter in Group 2. Procedural time and hospital stay were significantly shorter in Group 2 than Group 1. Group 2 had a significantly lower complication rate, need for revision surgery, and recannulation rate than Group 1. Modified secondary healing was more efficient in terms of procedural time and hospital stay, and safer (i.e., fewer complications). It is an effective surgical technique for closing a persistent TCF in younger patients more quickly after decannulation compared to primary closure.

Partial primary closure in sacrococcygeal pilonidal sinus: Modified with suture technique

Aim and backgroundThe primary purpose of pilonidal sinus treatment is to minimize complications, accelerate wound healing, and minimize recurrence. However, invasive and minimally invasive methods are being developed to reduce these problems. Early and late postoperative complications remain significant problems in pilonidal surgery. This study aimed to contribute to this issue in surgery by comparing the results of the Karydakis flap (KF) technique and those of the partial primary closure (PPC) technique, to which we applied suture modification. MethodsA total of 96 patients diagnosed with pilonidal sinus disease (PSD) were randomly assigned to two groups. Apply the partial primary closure in 46 patients and the Karydakis technique in 50. ResultsIn comparison to the Karydakis technique, the partial primary closure (PPC) group's hospitalization stay was shorter, although the difference was not significant. Healing time was also longer in uncomplicated cases (p = 0.200 and 0.064, respectively). Abscesses and hematomas were not observed with partial primary closure, but the total complication rate was similar to that of the Karydakis technique. Surgical site infections were often seen in the PPC group (21.7% vs. 10%). In contrast, healing time for complicated cases was found to be significantly shorter in the PPC technique (p < 0.05). ConclusionPostoperative abscess, hematoma, and seroma are the most common causes of total wound dehiscence, and delay in wound healing in off-midline techniques. We recommend the PPC technique with suture modification as an alternative to off-midline techniques in clean and chronically infected cases, other than cellulitis, abscess, and purulent discharge cases. However, we primarily recommend off-midline techniques in clean or asymptomatic cases.

Prophylactic incisional negative pressure wound therapy for gynaecologic malignancies.

Wound complications are an important cause of postoperative morbidity among patients with gynaecologic malignancies. We evaluated whether the placement of closed‐incisional negative pressure therapy (ciNPT) at the time of laparotomy for gynaecologic cancer surgery reduced wound complication rates. A retrospective cohort study with primary wound closure performed by a gynaecologic oncologist was carried out. We evaluated two cohorts of patients who underwent surgery in 2017 with standard closure and patients who underwent surgery in 2019 with the placement of prophylactic ciNPT. Postoperative outcomes were examined. A total of 143 patients were included, 85 (59.4%) vs 58 (40.6%) with standard closure and ciNPT, respectively. The total complication rate in our sample was 38.71%. The rate of surgical complications in patients treated with ciNPT was 6.9% compared with 31.8% (P = .000) in patients treated with standard closure. In the analysis of complications, a significant reduction in infections (17.1%), seromas (15.4%), and wound dehiscence (17.1%) were observed when ciNPT was applied. The median hospital stay was 8 vs 6 days in the standard closure vs ciNPT groups (P = .048). The use of the prophylactic ciNPT following a laparotomy may decrease wound complications and hospital stays in oncological patients. ciNPT could be considered as part of clinical practice in patients at high risk of wound complications, such as patients with gynaecological malignancies.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when duraltenting sutures were placed during postsurgical closure. Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.

A randomised study to evaluate wound outcome following delayed primary vs primary closure of skin in duodenal perforation peritonitis

Background: This study aimed to evaluate wound outcome following delayed primary versus primary closure of skin in duodenal perforation peritonitis.Methods: The present study was a randomised interventional study that included 90 patients on accrual of duodenal perforation peritonitis which were divided into primary closure (PC) and delayed primary closure (DPC) groups comprising 45 patients each. The outcome measures were complications, surgical site infections, hospital stay and final wound status during the follow up of 30 days. Data collected was compared taking P-value &lt;0.05 as significant.Results: The patients were in the age group of 12–60 years, with men in majority in both groups. Mean SSI score in PC and DPC was comparable (2.67 SD 1.58 vs. 2 SD1.61, P=0.058). SSI was more in PC group than DPC group (11.11% vs. 2.22%, P&lt;0.05). Wound/pus culture was positive in 62.22% in PC and 46.67% in DPC. Major complications like wound dehiscence was noticed mainly in PC group while minor Complications like Stitch abscess, granuloma, sinus was more in DPC group. Mean of duration of stay (days) was comparable between PC and DPC group (14.07 SD 7.64 vs. 13.96 SD 6.94, P=0.805). Final wound outcome after 30 days was healthy scar in majority of patients in PC and DPC group (57.78% vs. 66.67%) with no significant difference between them (p=0.434).Conclusions: In conclusion, DPC showed comparable results with PC with similar SSI and wound healing without significant complications.

Patent foramen ovale closure in stroke patients with migraine in the CLOSE trial. The CLOSE-MIG study.

The efficacy of patent foramen ovale (PFO) closure to reduce the frequency of migraine attacks remains controversial. This was a planned sub-study in migraine patients enrolled in a randomized, clinical trial designed to assess the superiority of PFO closure plus antiplatelet therapy over antiplatelet therapy alone to prevent stroke recurrence in patients younger than 60years with a PFO-associated cryptogenic ischaemic stroke. The main outcome was the mean annual number of migraine attacks in migraine patients with aura and in those without aura, as recorded at each follow-up visit by study neurologists. Of 473 patients randomized to PFO closure or antiplatelet therapy, 145 (mean age 41.9years; women 58.6%) had migraine (75 with aura and 70 without aura). Sixty-seven patients were randomized to PFO closure and 78 to antiplatelet therapy. During a mean follow-up of about 5years, there were no differences between antiplatelet-only and PFO closure groups in the mean annual number of migraine attacks, both in migraine patients with aura (9.2 [11.9] vs. 12.0 [19.1], p=0.81) and in those without aura (12.1 [16.1] vs. 11.8 [18.4], p>0.999). There were no differences between treatment groups regarding cessation of migraine attacks, migraine-related disability at 2years and use of migraine-preventive drugs during follow-up. In young and middle-aged adults with PFO-associated cryptogenic stroke and migraine, PFO closure plus antiplatelet therapy did not reduce the mean annual number of migraine attacks compared to antiplatelet therapy alone, in migraine patients both with and without aura.

English

BACKGROUND The method adopted for incision closure has an influence on the outcomes of wound healing. The study was conducted to compare the ‘mass closure’ method with the conventional layer closure, and to find out the suitable surgical closure method for midline laparotomy incision. METHODS A prospective comparative study was conducted at a tertiary care teaching institute over a period of 2 years. Patients &gt; 14 years of age, who were operated on by midline laparotomy incision, were included in the study group (N = 60). Either a ‘mass closure’ or the conventional layer closure method was adopted as per the operating surgeon’s choice. Based on the method used the cases were allocated into two groups, each with 30 patients. In the ‘mass closure’ group (Group A), continuous suturing was used in 22 patients and interrupted closure in 8 patients. In the ‘layered closure’ group (Group B), the abdomen was closed in layers using absorbable suture for the peritoneum (together with transversalis fascia) and non-absorbable for the linea alba. The patients were followed up postoperatively, and for 6 months after discharge from the hospital in follow-up for the detection of the wound complications. RESULTS The mean age of patients in Group A was 40.9 ± 15.48 years, and 41.03 ± 14.73 in Group B. There were 25 males and 5 females in Group A and 23 males and 7 females in Group B. Closure time of incision was significantly lower in the mass closure group (P &lt; 0.05). The postoperative complications in Group A was 20 % (Seroma-1 patient, infection-3, partial wound dehiscence-1, and hernia-1). In Group B, the overall complication rate was 36 % (Seroma-3 patients, infection-5, burst abdomen- 1, hernia- 2). CONCLUSIONS Mass closure method is better than the conventional layer closure for the midline laparotomy incision. KEYWORDS Laparotomy, Layered Closure, Midline Incision, Mass Closure, Suture Technique

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults

BackgroundSecundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies.ObjectiveWe thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG.ResultsWe prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure.There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling.In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03).ConclusionOur study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Second-look endoscopy findings after endoscopic submucosal dissection for colorectal epithelial neoplasms.

Background/AimsAlthough second-look endoscopy (SLE) is frequently performed after gastric endoscopic submucosal dissection (ESD) to prevent bleeding, no studies have reported SLE findings after colorectal ESD. This study aimed to investigate SLE findings and their role in preventing delayed bleeding after colorectal ESD.MethodsPost-ESD ulcer appearances were divided into coagulation (with or without remnant minor vessels) and clip closure groups. SLE findings were categorized according to the Forrest classification (high-risk ulcer stigma [type I and IIa] and low-risk ulcer stigma [type IIb, IIc, III, or clip closure]), and risk factors for high-risk ulcer stigma were analyzed.ResultsAmong the 375 cases investigated, SLEs were performed in 171 (45.6%) patients. The incidences of high-risk ulcer stigma and low-risk stigma were 5.3% (9/171) and 94.7% (162/171), respectively. During SLE, endoscopic hemostasis was performed more frequently in the high-risk ulcer stigma group than in the low-risk ulcer stigma group (44.4% [4/9] vs. 1.9% [3/162], respectively; p < 0.001), but most of the endoscopic hemostasis in the high-risk ulcer stigma group (3/4, 75.0%) were prophylactic hemostasis. Post-ESD delayed bleeding occurred in three (0.8%) patients belonging to the SLE group, of which, one patient was from the high-risk stigma group and two were from the low-risk stigma group.ConclusionsThe incidence of high-risk ulcer stigma during SLE was low, and delayed bleeding occurred in, both, high-risk and low-risk groups of SLE. SLEs performed after colorectal ESD may not be effective in preventing delayed bleeding, and further prospective studies are needed to evaluate the efficacy of SLE in post-colorectal ESD.

A Single-Center Randomized Prospective Study Investigating the Efficacy of Various Wound Closure Devices in Reducing Postoperative Wound Complications

BackgroundSutures and staples are the mainstay wound closure techniques in total joint arthroplasty. Newer techniques such as zipper devices and novel skin adhesives have emerged because of their potential to decrease operative time and possibly minimize complications. The aim of this study is to compare these newer techniques against conventional sutures with respect to wound complications, closure time, and costs. MethodsA single-center randomized control trial was conducted on 160 patients (52 zipper, 55 suture, 53 mesh) who underwent primary total hip or knee arthroplasty between February 2017 and May 2018. Patients were divided into 3 closure groups: zipper device, monofilament suture plus adhesive, and monofilament plus polyester mesh with adhesive. The primary endpoint was closure time (superficial skin layer). Secondarily we collected perioperative complication rates, including infection, persistent (14-day) wound drainage, 90-day readmission, and emergency room visit rates as well as compared material costs. ResultsThere were no differences in baseline characteristics between groups for age, body mass index, and American Society of Anesthesiologists classification. There was a trend toward decreased time to closure for the suture group. There were no significant differences between groups for our secondary endpoint, complications. ConclusionsOur study shows that the suture group trended toward shorter closure time but suggests that each of the closure methods after total joint arthroplasty has equivalent complication rates. With small differences in closure time and no significant differences in complications, the decision to use one wound closure device or technique over another should be driven by institutional costs and provider familiarity.

OP18 Treatment of perianal fistulas in Crohn’s Disease: Surgical closure after anti-TNF induction treatment versus anti-TNF without surgery (PISA II) - A patient preference RCT

Abstract Background Current guidelines on Crohn’s perianal fistulas recommend anti-TNF treatment and suggest to consider surgical closure in amendable patients. However, long-term outcome of both treatments have not been directly compared. The aim of this study was to assess MRI healing in a patient preference RCT comparing both treatment modalities. Methods This multicentre, international trial compared surgical closure following anti-TNF induction (4 months) to anti-TNF therapy without surgery. Patients were counselled for both treatment arms and randomised if there was no preference. Due to the combination of a preference and randomised cohort, the appropriate sample size to detect a clinically relevant increase of 25% closure (from 15% to 40%) was flexible and adjusted for a possible skewed distribution (86 patients in case of 1:1 treatment allocation). All Crohn’s patients ≥ 18 years with a (re)active high perianal fistula and a single internal opening were eligible. Exclusion criteria were previous failure of anti-TNF, recto-vaginal fistula, proctitis, or stoma. Patients received seton placement prior to treatment. Primary outcome was MRI healing after 18 months (defined as a complete fibrotic fistula or MAGNIFI-CD score of 0–5). Secondary outcomes included clinical healing, re-interventions and fistula recurrence. Results Between September 2013 and December 2019, 7 hospitals in the Netherlands and Italy included 93 patients (59% females, median age 34 years) of which 32 were randomised. Thirty-seven patients were treated in the surgical closure group and 56 in the anti-TNF group, with comparable baseline characteristics. After 18 months, MRI healing was significantly higher after surgical closure (41% vs 11%; P=0.002). Although a trend was seen in favour of surgical closure, clinical healing rates and surgical re-interventions were not significantly different between groups (65% vs 45%, P=0.07 and 19% vs 34%, P=0.1). After median 38 months follow-up, 12 patients in the anti-TNF group crossed over to surgical closure. Both long-term MRI healing and clinical closure in the per protocol analysis remained significantly higher for the surgical closure group (46% vs 11%, P=0.002 and 65% vs 29%, P=0.006). One patient (4%) with a MAGNIFI-CD score ≤5 developed a recurrent fistula after 46 months, whereas recurrences occurred in 37% of patients with MAGNIFI-CD score &amp;gt;5 (P=0.004). Conclusion These results demonstrate that surgical closure following anti-TNF induction treatment induces MRI healing more frequently than anti-TNF alone. This is associated with increased long-term clinical closure and reduced recurrences. These data suggest that Crohn’s perianal fistula patients amendable for surgical closure should be counselled for this therapeutic approach.

Neurocognitive disorders amongst patients with congenital heart disease undergoing procedures in childhood

BackgroundAmongst children with congenital heart disease (CHD), earlier age of repair improves cardiovascular outcomes. The effects of early intervention on neurodevelopment remains unclear. We assessed the association between early life repair, cardiopulmonary bypass (CPB) and the incidence of neurocognitive disorders (NCD) amongst CHD patients. MethodsWe created two retrospective cohorts from the Quebec CHD Database; with data from 1988 to 2010. Complexity of reparative procedures for CHD lesions were used as the proxy of CPB exposure with more complex procedure means longer exposure to CPB. Study Population 1 included pediatric patients with a single reparative procedure and compared patients with complex (long CBP) versus isolated shunt (short CBP) lesions. To assess the effects of CPB alone in Study Population 2 we compared patients with isolated atrial septal defects (ASD) who had surgical (short CBP) versus percutaneous (no CBP) repairs. The primary endpoint for both cohorts was development of an NCD. ResultsIn Study population 1, 1174 patients underwent complex surgical repair and 1620 had a shunt closure. The incidence of NCDs was 2.45/100 person-years in the complex surgery group, and 2.08/100 person-years in the shunt closure group. The following were associated with increased risk of developing a NCD: surgical complexity (Hazard Ratio [HR] = 1.20, 95% Confidence Interval [CI]: 1.01–1.42), younger age at intervention (AAI) (HR = 1.20, 95% CI: 1.16–1.25), male sex (HR = 1.91, 95% CI: 1.61–2.27), and later calendar year at intervention (HR = 1.06, 95% CI: 1.04–1.07). Study population 2 had 527 isolated ASD patients; 202 underwent surgical repair and 325 had percutaneous closure. The incidence of NCDs was not statistically different between groups. Male sex (HR = 1.77, 95% CI: 1.08–2.89) and younger AAI (HR = 1.15, 95% CI: 1.06–1.25) were associated with increased NCD risk. ConclusionIncreased surgical complexity, male sex and younger AAI were associated with increased risk of NCDs in pediatric CHD patients. Surveillance protocols should be considered to identify NCDs in CHD patients after cardiac intervention.

Comparison of Peritoneal Closure Versus Non-closure After Non-infected Elective Laparotomy with a Midline Incision: A Randomized Clinical Trial

Background: There is no consensus regarding closure or non-closure of peritoneum in laparotomy, and this topic remains a controversy among surgeons. Objectives: This clinical trial aimed to compare short-term and long-term benefits of peritoneal closure with non-closure in an academic medical center. Methods: In this double-blinded two-arm parallel-group randomized trial, 124 patients undergoing laparotomy with midline incision were assessed from March 2019 to September 2019 at Imam Hossein Medical Center, Tehran, Iran. We used the Rand function of the Excel software to randomly assign 62 patients to the peritoneal closure group and 62 patients to the non-closure group. The patients were evaluated for short-term complications including wound-related fever, infection, need for analgesics, pain in the first 2, 6, 24, and 48 hours postoperatively according to the Visual Analogue Scale (VAS), duration of hospitalization, as well as long-term complications including incisional hernia and intraperitoneal adhesion one year after the surgery. Statistical analysis was carried out with SPSS version 22 software. Results: The non-closure peritoneum group had a lower rate of wound-related fever, infection, and analgesic need than the peritoneal closure group, but these differences were not statistically significant (P = 0.488, P = 0.455, and P = 0.062, respectively). The adhesion rate and incisional hernia incidence one year after the surgery were not significantly different between the two groups (P = 0.363, P = 0.586). Pain intensity was significantly lower in the non-closure group than in the closure group in the first two, six, and 24 hours (P = 0.008, P = 0.004, and P = 0.047, respectively) but not significantly at 48 hours (P = 0.146). Conclusions: Peritoneum closure after non-emergency, non-infected laparotomy increases the postoperative pain while it has no benefit for long-term complications like incisional hernia or intra-peritoneal adhesion.

Utility of a Suture-Mediated Closure System for Large Bore Arterial Access During Challenging Liver Intra-Arterial Catheters Implantation

To describe and study the utility of vascular suture-mediated closure systems for large bore arterial access during challenging implantation of liver intra-arterial catheters taking as a reference the conventional procedure involving patients without challenging anatomy. Between January 2017 and January 2019, 61 consecutive patients underwent 65 intra-arterial catheter IAC implantations for colorectal cancer. Twenty-three procedures (35%) considered by the operators with challenging coeliac trunk angulations were treated using a vascular suture technique where a 6-F introducer was used, the other patients were treated with a conventional 4F access technique. Clinical and radiological characteristics of patients, technical success (implantation of catheters allowing safe infusion of chemotherapy) and complications (Common Terminology Criteria for Adverse Events, CTCAE 5.0) were recorded. Mean coeliac trunk angulations were 36.3° (± 14.3) for the vascular closure group and 49.6° (± 17.1) for the conventional group. Technical success of the procedures was 100% for the vascular closure group and 80% in the conventional group (p < .05). Four patients with technical failure in the conventional group had a successful IAC implantation on the second attempt using the vascular closure technique. The use of a suture-mediated closure system for large bore arterial access allowed more frequent positioning of the distal tip into the gastro duodenal artery (GDA) (p = .01). No major complication occurred. The use of a large bore arterial access combined with a suture-mediated closure system may be useful for challenging IAC implantation without major complications.

A randomized controlled trial of closure or non-closure of subcutaneous fatty tissue after midline vertical incision

Background/Aim: There are limited studies that evaluate the closure of subcutaneous tissue, particularly among gynecologic oncology patients, a group with a high rate of obesity and more co-morbidities. This prospective randomized controlled study aimed to assess the effects of subcutaneous closure versus non-closure on wound complication rate in patients with subcutaneous tissue thicknesses of more than >4 cm. Methods: All patients with a subcutaneous tissue depth≥4 cm measured with ultrasonography and undergoing gynecologic surgery via a midline vertical incision from February 2019 to March 2020 in the gynecologic oncology department at a teaching hospital were considered for inclusion. Patients were intraoperatively and sequentially randomized as 1:1 only when the measurement of subcutaneous tissue depth was verified to be 4 cm or more. Results: A total of 82 patients who underwent randomization were assigned to undergo or not undergo subcutaneous closure with sutures (41 patients each). Subcutaneous wound depth (mean: 6.36 cm, range: 4-11 cm), vertical incision length (mean: 24.32 cm, 12-36 cm), body mass index (33.82 kg/m2, 19.6-33.82 kg/m2) were similarly distributed between the groups (P>0.05 for all). Wound complications were observed in 17 (20.7%) patients. Wound infection occurred in two patients in the closure group as compared to three patients in the control group (P=0.644). Seroma and wound dehiscence were seen more often in the control group, but neither of these findings reached statistical significance (P=0.077, P=0.284). Conclusion: We found no significant differences in the rate of surgical wound complications with suture approximation of the subcutaneous tissue in patients with 4 cm or more subcutaneous thickness undergoing gynecologic surgery via a vertical midline incision.

Interlocking Multi-Twisted Wires Versus Interrupted Simple Sternal Wires for Closure of Median Sternotomy.

Although closure of a sternotomy incision is usually a simple procedure, failure to do so (sternal dehiscence) is a serious complication and is an independent factor that poses a high degree of morbidity or mortality after open heart surgery. Instability of the bone fragments can lead to complete sternal breakdown, sternal wound infection, and mediastinitis. The stainless-steel encircling wire used as either interrupted simple sutures or as figure of eight sutures is the current standard method of median sternotomy closure. Interlocking multi-twisted sternal wire closure is an alternative that provides rigid sternal fixation. We aim to identify the best method of sternal closure in order to implement it as a standardised protocol for our department. Two-hundred patients aged 18-70 years were undergoing cardiac surgeries at Ain Shams University hospitals. They were divided into two groups: Group I included 100 patients with sternal closure using simple wire, and group II included 100 patients with sternal closure using interlocking multi-twisted wires. The day 7, 1 month, and 3 months sternal instability, superficial wound infection, ventilation time, cross-clamp time, length of ICU stay, and length of hospital stay were analyzed. The incidence of sternal instability on the 7th day, 1 month, and 3 months was significantly higher in the simple wire closure group (P < 0.05). However, incidence of superficial wound infection, length of ICU stay, and duration of mechanical ventilation were comparable between the two groups. The interlocking multi-twist is a safe, effective, and easily reproducible method for preventing sternal dehiscence.

Optimal definition of coagulation syndrome after colorectal endoscopic submucosal dissection: a post hoc analysis of randomized controlled trial.

Endoscopic clipping closure after colorectal endoscopic submucosal dissection (ESD) did not reduce the incidence of post-ESD coagulation syndrome (PECS) in our recent randomized controlled trial (RCT); however, the definition of PECS is still controversial. The aim of this study is to establish optimal definition of PECS with additional analysis of RCT based on another definition. In this multicenter, single-blind RCT, individuals were randomly assigned to colorectal ESD followed by endoscopic clipping closure or non-closure. In this post hoc analysis, the definition of PECS was modified as both localized abdominal pain on visual analogue scale and inflammatory response (fever or leukocytosis), from either localized abdominal pain or inflammatory response in the original study. All participants underwent a computed tomography after ESD, and PECS was classified into type I, conventional PECS without extra-luminal air, and type II, PECS with peri-luminal air. A total of 155 patients (84 in the non-closure group and 71 in the closure group) were analyzed. As a result of criteria modification, 21 type I PECS and four type II PECS cases in the original study, which included patients with clear pain and inflammatory response, were downgraded to no adverse event and simple peri-luminal air, respectively. The frequency of PECS showed no significant difference between non-closure and closure groups. Clipping closure after colorectal ESD does not reduce the incidence of PECS regardless of the diagnostic criteria. Either localized abdominal pain or inflammatory response might be optimal criteria of PECS (UMIN000027031). UMIN000027031 DATE OF REGISTRATION: April 18, 2017.

A novel and simple technique to close the enterotomy after intracorporeal anastomosis in laparoscopic right hemicolectomy.

We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2min (± 36.7) in Group A and 165.9min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients.

Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score

The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p= 0.001), 2 years (85 vs 33.3; p= 0.003), and 3 years (86.7 vs 63.3; p= 0.049). In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.