Severe Postoperative Infection Research Articles

Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan.

Position of the nipple-areolar complex (NAC) is an important factor in the esthetic impression of the breast, and NAC malposition is often an issue in breast reconstruction after nipple-sparing mastectomy (NSM). The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan). Patients who underwent unilateral breast reconstruction after NSM at eight hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6-24months post-operatively. The degree of malpositioning was then statistically compared using various factors. The NAC deviated more cranially and medially with implants than that with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition, and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to the degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants. This study provides insights into the tendencies and characteristics of NAC malposition.

Non-antigen-specific Immunoadsorption Is a Risk Factor for Severe Postoperative Infections in ABO-Incompatible Kidney Transplant Recipients.

ABO-incompatible (ABOi) living kidney transplantation (KTx) is an established procedure to address the demand for kidney transplants with outcomes comparable to ABO-compatible KTx. Desensitization involves the use of immunoadsorption (IA) to eliminate preformed antibodies against the allograft. This monocentric retrospective study compares single-use antigen-selective Glycosorb® ABO columns to reusable non-antigen-specific Immunosorba® immunoglobulin adsorption columns regarding postoperative infectious complications and outcome. It includes all 138 ABOi KTx performed at Freiburg Transplant Center from 2004-2020. We compare 81 patients desensitized using antigen-specific columns (sIA) to 57 patients who received IA using non-antigen-specific columns (nsIA). We describe distribution of infections, mortality and allograft survival in both groups and use Cox proportional hazards regression to test for the association of IA type with severe infections. Desensitization with nsIA tripled the risk of severe postoperative infections (adjusted HR 3.08, 95% CI: 1.3-8.1) compared to sIA. nsIA was associated with significantly more recurring (21.4% vs. 6.2%) and severe infections (28.6% vs. 8.6%), mostly in the form of urosepsis. A significantly higher proportion of patients with sIA suffered from allograft rejection (29.6% vs. 14.0%). However, allograft survival was comparable. nsIA is associated with a two-fold risk of developing a severe postoperative infection after ABOi KTx.

A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases

BackgroundTo investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures.MethodsThe clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients’ age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle–hindfoot score.ResultsPatients were followed up for 16–36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12–24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle–hindfoot function score was 40.0 ± 3.8 (range, 30–52) points, and it increased to 75.0 ± 3.0 (range, 67–78) points at the last follow-up.ConclusionA unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle–hindfoot function, and improves the patient’s quality of life.

Computed tomography-guided intraoperative navigation in children with congenital scoliosis versus freehand/fluoroscopy methods

BACKGROUND: The choice of techniques for the treatment of children with congenital spinal deformities remains one of the most significant problems of spinal surgery. This topic is relevant given the peculiarities of the disease course, severity and rigidity of deformities, their steady and rapid progression, formation of compensatory curvature, and a significant decrease in the quality and life expectancy of patients.
 AIM: To compare screw misposition, adverse outcomes, intraoperative blood loss, and time required for pedicle screw placement with further deformity correction under computed tomography (CT) guidance with intraoperative navigation versus fluoroscopy.
 MATERIALS AND METHODS: This single-center, prospective comparative study was conducted from 2019 to 2022 at the National Scientific Center of Traumatology and Orthopedics named after academician N.D. Batpenov. Patient demographics and surgical outcomes were obtained from the medical records. All patients underwent a comprehensive clinical and radiological examination before surgery, after surgery, and at the stages of dynamic observation. Data of patients with congenital malformations of the spine were analyzed. The study involved 42 patients aged 318 years with congenital kyphoscoliosis of the thoracic and/or lumbar spine. The patients were divided into two groups according to the method of surgical correction used: the O-arm navigation group and the C-arm group.
 RESULTS: Data of patients who underwent surgery for congenital scoliosis of the spine were analyzed. The patients were divided into the O-arm navigation group, which included patients who underwent surgery using the O-arm mobile intraoperative CT with the seventh-generation Stealth Station navigation system in combination with intraoperative neuromonitoring, and the C-arm group, which included patients who underwent surgery under the control of the intraoperative C-arm. In both groups, 364 screws were placed, of which 189 screws were placed under neuronavigation, and 175 screws were placed using the C-arm. The effectiveness of the intraoperative neuronavigation system in combination with neuromonitoring showed 97.11% correct placement (grades A and B) of pedicle screws. The use of an intraoperative C-arm showed 89.63% (grades A and B) correctness. The proportion of misplaced screws corresponding to GertzbeinRobbins classes CE was higher in the C-arm group (10.37%) than in the navigation group (1.49%) (p 0.005). No severe neurological disorders, postoperative infection, or adverse clinical outcomes were observed in both groups.
 CONCLUSIONS: The installation of pedicle screws using CT-guided navigation (O-arm) did not prolong the operation time, did not increase blood loss, and reduced the risk of screw mispositioning compared with freehand and fluoroscopy pedicle screw placement.

Not Just Another Trigger Finger.

Open A1 pulley release for trigger finger has generally been considered a minor procedure with infrequent complications. Most reported complications are minor, including scar pain and tenderness, mild extension lag, and recurrence of triggering. Rates of major complications, such as bowstringing, neurovascular bundle injury, and infection requiring reoperation, are less than 1% to 4%. We aimed to describe the potentially devastating sequelae of these major complications and the subsequent consequences. Three patients underwent open trigger finger release, which were all complicated by severe postoperative surgical site infection requiring multiple subsequent procedures. We review our initial management, subsequent reconstructive options, and outcomes with up to 19 years follow-up. All 3 adult patients who underwent open A1 pulley release for trigger finger developed a surgical site infection, leading to flexor tenosynovitis requiring urgent operative debridement and multiple subsequent procedures. Two patients were poorly controlled diabetics, and the third patient was otherwise healthy. Each patient ultimately developed distinct consequences from their postoperative course-finger stiffness and contracture, disabling bowstringing requiring the use of a pulley ring, and flexor tendon rupture requiring staged tendon reconstruction, respectively. All 3 patients at final follow-up had a permanent functional deficit. Major complications after trigger finger release are infrequent. However, if left untreated, particularly in diabetic patients, there can be disastrous consequences, resulting in permanent loss of function. This case series highlights the importance of accurate diagnosis of postoperative infections and expedient treatment thereafter.

ROLE OF PROPHYLACTIC GATIFLOXACIN IN LAPAROSCOPIC CHOLECYSTECTOMY – A COMPARATIVE STUDY WITH CEFTRIAXONE

Objectives: The objective of this study was to evaluate and compare the effectiveness of gatifloxacin and ceftriaxone as prophylactic antibiotic in elective clean surgical procedures. Methods: Sixty patients, undergoing laparoscopic cholecystectomy, were recruited consecutively and divided into two groups, that is, Group A and Group B of 30 patients each. In Group A, a pre-operative dose of injection ceftriaxone 1 g was administered intravenously half an hour before induction of anesthesia and second dose was given 12 h postoperatively. In Group B, pre-operative dose of tablet Gatifloxacin 400 mg was administered night before operation and another tablet postoperatively when the patient started orally in the evening. If not accepting orally then single intravenous infusion of Gatifloxacin was given in the evening. Results: In Group A, one patient (3.33%) had grade 1 and two patients (6.66%) had grade 2 infection. Similarly in Group B, one patient (3.33%) had grade 1 and two patients (6.66%) had grade 2 infection. None of the patients in both the groups had severe post-operative wound infection (grade 3 and grade 4). Conclusion: Prophylactic gatifloxacin is non-inferior to the “current gold standard ceftriaxone” as far as effectiveness of the drug is concerned. In addition, it had a similar side effect profile and was equally safe as a prophylactic antibiotic in preventing wound infection following routine elective laparoscopic cholecystectomy.

Compensated Patient Injuries in the Treatment of Abdominal Aortic and Iliac Artery Aneurysms in Finland: A Nationwide Patient Insurance Registry Study

Patient injury claims data and insurance records provide detailed information on patient injuries. This study aimed to identify the errors and adverse events that led to patient injuries in vascular surgery for the treatments of abdominal aortic aneurysms (AAA) and iliac artery aneurysms (IAA) in Finland. The study also assessed the severity and preventability of the injuries. A retrospective analysis of Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of AAA and IAA. Records of all compensated patient injury claims involving AAA and IAA between 2004 and 2017 inclusive were reviewed. Contributing factors to injury were identified and classified. The injuries were assessed for their preventability by using the WHO Surgical Safety Checklist correctly. The degree of harm was graded by Clavien-Dindo classification. Twenty-six patient injury incidents were identified in the treatment of 23 patients. Typical injuries involved delays in diagnosis or treatment, errors in surgical technique or injuries to adjacent anatomic organs. Three (13.0%) patients died due to patient injury. Two deaths were caused by delays in diagnosis of ruptured abdominal aortic aneurysm (RAAA) and the third death was due to missed diagnosis of post-operative myocardial infarction. Retained foreign material caused injuries to two (8.7%) patients. One (4.3%) patient had a severe postoperative infection. Three (13.0%) patients experienced an injury to an adjacent organ. One patient had a bilateral and another a unilateral above-the-knee amputation due to patient injury. Three injuries were considered preventable. Most harms were grade IIIb Clavien-Dindo classification in which injured patients required a surgical intervention under general anesthesia. Compensated patient injuries involving the treatment of AAA and IAA are rare, but are often serious. Injuries were identified during all stages of care. Most injuries involved open surgical procedures.

Primary Reconstruction of Mandibular Defects after Resection of Aggressive Pediatric Mandibular Tumors by Split Rib Bundle Bone Graft. A Retrospective Study

Background: A retrospective study was done to evaluate the success rate of immediate reconstruction by split rib bundle bone grafting after segmental resection of Aggressive Pediatric mandibular tumors. Materials and Patients: The present study enrolled sixty-one pediatric patients with aggressive mandibular tumors that had been treated during the period from January 2008 to December 2018. All patients were examined clinically and radiographically by Orthopantomograms, CTs and CBCTs. Radical segmental resection with resultant mandibular continuity defects were thus created followed by immediate reconstruction with non-vascularized Split Rib Bundle Bone Graft (SRBBG). Patients were then rehabilitated by osseointegrated implants with fixed or removable partial dentures. Success of reconstruction was assessed by the percentage of complications, interincisal opening and patient satisfaction. Assessment was performed at 1,3,6 and 12 months postoperatively. All patients were followed up for 4-7 years. Results: Successful reconstruction was accomplished in 55 patients (90.16 %). Successful dental rehabilitation was accomplished in 49 patients (89%). Three patients had complete failure due to severe postoperative infection. Another three cases had partial resorption of the graft due to moderate infection to whom re-augmentation by another rib graft had been performed. Conclusion: Pediatric aggressive mandibular tumors should be treated in an aggressive manner relative to its biologic behavior and immediate reconstruction is advocated. The Split Rib Bundle Bone Graft is an adequate alternative for mandibular reconstruction in the absence of microvascular surgery as it shows early revascularization thus permitting rehabilitation with successfully osseointegrated dental implants.

Application strategy and effect of cuffed tracheostomy tube with inner cannula in the treatment of postoperative complications of laryngeal or hypopharyngeal cancer

Objective: To Investigate the application strategy and effect of cuffed tracheostomy tube with inner cannula in the treatment of postoperative complications of laryngeal and hypopharyngeal cancer. Methods: A total of 60 patients with laryngeal and hypopharyngeal cancer occurred serious postoperative complications, including 31 cases of severe postoperative neck infection, 8 cases of dyspnea, 5 cases of massive hemorrhage and 16 cases of seriously intractable aspiration. The tracheal cannula with inner cannula and outer cuff was immediately worn on these patients and the cuff was inflated. Different treatments were carried out according to different complications. The outer cuffs were inflated for patients with severe neck infections to prevent a large amount of neck secretions inhaled to the trachea. Patients with dyspnea immediately received ventilator-assisted ventilation. For those with massive hemorrhage on the wound, doctors should prevent bleeding and stop bleeding under general anesthesia. Patients with severely coughing should perform eating training to prevent food aspiration. The inner cannula was regularly replaced once a month for all of these patients. Results: Through targeted treatment, the complications of 60 patients with cuffed tracheostomy tube with inner cannula were effectively controlled. After dressing change, the neck wounds of 31 patients with neck infection were shrunk or healed. Finally, all of the patients were replaced with metal tracheal tubes. Eight cases with dyspnea were rescued with the symptomatic and related special treatment, and finally replace by metal tracheal tube. Five cases with massive bleeding in the neck wound were successfully rescued and replaced with metal tracheal cannula. Thirteen patients among 16 cases with intractable aspiration were removed the tracheal cannula and other 3 cases of old and severely ill were replaced with metal tracheal cannula. Conclusions: The cuffed tracheostomy tube with inner cannula is of great value in the treatment of severe postoperative complications of laryngeal or hypopharyngeal cancer. It is strongly recommended that the operators should fully understand and use it reasonably after the operation of laryngeal or hypopharyngeal cancer.

Risk factors for intracranial infection after craniotomy: A case-control study.

BackgroundIntracranial infection, serving as a severe postoperative infection after craniotomy, poses significant problems for patients' outcomes.ObjectiveTo explore risk factors for intracranial infection after craniotomy.MethodsA total of 2,174 patients who underwent craniotomy from 1 May 2018 to 30 June 2019 were retrospectively studied. Finally, 196 patients with intracranial infections were classified as case group, and 392 patients randomly selected from patients without intracranial infection were classified as control group. Demographic, clinical, laboratory, microbiological, and antimicrobial data were systemically recorded. The characteristics, pre‐ and postoperative variables, and other variables were evaluated as risk factors for intracranial infection by univariate analysis and binary logistic regression model.ResultsThere was no significant difference in terms of demographics between two groups, except for gender, hypertension, length of stay (LOS), intraoperative blood loss, tumor, and trauma surgery. The independent risk factors were male, age ≤45, hypertension, tumor surgery, surgery in autumn (compared with spring), surgical duration ≥4 hr, intraoperative blood loss ≥400 ml, and postoperative oral infection, coma, and serum RBC > normal value. Trauma surgery (p < .001, OR = 0.05, 95% CI: 0.017–0.144) was an independent protective factor (p < .05, OR < 1) for intracranial infection. All 196 patients in the case group submitted specimens for cerebrospinal fluid (CSF) cultures, and 70 (35.71%) patients had positive results. Gram‐positive pathogens predominated (59 cases, 84.28%). Staphylococcus were the most common causative pathogens, and fully resistant to aztreonam, cefazolin, and benzylpenicillin, but not resistant to linezolid and minocycline.ConclusionIdentifying the risk factors, pathogens, and pathogens' antibiotic resistance for intracranial infection after craniotomy plays an important role in the prognosis of patients.

Peri- and Post-operative Amplitude-integrated Electroencephalography in Infants with Congenital Heart Disease

To identify the factors influencing brain injury in infants with congenital heart disease (CHD) after cardiac surgery. This retrospective study investigated 103 infants with CHD undergoing cardiac surgery between January 2013 and February 2016. Pre- and postoperative amplitude-integrated electroencephalography (aEEG) recordings were assessed for background pattern, sleep-wake cycle pattern and seizure activity. Logistic regression model was used to determine the influencing factors of brain injury. Pre-operatively, most infants in our study exhibited a normal background pattern, with 16.5% showing discontinuous normal voltage, whereas this pattern was observed in only 7.8% of infants postoperatively. The improvement in background pattern after surgery was significant (P<0.05) in infants at no more than 39 weeks of gestational age. Infants with postoperative sepsis or severe postoperative infection were prone to show a worse sleep-wake cycle pattern after heart surgery. The improvement in brain function of infants with CHD after cardiac surgery was associated with the gestational age and postoperative infection.

Actinomyces neuii infection following ovarian cystectomy

Background: Abdominal Actinomyces infections are rare complications of surgery. A case of Actinomyces neuii presenting as a severe postoperative pelvic infection is described.Case: A 30 year-old nulligravid female was transferred from an outside hospital for a postoperative fluid collection, fever, leukocytosis, and abdominal pain following exploratory laparotomy and bilateral ovarian cystectomy. She rapidly decompensated requiring emergent exploratory laparotomy, bilateral salpingooophorectomy, and abdominal washout. Cultures isolated A. neuii. Following a prolonged ICU admission, she was treated with prolonged antibiotics and made a complete recovery.Conclusions: Rare pathogens, such as A. neuii, may cause severe infections following gynecologic surgery. Multidisciplinary care at tertiary care facilities is critical.

Small Bowel Perforation due to Ingested Foreign body

Small bowel perforation due to ingested foreign body is a rare but potentially life-threatening event. We present here 4 cases of small intestinal perforation caused by accidental ingestion of foreign bodies, from a total of 1,100 surgical procedures in one unit over a one-year period (September 2016 -August 2017). All 4 cases occurred in elderly patients who were using an artificial denture. The clinical appearance was that of acute abdomen, and in one case there had been formation of an enterocutaneous fistula a long time after the foreign body was swallowed. Typically, preoperative abdominal computed tomography (CT) showed the possible presence of a foreign body, which was confirmed intraoperatively. All 4 patients underwent surgery. Removal of the foreign body was performed, followed by primary intestinal closure or small bowel resection with a side-to-side anastomosis. Three of the 4 patients had an uneventful postoperative course, but one died on the 10th postoperative day, due to a severe postoperative pulmonary infection. Old age and artificial denture use appear to be strong risk factors, and the time and location of the perforation, and the presence of co-morbidities are prognostic factors for a successful surgical outcome. The choice of the type of surgery is individualized. A high level of clinical suspicion and meticulous investigation of the entire small intestine are required to ensure the correct diagnosis and early intervention for a successful outcome.

Surgical Treatment of Congenital Basilar Invagination with Different Pathological Characteristics: Report of 139 Cases

Objective To describe the different pathological characteristics of congenital basilar invaginations and discuss the surgical treatment of such cases. Methods A total of 139 patients diagnosed with basilar invaginations underwent surgical treatment from 2008 to 2015. Based on Atul Goel's classification and simultaneous consideration of atlantoaxial dislocation or syringomyelia, the cases were subdivided into four groups. Individualized posterior surgical decompression and/or atlantoaxial reset procedures were performed to correct atlantoaxial dislocation, decompress the brain stem, or resolve syringomyelia. The indications and critical points of each procedure were documented. Results All 139 patients were surgically treated; 27 patients (19.4%) had underwent at least one decompression surgery previously. On an average, there was gratifying clinical improvement based on the Japanese Orthopaedic Association score analysis. One patient exhibited severe postoperative infection, and the fusion instrument was removed. One patient experienced fracture of internal fixation. Two patients exhibited persistent respiratory symptoms at early stages after the surgery. Four patients felt worse at the latest follow-up. There was no surgical mortality. The poor outcome/ morbidity in this series was 5.8% (8/139). Conclusion The different pathological image characteristics of congenital basilar invaginations based on the presence or absence of syringomyelia and/or atlantoaxial dislocation, reflected the pathological features of complicated basilar invaginations more accurately. Based on these features, different posterior decompression and/or reset procedures, combined with occipitocervical fusion and C1-2 fusion, could be tailored to different patients. These individualized surgeries could reduce surgical complications, decrease morbidity and mortality, and further promote positive outcomes.

444 - Severe Postoperative Infection of an Urachal Remnant after a Primary Umbilical Closed Approach

Study Objective: The primary approach for gynecologic laparoscopic surgery is commonly performed at the umbilicus because of cosmetic benefits and the low incidence of port-site complications. We report a patient who underwent laparoscopic surgery and developed postoperative severe port-site infection following the primary closed approach at the umbilicus due to the presence of an asymptomatic urachal remnant.

Novel targeted puncture technique for percutaneous transforaminal endoscopic lumbar discectomy reduces X-ray exposure.

The present study explored a method to reduce X-ray exposure dose and avoid targeted puncture complications in percutaneous transforaminal endoscopic lumbar discectomy (PTELD). A total of 66 patients with lumbar disc herniation were divided into two groups for a controlled study. In the experimental group, 31 patients were subjected to PTELD using a novel targeted puncture technique with application of a lumbar disc herniation target collimator. The remaining 35 patients in the control group were subjected to free-hand targeted puncture PTELD. The number of X-ray fluoroscopies performed intraoperatively, targeted puncture accuracy, visual analogue scale for surgical pain and Oswestry disability index of the two groups were statistically analyzed. The experimental and control groups exhibited a statistically significant difference in the number of X-ray fluoroscopies required during the procedure (P<0.01). The number of successful first targeted punctures was 27 (87.1%) in the experimental group and three (8.6%) in the control group, indicating that the puncture accuracy was higher in the experimental group than in the control group. As for the pain response to outer sleeve insertion (local anesthetic injection through the guide sleeve), the experimental group had 25 mild cases (80.6%), five moderate cases (16.1%) and one severe care (3.2%), whereas the control group had five mild cases (14.3%), 19 moderate cases (54.3%) and 11 severe cases (31.4%). These results demonstrated that the overall pain response of the experimental group was milder than that of control group. Due to a larger puncture deviation, the nerve root was touched by the puncture needle in 12 cases in the control group and resulted in one case of severe postoperative infection. In conclusion, the novel targeted puncture technique guided by a lumbar disc herniation target collimator outlined in the present study is able to markedly reduce X-ray exposure dose in PTELD and limit the surgical risk and pain experienced by patients. Mastering this novel puncture technique may aid those new to performing PTELD.

Surgical treatment of congenital basilar invagination with different pathological characteristics: Report of 139 cases

Objective To describe the different pathological characteristics of congenital basilar invaginations and discuss the surgical treatment of such cases. Methods A total of 139 patients diagnosed with basilar invaginations underwent surgical treatment from 2008 to 2015. Based on Atul Goel's classification and simultaneous consideration of atlantoaxial dislocation or syringomyelia, the cases were subdivided into four groups. Individualized posterior surgical decompression and/or atlantoaxial reset procedures were performed to correct atlantoaxial dislocation, decompress the brain stem, or resolve syringomyelia. The indications and critical points of each procedure were documented. Results All 139 patients were surgically treated; 27 patients (19.4%) had underwent at least one decompression surgery previously. On an average, there was gratifying clinical improvement based on the Japanese Orthopaedic Association score analysis. One patient exhibited severe post-operative infection, and the fusion instrument was removed. One patient experienced fracture of internal fixation. Two patients exhibited persistent respiratory symptoms at early stages after the surgery. Four patients felt worse at the latest follow-up. There was no surgical mortality. The poor outcome/ morbidity in this series was 5.8% (8/139). Conclusion The different pathological image characteristics of congenital basilar invaginations based on the presence or absence of syringomyelia and/or atlantoaxial dislocation, reflected the pathological features of complicated basilar invaginations more accurately. Based on these features, different posterior decompression and/or reset procedures, combined with occipitocervical fusion and C1-2 fusion, could be tailored to different patients. These individualized surgeries could reduce surgical complications, decrease morbidity and mortality, and further promote positive outcomes.

Gram negative bacteria increase non-small cell lung cancer metastasis via Toll-like receptor 4 activation and mitogen-activated protein kinase phosphorylation.

Surgery is required for the curative treatment of lung cancer but is associated with high rates of postoperative pneumonias predominantly caused by gram negative bacteria. Recent evidence suggests that these severe infectious complications may decrease long term survival after hospital discharge via cancer recurrence, but the mechanism is unclear. Lung cancer cells have recently been demonstrated to express Toll-like receptors (TLR) that mediate pathogen recognition. We hypothesized that incubation of non-small cell lung cancer (NSCLC) cells with heat-inactivated Escherichia coli can augment cancer cell adhesion, migration and metastasis via TLR4 signaling. Incubation of murine and human NSCLC cells with E. coli increased in vitro cell adhesion to collagen I, collagen IV and fibronectin, and enhanced in vitro migration. Using hepatic intravital microscopy, we demonstrated that NSCLC cells have increased in vivo adhesion to hepatic sinusoids after coincubation with gram negative bacteria. These enhanced cell adhesion and migration phenotypes following incubation with E. coli were attenuated at three levels: inhibition of TLR4 (Eritoran), p38 MAPK (BIRB0796) and ERK1/2 phosphorylation (PD184352). Incubation of murine NSCLC cells in vitro with E. coli prior to intrasplenic injection significantly augmented formation of in vivo hepatic metastases 2 weeks later. This increase was abrogated by NSCLC TLR4 blockade using Eritoran. TLR4 represents a potential therapeutic target to help prevent severe postoperative infection driven cancer metastasis.

Calf Implants: A 25-Year Experience and an Anatomical Review

Body contouring in the calf region is becoming a more frequently requested procedure. There are several techniques for calf enhancement, including implants, liposuction, and free flaps. Alloplastic augmentation can be performed with several implant types and several layers of pocket dissection. We present our 25 years of experience using the subfascial technique for calf implantation along with an anatomical study to illustrate all the important steps and relevant anatomy of this augmentation technique. The subfascial technique was performed in 25 cadavers, in which the important layers were dissected for high-resolution photos of the surgery to learn about the relevant anatomy of the region. Also, we did a retrospective study of our experience with calf implants, studying the aesthetic outcome, the presence of early complications, and the presence of late complications. We performed dissections in 25 cadavers and surgery in 63 patients (126 implants). In our series of patients the final aesthetic index was of 9.8. The early complications were severe postoperative pain (11.11%), infection (0.79%), seroma (21.42%), hematoma (0%), and wound dehiscence (7.14%). The late complications were capsular contracture (Baker grades III and IV) (3.17%), implant rupture (1.58%), implant leaking (0%), implant displacement (3.96%), numbness at the ankle (2.38%), and palpability of the implant (0%). The subfascial technique for calf augmentation has complication rates low enough and surgical outcomes good enough to recommend it as the gold standard for alloplastic calf augmentation.

Umbilical Epithelial Cyst in Secondary Abdominoplasty: Case Report

A retained epidermal inclusion cyst (REIC) at the umbilicus after abdominoplasty is a rare phenomenon that has had limited description in the literature. This case report describes a woman who came for a secondary abdominoplasty and presented intraoperatively with an unexpected large epidermal inclusion cyst. The woman was disappointed with the result of a previous abdominal surgery. She initially had severe postoperative wound infection followed by revision surgery and subsequent intermittent secretion in the umbilical region. Then seven years later, hip backplasty combined with liposuction was performed. After another six months, full abdominoplasty combined with exploration of the umbilical region was performed. The surgical exploration showed a large, 3×4.5 cm indurated structure highly suspected to be a REIC. The excision was effective without recurrence, and the healing was uneventful. The patient was very satisfied with the result. As a typical epidermoid cyst, REIC consists of squamosed stratified epithelial cells that continue to the granular layer. In most cases, the cyst is filled with a keratin-like material. When this tumor is solid, a histologic evaluation may be necessary. When the cyst has been excised, the umbilicus gets reconstructed after the abdominoplasty. A history of poor healing in the umbilicus area may arouse suspicion of an epidermoid cyst. Epidermoid cysts in the region of the umbilicus could easily be overlooked in preparation of the umbilicus.