Ulcer Surgery Research Articles

Early mobilization program with nonweight-bearing brace improves functional capacity after diabetic foot ulcer surgery: a randomized controlled trial

PurposeThis study aimed to evaluate the effectiveness of early mobilization program with nonweight-bearing braces in improving functional outcomes and clinical indicators after diabetic foot ulcer surgery.MethodsWe conducted a randomized trial involving patients with diabetic foot ulcers (DFUs) who underwent surgery at a tertiary university hospital. Participants were randomized to receive either early mobilization with nonweight-bearing braces or standard rehabilitation care. The primary outcome was the ability to walk a distance of three meters without human assistance upon hospital discharge. Secondary outcomes included activity of daily living (ADL), measured by the Barthel Index survey; reduction in lean body mass, assessed via thigh circumference on postoperative day 10 (POD 10); length of stay (LOS); and the incidence of postoperative complications such as deep venous thrombosis (DVT), pain, and wound dehiscence.ResultsA total of 46 patients were enrolled, with 23 assigned to the early mobilization program with nonweight-bearing braces (intervention group) and 23 to the standard rehabilitation care group (control group). The primary outcome was achieved in 16 patients (69.6%) in the intervention group and 6 patients (26.1%) in the control group [RD43.5%, 95%CI (17.5%,69.5%); P = 0.003]. The intervention group demonstrated improved outcomes in ADL. Additionally, the intervention facilitated earlier discharge with a LOS of 12 days in the intervention group compared to 18 days in the control group.ConclusionAn early postoperative mobilization program with nonweight-bearing brace is demonstrated to be feasible and effective in improving functional capacity in patients with diabetic foot ulcers undergoing surgery.

Evolving challenges in the management of peptic ulcers: launch of the Korean Peptic Ulcer Surgery Group

Evolving challenges in the management of peptic ulcers: launch of the Korean Peptic Ulcer Surgery Group

Comparison of high-pressure compression stockings and compression bandages for ulcer treatment in venous ulcer patients.

This study aims to compare the effectiveness of compression bandages and compression stockings in the treatment of venous ulcers following venous ulcer surgery. A total of 170 patients who underwent venous ulcer surgery were included in this retrospective study. Patients were divided into two groups: the first group used compression bandages, and the second group used compression stockings. In all patients, a sterile cotton dressing from the venous ulcer care kit was first applied directly over the open ulcer to protect the wound bed. Both groups were followed for 3months. Demographic and clinical characteristics such as age, gender, smoking status, hypertension, peripheral arterial disease (PAD), and diabetes mellitus (DM) were recorded. Primary endpoints included changes in ulcer size, calf circumference, NPRS pain scores, and VCSS scores. Measurements were taken before treatment, at 1week, at 1month, and at 3months. The data were statistically analyzed using appropriate methods. The results showed that the compression bandage group had a more significant reduction in ulcer size compared to the compression stocking group. The ulcer size in the bandage group decreased from 16.5 ± 2.2cm2 to 7.9 ± 5.1cm2 after 3months, while in the stocking group, it reduced from 16.1 ± 1.8cm2 to 9.6 ± 3.1cm2 (p < .001). Additionally, the calf circumference showed a greater reduction in the bandage group, from 41.3 ± 1.9cm to 35.3 ± 2.9cm, compared to the stocking group, which showed a reduction from 40.7 ± 1.8cm to 38.1 ± 2.4cm (p < .001). NPRS pain scores also decreased more significantly in the bandage group, with scores dropping from 8.0 ± 1.1 to 2.9 ± 2.8, while the stocking group saw a decrease from 7.9 ± 1.2 to 5.4 ± 2.4 (p < .001). VCSS scores improved in both groups, but the bandage group showed a more marked improvement from 19.6 ± 5.1 to 5.2 ± 8.3 compared to the stocking group, which improved from 18.0 ± 5.1 to 7.1 ± 4.7 (p < .001). The findings suggest that compression bandages may be more effective than compression stockings in the post-surgical treatment of venous ulcers, particularly in terms of reducing ulcer size, calf circumference, and pain, as well as improving VCSS scores. These results support the continued use of compression bandages as a primary treatment modality for venous ulcers following surgery.

Dumping syndrome: Update on pathophysiology, diagnosis, and management.

Dumping syndrome is a complex of gastrointestinal symptoms originally studied in peptic ulcer surgery patients. At present, it is most prevalent in patients who underwent bariatric, upper gastrointestinal cancer or anti-reflux surgery. The symptom pattern comprises early and late dumping symptoms. Several management options have been reported including nutritional, pharmacological and surgical approaches. In this study, we aimed to review the current evidence on dumping syndrome definition, diagnosis and treatment, including preliminary data from newer pharmacological studies. Current pathophysiological concepts and analyses of provocative tests has led to a clear definition of dumping syndrome, including both early and late dumping symptoms. The term postbariatric hypoglycemia represents a limited focus on late dumping only. The diagnosis relies on recognition of symptoms and signs in a patient with appropriate surgical history; and can be confirmed by provocative testing or registration of spontaneous hypoglycemia. The initial treatment focuses on dietary intervention, to which meal viscosity enhancers and/or the glycosidase inhibitor acarbose can be added. The most effective therapy is the use of short- or long-acting somatostatin analogues, which is however expensive and entails side effect issues. In case of refractory hypoglycemia, diazoxide or SGLT2 inhibitors can be considered, based on limited evidence. In refractory patients, continuous enteral feeding or (rarely) surgical reinterventions have been advocated, although not supported by solid evidence. Therapies under current evaluation include the broad-spectrum somatostatin analogue pasireotide, GLP-1 receptor antagonists, GLP-1 receptor agonists and administration of stable forms of glucagon are currently under study. Dumping syndrome is a well-defined but probably under-diagnosed complication of upper gastrointestinal, especially bariatric, and surgeries. Diagnosis is confirmed by a provocative test and incremental therapies starting with diet, adding meal viscosity enhancers or glycosidase inhibitors and adding somatostatin analogues in refractory cases. A number of emerging therapies targeting intestinal propulsion, peptide hormone effects and hypoglycemic events are under evaluation.

013. Black Stools and Vomiting of Blood in Children Caused by Anemia Gravis ec Duodenal Ulcer Pars 2 with Perforation (Wound Healing with Branch A. Cystica Ruptur)

Background: Duodenal ulcers are rare in children but can lead to life-threatening complications such as perforation and severe anemia. Upper gastrointestinal bleeding, manifesting as hematemesis and melena, can result in anemia gravis, necessitating urgent intervention. The rupture of a cystic artery branch during the wound healing process adds further complexity to the condition. This case report aims to describe presentation, diagnosis, and management of a child with duodenal ulcer pars 2 complicated by perforation and anemia gravis, with attention to the role of a ruptured cystic artery branch in the wound healing process. Case: A 15-year-old boy presented with a 5-day history of vomiting blood and black stools. Initial evaluation included thorough physical examination, laboratory tests to assess anemia severity, and imaging studies to localize the source of bleeding. The patient underwent emergency surgery for perforated duodenal ulcer and associated hemorrhage. Intraoperative findings revealed rupture of a branch of the cystic artery. The patient was diagnosed with anemia gravis due to gastrointestinal bleeding secondary to a perforated duodenal ulcer. Surgical repair of the perforation and arterial rupture was performed. Postoperatively, the patient's hemoglobin levels improved following blood transfusion and supportive care. The patient recovered without complications. Conclusion: Early recognition of duodenal ulcers with perforation in children is crucial, especially in cases with severe anemia. Prompt surgical intervention and management of associated arterial complications, such as cystic artery rupture, are essential for favorable outcomes. This case underscores the importance of a multidisciplinary approach in managing complex pediatric gastrointestinal emergencies.

Perioperative Nutritional Support Case Study for a Patient Undergoing Gluteus Maximus Flap Transfer Surgery for Pressure Ulcer

Pressure ulcers are caused by prolonged pressure on local tissues, leading to continuous ischemia, hypoxia, and malnutrition, resulting in tissue necrosis. Patients with pressure ulcers often experience varying degrees of malnutrition due to gut flora imbalance and a hypercatabolic state. This paper documents the case of a patient with a sacral pressure ulcer admitted to the Department of Burn and Plastic Surgery of the Affiliated Hospital of Qinghai University on November 28, 2023. Clinical nutrition treatment began on the second day of admission, including dietary guidance and enteral nutrition intervention. The patient's nutritional status gradually improved, leading to a successful recovery. By reviewing the nutritional treatment process and clinical outcomes, this case study provides valuable insights into the nutritional management of pressure ulcer patients.

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This study conducts a systematic review comparing open surgery and laparoscopic repair techniques for perforated peptic ulcer. The research was performed using PubMed and ScienceDirect databases, covering studies published in the last five years. Nine articles directly comparing the two surgical techniques were included, evaluating factors such as hospitalization time, postoperative complications, wound healing time, and infection rates. The results suggest that laparoscopic surgery offers several advantages, including reduced hospital stay and faster recovery, while open surgery remains relevant in specific cases. The analysis highlights the importance of selecting the surgical technique based on the patient's clinical condition and the surgeon's expertise, with laparoscopy emerging as the preferred approach in most cases. This study aims to provide evidence that can guide surgical practice, promoting better outcomes and a more patient-centered approach to the management of perforated peptic ulcers.

Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review

Less Invasive Off-loading Surgery of Chronic Plantar Diabetic Forefoot Ulcers: A Narrative Review

Global 30-day morbidity and mortality of surgery for perforated peptic ulcer: GRACE study.

There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. We performed an international study of adults (≥ 18years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. 1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality. This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality.

Fast-track recovery after surgery for perforated peptic ulcer safely shortens hospital stay: A systematic review and meta-analysis of six randomized controlled trials and 356 patients.

Postoperative management after surgery for perforated peptic ulcer is still burdened by old traditions. All available data for fast-track recovery in this setting are either very unspecific or underpowered. The aim of this study was to evaluate fast-track recovery in this diagnosis-specific context in a larger sample. Electronic data sources were searched. Eligible studies were randomized controlled trials (RCTs) comparing fast-track recovery and traditional management after surgery for perforated peptic ulcer in adults. A systematic review and meta-analysis was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines regulated the process. Quality and risk of bias assessments of individual RCTs were performed by means of the Let Evidence Guide Every New Decision criteria and the Cochrane risk-of-bias tool. Primary endpoints were length of hospital stay and risk of complications. Random or fixed effects modeling were applied as indicated. Outcomes were measured by mean difference and risk difference. Six RCTs with a total cohort of 356 patients were included. Results of our meta-analysis showed significantly shortened length of hospital stay (mean difference -3.50days [95% CI -4.51 to -2.49], p≤0.00001), significantly less superficial and deep surgical-site infections (risk differences -0.12 [95% CI -0.20, -0.05], p=0.002 and -0.03 [95% CI -0.09, 0.03], and p=0.032, respectively), and significantly fewer pulmonary complications (risk difference -0.10 [95% CI -0.17, -0.03], p=0.004) in the fast-track group. This systematic review and meta-analysis shows that fast-track recovery after surgery for perforated peptic ulcer significantly shortened hospital stay in the studied cohort without increasing the risk of postoperative complications.

Laparoscopic management of benign gastric outlet obstruction: a case series with review of literature

Surgery for peptic ulcer disease has since long become a thing of the past, in the era of proton pump inhibitors. Today, it is difficult to believe that these were common operations about 6-7 decades ago. Such has been the impact of proton pump inhibitors (PPI), that, surgery for peptic ulcer has been relegated to the realms of history. However, even in present day, in some rare clinical situations, surgeons may have to resort to surgery for patients suffering from peptic ulcer disease. Herein, we present our experience of laparoscopic surgical management of one of those rare clinical scenarios related to severe peptic ulcer disease. The clinical condition in discussion is gastric outlet obstruction caused by severe peptic ulcer disease in the first part of duodenum. We identified 8 patients (7 males and 1 female) who underwent laparoscopic vagotomy with gastrojejunostomy for benign gastric outlet obstruction, at our institution, operated upon by a single surgeon, between 2004 to 2023. All patients had undergone oesophago-gastro-duodenoscopy (OGD scopy), and contrast enhanced computerised tomography (CECT) of the abdomen. The patients were analysed for age, sex, symptoms, pre-operative evaluation, morbidity/mortality and functional outcomes. They were also reviewed to examine the length of stay, length of procedure, complications and recurrent symptoms on follow-up.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2mmol/L upon presentation preoperatively. While surgery >24h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6h or <12h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p<0.001). WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Immunological Assessment of Interleukin-6 in Patients with Gastric (Stomach) Ulceration of Acute and Chronic Types in Babylon Province

Stomach ulcers have emerged as a serious public health concern. Serum interleukin-6 (IL-6) levels in individuals with chronic and acute gastric ulcers will be examined in this study. Sixty blood samples were obtained from participants in the research. The Marjan Teaching Hospital, Al-Sadiq Hospital in Babylon Province, Iraq, treated forty patients having stomach ulcer surgery between March and November 2023; the control group consisted of twenty individuals. A high mean value for IL-6 concentration was seen in both the chronic and acute patient groups compared to the control group (44.1 ± 28.6 pg/ml) for chronic patient and (30.2 ± 15.4 pg/ml) for acute patients with significant differences(P&lt;0.05). The results conducted a noteworthy rise in the level of interleukin-6 in the age group of 71–80 years, with a mean value of 10.9±9.02 pg/ml, compared to other age groups. Additionally, when considering gender, it was observed that males had a higher mean value of 73.4±30.60 pg/ml, while females had a similar mean value of 73.4±30.60 pg/ml. These findings were found to be statistically significant (P&lt;0.05).

Consistent Reconstruction of Sacrococcygeal Pressure Ulcers using Modification of En Bloc Sliding Gluteus Maximus Myocutaneous Flap Technique

Background: The en bloc sliding gluteus maximus myocutaneous flap was introduced to preserve the vasculature, muscular integrity, sensory innervation, and normal gluteal contour with a midline scar in sacrococcygeal pressure ulcer reconstruction. However, its critical disadvantages include incomplete detachment of the origin of the gluteus maximus and central tension of the closed wound due to round ulcer excision. Therefore, we reviewed the surgical anatomy and applied modifications to achieve sufficient flap mobilization and to decrease complications.Methods: After fusiform or rocket-shaped ulcer excision, submuscular flap elevation was initiated by completely detaching the origin of the gluteus maximus, including the posterior iliac crest, followed by comprehensive lateral submuscular dissection in the gluteal space while preserving the neurovascular pedicles. Bony protrusions were tangentially resected from the lower sacrum and upper coccyx. After en bloc medial advancement of the bilateral flaps, defects were closed in layers, with muscle ligament fixation at the midline.Results: Twenty-nine patients underwent surgery for sacrococcygeal pressure ulcers (primary, n=22; recurrent, n=7). Transverse width of the excised ulcers was 5–12 cm (final defect, 7–15 cm). During the follow-up period (6 months to 7 years), no early postoperative complications or late aesthetic or functional discomfort occurred; however, intermittent skin sloughing occurred in four cases and one coccygeal sore recurrence occurred. The recurrent ulcer was treated using the same surgical method, with no recurrence after 2 years.Conclusion: This modification can be successfully used for the reconstruction of primary and recurrent sacrococcygeal pressure ulcers.

Disparities in prehospital and emergency surgical care among patients with perforated ulcers and a history of mental illness: a nationwide cohort study

PurposeTo compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer.MethodsA nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016–2017 and the Danish Emergency Surgery Registry 2004–2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history.ResultsWe identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up.ConclusionOne-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.

Conjunctival flap surgery for traumatic corneal ulcers

Introduction : Trauma was the most common risk factor for corneal ulcers and blindness. Death of corneal tissue due to loss of part of the surface of the cornea is called a corneal ulcer. Conjunctival flap (CF) surgery has an acknowledged role in assuring a stable ocular surface and repressing inflammation in compromised corneas or eyes with reduced visual potential.&#x0D; Case Illustration : 26-year- old male patient came to the Chasan Boesorie Ternate Hospital polyclinic with pain in the left eye after splash cement 3 days before being admitted to the hospital. The left eye is runny, feels itchy, looks red and like there is a block and glare. On ophthalmology status there was a visual acuity OD 6/6, OS 1/300, OS cloudy cornea, hypopion, prolapse of iris and central corneal ulcer with a size of ± 2 x 1 mm.&#x0D; Discussion : The remaining flaps were performed for corneal perforation, graft rejection, bullous keratopathy, and secondary corneal edema. Conjunctival flaps have previously proven to be effective in preserving the globe for individuals with severe ocular surface disease. The flaps promote nutrition, metabolism, structure, and vascularity, as well as reduce pain, irritation, inflammation, and infection. After 6 weeks of surgery visual acuity become better, OS 20/200.&#x0D; Conclusion : Conjunctival flap surgery is an important and useful surgical option of ocular surface disease, especially recalcitrant infectious keratitis and corneal ulcers, particularly in nonresponsive and some perforated cases. CF procedure went well, provides mechanical support for corneal wound healing with good visual outcomes on the patient.

Emergency laparoscopic surgery in Russia: a current state

To determine the current status and main factors influencing the level of emergency laparoscopic surgery in the Russian Federation. A retrospective nationwide analysis included patients ≥18 years old undergoing surgery for acute cholecystitis (AC), acute appendicitis (AA), perforated ulcer (PU) and ileus. The database of the chief surgeon of the Russian Ministry of Health for 2018 - 2022 was used. To investigate possible reasons influencing the level of emergency laparoscopic surgeries, we performed online survey of medical organizations connected to the electronic reporting system. Over five years, the incidence of laparoscopic surgeries for AC increased from 52.6% to 70.5% (p<0.001), for AA from 25.1% to 41.0% (p<0.001), for PU from 9.4% to 13.2% (p<0.001) and for ileus from 5.9% to 8.5% (p<0.001). The percentage of emergency laparoscopic surgeries in rural hospitals (level I) was 14.8%, level II hospitals - 40.2%, level III - 67.7% (p<0.001). We obtained responses from 1.982 (84.9%) out of 2.335 hospitals included in the database. Significant differences were revealed in equipment of hospitals of different levels with laparoscopic surgical systems and proportion of surgeons proficient in laparoscopic techniques (p<0.001). The same factors influence laparoscopy in different federal districts to a greater extent than their geographic and demographic characteristics. Laparoscopic emergency procedures became more widespread, but vary widely between regions, urban and rural. Availability of laparoscopic surgery is influenced by availability of equipment and trained surgeons, geographic distance and population density, level of hospital and ability to maintain acquired skills and increase experience in appropriate surgeries.

Early Enteral Nutrition Support Combined with Health Education Improves Quality of Rehabilitation After Repair of Acute Perforation of Duodenal Ulcers

Acute perforation is a severe life-threatening complication of duodenal ulcers. During perforation repair surgery, it is necessary to provide patients with enteral nutrition support to ensure their life safety. Herein, we developed and administered a health education form targeted at patients undergoing early enteral nutrition after duodenal ulcer surgery to help them manage the pains associated with enteral nutrition infusion. We found that patients in the research group who received health education combined with early enteral nutrition support had better nutritional status and a significantly reduced risk of malnutrition than patients in the control group after the treatment. Furthermore, patients in the research group had a significantly improved understanding of enteral nutrition support than patients in the control group. However, no significant difference was observed between the groups based on the recovery process and the incidence of adverse reactions. In conclusion, health education combined with early enteral nutrition support can substantially improve the nutritional status of patients and enhance their recovery after the repair of acute perforation of duodenal ulcers.

Delayed lethal central nervous system toxicity induced by a low-dose intrathecal administration of bupivacaine: case report

Spinal anesthesia by intrathecal administration of local anesthetic (LA) is a routine practice. Local anesthetic system toxicity, occurring in the central nervous system (CNS) and cardiovascular system, is a common and life-threatening adverse event of LA through a variety of routes, but is rarely encountered in spinal anesthesia when a very low dose of LA is injected into the subarachnoid space. Here, we report a case with manifestations of delayed lethal CNS toxicity after spinal anesthesia. A 55-year-old man underwent elective repair surgery for a chronic ulcer after receiving 10 mg intrathecal administration of bupivacaine. He developed nausea, agitation, paresthesia and myoclonus on the arms, legs, and trunk, as well as a gradually reduced level of consciousness one hour after intrathecal administration. He was sedated, intubated, and transferred to the intensive care unit. Both CT and MRI scans of the brain and assessments of blood showed no abnormalities. The electroencephalogram showed spike waves occurring at electrodes C3, C4, P3, P4, and T5. The patient was sedated continuously and treated with valproate. These symptoms were completely resolved in the following days without residual neurological complications. No cardiovascular complications were observed during the entire process. The delayed lethal symptoms in this case were most likely to be CNS toxicity induced by intrathecal bupivacaine administration. CNS toxicity after spinal anesthesia may be underestimated and unpredictable and should be vigilantly cared for in clinical settings.

Flap Survival after Reconstructive Surgery for Pressure Ulcers: A Cohort Study

Background: Pressure ulcers are troublesome for patients and require considerable resources to resolve. Previous studies have focused on recurrence, whereas there are few studies on flap survival. The aim was to describe the group and to analyze possible factors for flap survival. Method: A descriptive retrospective analysis of all operations between 2008 and 2020 was carried out. Flap survival at 40 days was assessed. A flap was classified as a failure if a reoperation with removal or replacement was planned before, or in connection with, the first return visit. Variables of patient demographics, details of the pressure ulcers, and surgical treatment and care were analyzed with multivariable logistic regression for their effect on flap survival. Results: A total of 111 flaps were included [78 (70%) with random blood supply and 33 (30%) with axial or perforator-based blood supply]; 54 (49%) of the flaps were fasciocutaneous. Body mass index was 25 (IQR 22–28). Flap survival rate was 90%. Variables associated with flap failure were higher body mass index, congenital spinal cord injury, type of blood supply to the flap, and the use of methylene blue to guide debridement of the wound. Conclusions: The findings show factors that can be modified to improve future results, including a normalized body mass index and use of methylene blue in surgery to outline wound edges and depth, as this has been shown to protect against flap failure. Our data suggest that random flaps, such as V-Y, are preferable to axial flaps in the studied group.