Wound Healing Complications Research Articles

The Burn Wound Healing Process : A Review

Burn wounds are a serious injury that can lead to significant morbidity and mortality. The burn wound healing process is a complex and dynamic process that involves a number of different cellular and molecular events. The three main stages of burn wound healing are inflammation, proliferation, and remodeling. Inflammation is the first stage of burn wound healing. During this phase, white blood cells (WBCs) and other immune cells are recruited to the wound site to remove dead tissue and bacteria. The inflammatory response also produces a number of growth factors that stimulate the growth of new tissue. The proliferative phase of burn wound healing begins about 3-4 days after the injury. During this phase, new blood vessels, connective tissue, and epithelial cells are formed. The epithelial cells eventually form a new layer of skin over the wound. The remodeling phase of burn wound healing begins about 2 weeks after the injury and can last for months or even years. During this phase, the new tissue is reorganized and remodeled. The scar tissue that forms during this phase is usually thicker and less elastic than the original skin. The healing of burn wounds can be affected by a number of factors, including the size and depth of the burn, the patient's age and overall health, and the presence of infection. Complications of burn wound healing can include infection, sepsis, and death. The latest advances in burn wound treatment include the use of skin grafts, growth factors, and artificial skin substitutes. These advances have improved the healing of burn wounds and reduced the risk of complications.

Nanothermometry-Enabled Intelligent Laser Tissue Soldering.

While often life-saving, surgical resectioning of diseased tissues puts patients at risk for post-operative complications. Sutures and staples are well-accepted and routinely used to reconnect tissues, however, their mechanical mismatch with biological soft tissue and invasiveness contribute to wound healing complications, infections, and post-operative fluid leakage. In principle, laser tissue soldering offers an attractive, minimally-invasive alternative for seamless soft tissue fusion. However, despite encouraging experimental observations, including accelerated healing and lowered infection risk, critical issues related to temperature monitoring and control during soldering and associated complications have prevented their clinical exploitation to date. Here, intelligent laser tissue soldering (iSoldering) with integrated nanothermometry is introduced as a promising yet unexplored approach to overcome the critical shortcomings of laser tissue soldering. It demonstrates that adding thermoplasmonic and nanothermometry nanoparticles to proteinaceous solders enables heat confinement and non-invasive temperature monitoring and control, offering a route to high-performance, leak-tight tissue sealing even at deep tissue sites. The resulting tissue seals exhibit excellent mechanical properties and resistance to chemically-aggressive digestive fluids, including gastrointestinal juice. The iSolder can be readily cut and shaped by surgeons to optimally fit the tissue defect and can even be applied using infrared light from a medically approved light source, hence fulfilling key prerequisites for application in the operating theatre. Overall, iSoldering enables reproducible and well-controlled high-performance tissue sealing, offering new prospects for its clinical exploitation in diverse fields ranging from cardiovascular to visceral and plastic surgery.

The Efficacy of Daily Local Antibiotic Lavage via an Epidural Suction-Irrigation Drainage Technique in Spondylodiscitis and Isolated Spinal Epidural Empyema: A 20-Year Experience of a Single Spine Center.

Various treatment modalities are available for local antibiotic therapy in spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE), but there is no evidence-based recommendation. Postoperative epidural suction-irrigation drainage (ESID) is thought to reduce bacterial load, which may prevent the development of relapse, wound healing, hematogenous spread, and systemic complications. We evaluated the efficacy of postoperative ESID over 20 years on disease progression and outcome in SD and ISEE. Detailed demographic, clinical, imaging, laboratory, and microbiological characteristics were examined in our cohorts of 208 SD and ISEE patients treated with and without ESID at a university spine center in Germany between 2002 and 2022. Between-group comparisons were performed to identify meaningful differences for the procedure. We included data from 208 patients (142 SD, 68.3% vs. 66 ISEE, 31.7%) of whom 146 were ESID patients (87 SD, 59.6% vs. 59 ISEE, 40.4%) and 62 were NON-ESID patients (55 SD, 88.7% vs. 7 ISEE, 11.3%). ESID patients with SD showed more frequent SSI (ESID: 22, 25.3% vs. NON-ESID: 3, 5.5%, p = 0.003), reoperations due to empyema persistence or instability (ESID: 37, 42.5% vs. NON-ESID: 12, 21.8%, p = 0.012), and a higher relapse rate (ESID: 21, 37.5% vs. NON-ESID: 6, 16.7%, p = 0.037) than NON-ESID patients with SD. The success rate in NON-ESID patients with SD was higher than in ESID patients with SD (ESID: 26, 29.9% vs. NON-ESID: 36, 65.6%, p < 0.001). Multivariate binary logistic regression analysis showed that ESID therapy (p < 0.001; OR: 0.201; 95% CI: 0.089-0.451) was a significant independent risk factor for treatment failure in patients with SD. Our retrospective cohort study with more than 20 years of experience in ESID technique shows a negative effect in patients with SD in terms of surgical site infections and relapse rate.

Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy.

Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.

Practical Review on Delayed Primary Closure: Basic Science and Clinical Applications.

Wound healing complications present a significant burden on both patients and health-care systems, and understanding wound healing principles is crucial across medical and surgical specialties to help mitigate such complications. One of these longstanding principles, specifically delayed primary closure (DPC), described as mechanically closing a wound after several days of secondary intention healing, lacks clear consensus on its definition, indications, and outcomes. This practical review examines wound healing fundamentals, focusing on DPC, its execution, indications, and comparative outcomes. A PubMed literature search was conducted to retrieve studies on DPC. Inclusion criteria included comparative studies assessing outcomes and complications between DPC and other closure techniques, as well as articles investigating DPC's underlying physiology. Twenty-three comparative studies met inclusion criteria. DPC wounds have significantly higher partial pressure of oxygen, higher blood flow, and higher rates of collagen synthesis and remodeling activity, all of which help explain DPC wounds' superior mechanical strength. DPC seems most beneficial in contaminated wounds, such as complicated appendectomies, postcardiac surgery wounds, and complicated abdominal wall reconstructions, where it has been associated with lower rates of surgical site infections. This practical review provides an evidence-based approach to DPC, its physiology, technique, and indications. Based on the existing literature, the authors recommend that DPC wounds should be dressed in saline/betadine soaks, changed and irrigated daily, with delayed closure lasting between 3 and 5 days or until the infection has resolved. The clearest indications for DPC are in the context of contaminated abdominal surgery and sternal wound dehiscence post cardiac surgery.

COVID-associated complications after reconstructive breast surgery: a retrospective cohort study.

The COVID pandemic significantly influenced reconstructive breast surgery regimens. Many surgeries were cancelled or postponed. COVID entails not only respiratory, but also coagulative symptoms. It, therefore, potentially increases the risk of postoperative complications. The incidence of perioperative COVID infection and its influence on postoperative recovery after reconstructive breast surgery is still unknown. This dual center retrospective cohort study included patients that underwent reconstructive breast surgery between March 2020 and July 2021. Post-mastectomy autologous or implant-based breast reconstruction (ABR; IBR), as well as post-lumpectomy oncoplastic partial breast reconstruction (PBR) were eligible. Patient data were extracted from electronic medical records. Data regarding COVID-19 infection was collected through a questionnaire. The primary outcome was complication rate. The ABR, IBR and PBR groups consisted of 113 (12 COVID-positive), 41 (2 COVID-positive) and 113 (10 COVID-positive) patients. In the ABR and PBR groups, postoperative complications occurred significantly more often in patients with perioperative COVID-infection. Especially impaired wound healing occurred significantly more often in the ABR and PBR breasts, but also at the donor site of ABR patients with perioperative COVID. Perioperative COVID-infection increases susceptibility to complicated wound healing after reconstructive breast surgery. A possible explanation lies in the dysregulation of haemostasis by the virus, and its direct effects on microvasculature. A hypercoagulable state results. We recommend to postpone elective breast surgery for 4-6weeks after COVID-19 infection. Also, precautionary measures remain important to minimize the risk of perioperative COVID-19 infection.

Antibiofilm activity of bromelain from pineapple against Staphylococcus aureus

Bromelain is a set of proteolytic enzymes usually obtained from pineapple (Ananas comosus). Although bromelain has distinguished therapeutic properties, little is known about its proteolytic potential against opportunistic pathogens related to wound healing complications, such as Staphylococcus aureus. This study aimed to investigate the antibiofilm and antibacterial activity of bromelain in 43 clinical strains of S. aureus isolated from chronic wounds and blood cultures. Bromelain’s activity against S. aureus biofilm in vitro was assessed by analyzing biofilm formation in cultures grown in the presence of 1% bromelain and biofilm destruction after the addition of 1% bromelain to mature biofilms. Proteinase K and sodium metaperiodate were also added to mature biofilms in parallel to compare their activity with that of bromelain and, together with exopolysaccharide and protein production rate assays, to determine the chemical composition of the biofilm extracellular matrix of selected strains of S. aureus. Bromelain was also evaluated for its DNase activity and impact on cellular hydrophobicity and auto-aggregation. Mueller-Hinton agar dilution was used to determine bromelain minimal inhibitory concentration (MIC). Biofilm assays showed that 1% bromelain significantly inhibits S. aureus biofilm formation (p = 0.0157) by up to 4-fold and destroys its mature biofilms (p &lt; 0.0001) by up to 6.4-fold, both compared to the control grown without bromelain. Biofilms of methicillin-resistant S. aureus strains isolated from chronic wounds were the most affected by bromelain treatment. No antibacterial activity was detected with bromelain MIC assays and the proteolytic activity of bromelain was identified as the main antibiofilm mechanism of the enzyme, though its DNase activity may also contribute. The epithelial therapeutic properties of bromelain combined with its antibiofilm activity against S. aureus make it a promising alternative to compose the therapeutic arsenal for the control of S. aureus biofilms in the context of wound care.

Craniectomy size and decompression of the temporal base using the altered posterior question-mark incision for decompressive hemicraniectomy

The altered posterior question-mark incision for decompressive hemicraniectomy (DHC) was proposed to reduce the risk of intraoperative injury of the superficial temporal artery (STA) and demonstrated a reduced rate of wound-healing disorders after cranioplasty. However, decompression size during DHC is essential and it remains unclear if the new incision type allows for an equally effective decompression. Therefore, this study evaluated the efficacy of the altered posterior question-mark incision for craniectomy size and decompression of the temporal base and assessed intraoperative complications compared to a modified standard reversed question-mark incision. The authors retrospectively identified 69 patients who underwent DHC from 2019 to 2022. Decompression and preservation of the STA was assessed on postoperative CT scans and CT or MR angiography. Forty-two patients underwent DHC with the standard reversed and 27 patients with the altered posterior question-mark incision. The distance of the margin of the craniectomy to the temporal base was 6.9 mm in the modified standard reversed and 7.2 mm in the altered posterior question-mark group (p = 0.77). There was no difference between the craniectomy sizes of 158.8 mm and 158.2 mm, respectively (p = 0.45), and there was no difference in the rate of accidental opening of the mastoid air cells. In both groups, no transverse/sigmoid sinus was injured. Twenty-four out of 42 patients in the modified standard and 22/27 patients in the altered posterior question-mark group had a postoperative angiography, and the STA was preserved in all cases in both groups. Twelve (29%) and 5 (19%) patients underwent revision due to wound-healing disorders after DHC, respectively (p = 0.34). There was no difference in duration of surgery. Thus, the altered posterior question-mark incision demonstrated technically equivalent and allows for an equally effective craniectomy size and decompression of the temporal base without increasing risks of intraoperative complications. Previously described reduction in wound-healing complications and cranioplasty failures needs to be confirmed in prospective studies to demonstrate the superiority of the altered posterior question-mark incision.

Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study".

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Therapeutic Level III, retrospective cohort.

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94). In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level IV.

Evaluation of primary wound healing and potential complications after perioperative infiltration with lidocaine without adrenaline in surgical incisions in dogs and cats

BackgroundPre-emptive local analgesia with the use of lidocaine is practised increasingly in veterinary medicine as part of applied multimodal analgesia, despite its controversial impact on wound healing. The purpose of this prospective, randomised, double-blinded, placebo-controlled clinical study was to evaluate if preoperative subcutaneous infiltration of lidocaine has a negative impact on primary wound healing of surgical incisions. Fifty-two companion animals (3 cats and 49 dogs) were enrolled in the study. The inclusion criteria were as follows: American Society of Anaesthesiologists (ASA) score I or II, a minimum body weight of 5 kg, and a planned incisional length of at least 4 cm. Surgical incisions were infiltrated subcutaneously with lidocaine without adrenaline or NaCl (placebo). Follow-up questionnaires for owners and veterinarians and thermography of the surgical wound were used to assess wound healing. Antimicrobial use was documented.ResultsThere was no significant difference in either the total score or the individual assessment points between the treatment and the placebo group on the owner or the veterinary questionnaires in regard to primary wound healing (P > 0.05 for all comparisons). No significant difference was found between the thermography results of the treatment and placebo group (P = 0.78), and there was no significant correlation between the total score from the veterinary protocol and thermography results (Spearman’s correlation coefficient − 0.10, P = 0.51). Surgical site infections developed in 5/53 (9.4%) surgeries and its occurrence varied significantly between the treatment and the placebo group as all cases of infection were in the placebo group (P = 0.05).ConclusionThe results of this study indicate that lidocaine used as a local anaesthetic did not affect wound healing in patients with ASA scores I-II. The results suggest that lidocaine infiltration in surgical incisions can be safely used to reduce pain.

Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach

Surgical treatment of intra-articular calcaneus fractures via aminimally invasive approach. Intra-articular dislocated calcaneus fractures. Fracture older than 14days; poor soft tissue quality in the surgical area. Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsalIV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of aSchanz screw in the calcaneal tuberosity from lateral or posterior as areduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing acannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8weeks; subsequently increased load bearing. Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Scarring and Dyschromias in Fitzpatrick Skin Type IV-VI: A Review of Dermatologic Treatment Protocols.

Managing chronic conditions is an essential aspect of dermatologic care, especially regarding the resolution of inflammatory dermatologic disease and recovery of skin lesions. Short-term complications of healing include infection, edema, dehiscence, hematoma formation, and tissue necrosis. At the same time, longer-term sequelae may consist of scarring and scar widening, hypertrophic scars, keloids, and pigmentary changes. This review will focus on dermatologic complications of chronic wound healing in patients with Fitzpatrick skin type (FPS) IV-VI or skin of color (SOC), with an emphasis on hypertrophy/scarring and dyschromias. It will focus on current treatment protocols and the potential complications specific to patients with FPS IV-VI. There are multiple complications of wound healing that are more prevalent in SOC, including dyschromias and hypertrophic scarring. These complications are challenging to treat, and current protocols are not without complications and side effects that must be considered when offering therapy to patients with FPS IV-VI. When treating pigmentary and scarring disorders in patients with skin types FPS IV-VI, it is essential to implement a stepwise approach to management that is conscious of the side effect profile of current interventions. J Drugs Dermatol. 2023;22(7): doi:10.36849/JDD.7253.

Immediate Plastic Surgery Intervention after Soft Tissue Sarcoma Resection: Examining Wound Healing, Readmission, and Reoperation.

Adult patients who underwent index STS resection between 2005 and 2018 were queried from an institutional database. Main outcomes analyzed were 90-day same-site reoperation, any-cause readmission, and wound healing complications. Univariate and multivariate logistic regression were used to identify risk factors. Additional evaluation was then performed for the following two cohorts: patients with and without plastic surgeon involvement. In total, 228 cases were analyzed. Multivariate regression demonstrated the following predictors for 90-day wound-healing complications: plastic surgery intervention [OR = 0.321 (0.141-0.728), P = 0.007], operative time [OR = 1.003 (1.000-1.006), P = 0.039], and hospital length of stay [OR = 1.195 (1.004-1.367), P = 0.010]. For 90-day readmission, operative time [OR = 1.004 (1.001-1.007), P = 0.023] and tumor stage [OR = 1.966 (1.140-3.389), P = 0.015] emerged as multivariate predictors. Patients whose resection included a plastic surgeon experienced similar primary outcomes despite these patients having expectedly longer operative times (220 ± 182 versus 108 ± 67 minutes, P < 0.001) and hospital length of stay (3.99 ± 3.69 versus 1.36 ± 1.97 days, P < 0.001). Plastic surgeon involvement emerged as a significant protector against 90-day wound healing complications. Cases that included plastic surgeons achieved similar complication rates in all categories relative to cases without plastic surgery intervention, despite greater operative time, hospital length of stay, and medical complications.

What is the influence of negative pressure wound therapy on high-risk wounds in pelvic oncology?

Introduction& Aims: Hindquarter amputation (HQA) has a high incidence of post-operative wound complications. We aim to use the HQA procedure as a model to investigate the potential advantages of negative pressure wound therapy (NPWT) on wound healing complications in high-risk pelvic oncology wounds. MethodsWe conducted a retrospective analysis of all patients undergoing HQA between January 2009 and November 2020 ​at a single tertiary centre. 106 patients underwent HQA for sarcoma. 43.4% (46 patients) had NPWT therapy following HQA. We compared the incidence of wound complications necessitating a return to the operating theatre, total incidence of wound infection (according to CDC Surgical site infection guidelines) and local recurrence between patients with and without NPWT. ResultsIn the absence of neo-adjuvant radiotherapy, there was no difference in the incidence of wound complications requiring re-operation between the NPWT group and the conventional dressing group (odds ratio [OR], 1.01; p ​= ​0.983, 95% confidence interval [CI], 0.365–2.8). However, the use of NPWT decreased the incidence of reoperation after neo-adjuvant radiotherapy versus conventional dressings [OR], 0.087; p ​= ​0.033, 95% CI, 0.009–0.818). The incidence of wound infection has declined with the increasing use of NPWT between 2009 and 2020. There was no difference in the incidence of local recurrence after two years between patient groups with and without NPWT. ConclusionThe application of NPWT reduces the incidence of wound complications in high-risk pelvic oncology wounds after neo-adjuvant radiotherapy. We demonstrated a reduction in the incidence of reoperation due to wound complications in patients who received NPWT following HQA.

Spine

The June 2023 Spine Roundup360 looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

Open Median Arcuate Ligament Release With Complete Celiac Plexus Neurolysis Provides Substantial Relief in Symptomatic Patients

Median arcuate ligament syndrome (MALS) is a clinical entity that has historically been met with significant equipoise on how to diagnose and treat the constellation of symptoms. Our objective was to describe distinct patient outcomes following open median arcuate ligament release and complete celiac plexus neurolysis in patients diagnosed with MALS. We performed a prospective analysis of patients referred for MALS at a single institution between February 2020 and January 2022. We assessed duplex ultrasound studies, abdominal computed tomography angiography results, celiac plexus nerve block procedures, and patient reported questionnaires. Patients who experienced symptomatic relief from celiac plexus nerve block were offered surgical release and neurolysis. Their preoperative and postoperative health and quality of life measures were assessed using the 36-item Short-Form Health Survey (RAND). There were 75 patients who were referred for MALS and 29 patients (39%) underwent surgery. Duplex ultrasound examination revealed a significant increase in celiac artery peak systolic velocity at end-expiration (211 cm/s to 276 cm/s), with only 55% having a J-hooked appearance of the celiac artery on computed tomography angiography. All patients underwent transgastric celiac plexus block with a combination of bupivacaine and triamcinolone. After nerve block, surgical patients had a mean relief of 207 hours (48-1008 hours) from their symptoms. Postoperatively, 16 patients completed the 36-item Short-Form Health Survey with significant improvement noted in each category of the questionnaire (Fig 1). Significant quality of life improvement can also be appreciated in Fig 2. Surgical patients had an average weight gain of 8.8 kg (range, 1.3-34 kg) at a mean follow-up of 8 months. There were no perioperative wound healing complications. Our data suggest that patients who are carefully selected for median arcuate ligament release and neurolysis have significant improvement in quality of life and benefit from surgery. Wide surgical neurolysis of the celiac plexus is critical and the same diagnostic imaging findings are not consistent across all patients. Celiac plexus neurolysis is required for accurate patient selection.Fig 2Averages in each domain of the 36-item Short-Form Health Survey.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Drug suspending during wound healing effectively weakens immunosuppression-related complications by preserving CD8+ T cell function.

Immunosuppressive medications, which interfere with the activation and proliferation of T and B cells, increase the risk of wound healing complications. To address it, this study aimed to validate the feasibility of drug suspending during wound healing, whilst exploring the mechanisms exerted by T cells, which are important in the wound healing process. For this, a mouse skin wound model was set up. Tacrolimus (FK506) and fingolimod (FTY720) were both administered intraperitoneally prior to wounding to inhibit the T cell activation and migration, respectively. Flow-cytometric analysis subsequently revealed the functional T cell subtypes detected during the healing process. A CD8a antibody was also administered to deplete CD8+ T cells in vivo to verify their specific function. It was found that FK506 or FTY720 administration delayed the early phase of wound healing by reducing collagen production, which was also supported by the downregulation of col1a1, col3a1 and tgfb1. However, there was no significant difference in the total healing period. Both spleen- and skin-derived CD8+ T cells were proliferated and activated after injury without intervention, whereas CD4+ T cells showed no significant changes. Furthermore, selectively depleting CD8+ T cells retarded the healing process by downregulating collagen production-associated genes (col1a1, col3a1, tgfβ1 and en1) and proteins (collagen type 1 and 3). In addition, the CD8a antibody decreased the expression of genes lta, tnfa, il13 and il13ra, and protein interleukin-13Rα. In conclusion, suspending immunosuppressive drugs during wound healing was shown to be feasible through restraining the migration of activated T cells. CD8+ T cells represented the primary functional subtype positively associated with wound healing.

109 Effects of Fat-Rich Nutrients in the Pancreas of an Experimental Burn Model

Abstract Introduction Oversupply of nutrients overstimulates beta cells in standard conditions, and severe burn injuries increase the metabolic needs. In this study, we investigated the effects of fat-rich nutrients on the endocrine pancreas during the acute phase of severe burns. Methods Twenty-one Wistar albino rats were randomly divided into 3 groups. Two groups were fed with standard commercial rat chow (1 with sham procedure and 1 with burn procedure), and the third group (also with burn procedure) was fed a fat-rich diet (60% kcal fat). The burn procedure involved a 25% total body surface area fullthickness burn. Blood samples were taken at 36 hours and 7 days after burn injury or sham procedure. On postburn day 7, skin biopsies were taken and a pancreatectomy was performed. Pancreatic tissues were examined under light microscopy; islets size and cellularity were calculated and investigated immunohistochemically. Results Plasma glucose, C-Peptide, and insulin levels were similar in all the study groups 36 hours and 7 days after burn induction or sham procedure. There was a significant increase in the number of cells per one islet in the burn group given a fat-rich diet compared with the other groups (P = .05). Caspase-3 was strongly expressed in both groups with burn injuries. Conclusions Overconsumption of certain fats can lead to a compensatory response by beta cells that eventually can progress to beta-cell dysfunction during the acute phase of burns. Severe burns induce pancreatic islet cell hyperplasia. Providing excessive fat nutrients during the acute postburn period attenuates this response. Despite the morphophysiological changes observed in the pancreas, all animals in our study achieved similar glycemic homeostasis. Applicability of Research to Practice The delivery of nutritional support is a vital element of burn care, and the main goal is simply to avoid nutritional complications. Lipotoxicity contributes to multisystem organ failure and worse clinical outcomes in obese patients and mice with pancreatitis. Neutralization of IL-1β produces beneficial effects on postburn glycemic control and improves survival. apoptosis in the pancreas of patients with severe burns may be linked to a series of events that can induce Caspase-1 activation and IL-1β release, and these pathways may be influenced by the nutritional status, especially in the early postburn phase. Effective nutritional assessment and management can optimize wound healing and decrease complications and mortality.

The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Data Sets.

Timing of surgical intervention is controversial among patients seeking correction of congenital breast deformities. This study aimed to assess the influence of age on 30-day complications and unplanned healthcare utilization after reconstruction of congenital breast deformities. Female patients undergoing breast reconstruction for congenital breast deformities and Poland syndrome were identified on the basis of International Classification of Diseases (ICD) codes in the 2012 to 2021 pediatric and adult National Surgical Quality Improvement Project (NSQIP) data sets. Complications based on age at correction were compared, and multivariate logistic regression was used to identify predictors of overall and wound healing complications. Among 528 patients meeting inclusion criteria, mean (SD) age at surgical correction was 30.2 (13.3) years. Patients most commonly underwent implant placement (50.5%), mastopexy (26.3%), or tissue expander placement (11.6%). Across the cohort, overall incidence of postoperative complications was 4.4%, most commonly superficial surgical site infection (1.0%), reoperation (1.1%), or readmission (1.0%). After multivariate adjustment, increasing age at time of correction was associated with higher incidence of wound complications [odds ratio (OR) 1.001; 95% confidence interval (CI) 1.0003-1.002; P = .009], in addition to BMI (OR 1.002; 95% CI 1.0007-1.004; P = .006) and tobacco use (OR 1.06; 95% CI 1.02-1.11; P = .003). Breast reconstruction for congenital breast deformities may be safely undertaken at a young age with a low associated risk of postoperative complications. Large, multi-institutional studies are needed to assess the influence of surgical timing on psychosocial outcomes in this population.