Wound Healing In Surgical Patients Research Articles

Prophylactic "Xymedon" in Abdominal Surgery

Importance. Surgical procedures have a lot of stress, causing significant violation of the non specific defense mechanisms of the body and the immune system, which requires the use of different pharmacological agents in order to increase natural resistance to infection.Purpose. An analytical review of experimental and clinical research in the direction of studying the effectiveness of the impact of enteral xymedon on reparative process of surgical wounds and tissue non-specific resistance of the organism to infection for the prevention of inflammatory wound complications.Materials and methods. The analysis of experimental and clinical data, dealing with the question of studying the effect of enteral and topical xymedon to repair tissue in the area of the surgical wound and the non-specific resistance to infection.The criteria for the effectiveness of the drug were clinical and laboratory parameters, and statistic methods.Results and their discussion. The analysis of experimental and clinical studies have shown that enteral and topical use xymedon in surgical patients stimulates wound healing surgical site and increases nonspecific resistance to infection by increasing the functional activity of neutrophils, their backup potentials normalize the concentration of a bioactive and immunoreactive fibronectin in blood plasma, improve antimicrobial activity of wound.Conclusions. Xymedon is recommended as an effective means of pharmacological support of wound healing in surgical patients to prevent postoperative wound complications.

Abstract: Anemia and Plastic Surgical Outcomes

INTRODUCTION: There is a large amount of literature reporting that anemia is not a risk factor for wound complications.1–3 However, other comorbidities associated with anemia have been associated with negative surgical outcomes.1 In this study, we examined the association between anemia and various postoperative outcomes in plastic surgical procedures. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program dataset, patients who underwent implant and/or flap-based breast reconstruction, breast revisions, augmentation mammoplasty, mastopexy, breast capsulectomy, nipple reconstruction, or abdominoplasty were identified. Multivariable logistic regression models were created to assess the relationship between anemia and various postoperative outcomes, including medical complications, surgical complications, and wound complications while controlling for confounding variables. RESULTS: We identified 48,918 patients who underwent the aforementioned plastic surgical procedures, and 35,062 had preoperative bloodwork. Preoperatively, 6,437 (18.4%) of these patients were anemic (Hematocrit < 36%). Multivariate analysis showed that anemia was an independent risk factor for medical complications (OR = 1.855, 95% CI = 1.639–2.099, p<0.001) and surgical complications (OR = 1.129, 95% CI = 1.021–1.248, p=0.019). Anemia was not associated with an increase in wound complications (OR = 1.092, 96% CI = 0.959–1.249, p=0.186). When stratified by procedure, anemia is not associated with wound complications in any plastic surgical procedure. CONCLUSION: Anemia may not be a causative risk factor of negative postoperative outcomes, but preoperative anemia is a marker for an increased risk of both medical and surgical complications. As previously reported, anemia is not an independent risk factor for wound complications. Out of the patients who have preoperative bloodwork performed, anemic patients should be identified, managed, and appropriately counseled regarding their increased risk for complications. Reference Citations: 1. Heughan, C., Grislis, G. and Hunt, T.K. (1974). The effect of anemia on wound healing. Annals of surgery 179, 163–167. 2. Janis, J.E. and Harrison, B. (2016). Wound Healing: Part I. Basic Science. Plastic and reconstructive surgery 138, 9S-17S. 3. Jonsson, K., Jensen, J.A., Goodson, W.H., 3rd, Scheuenstuhl, H., West, J., Hopf, H.W. and Hunt, T.K. (1991). Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Annals of surgery 214, 605–613.

Abstract # 1758 The effects of expressive writing on wound healing in surgical patients

Written emotional disclosure (expressive writing) has been shown to reduce stress and speed the healing of punch-biopsy wounds in laboratory studies. However, no research has investigated whether expressive writing can improve wound healing in surgical patients. We investigated whether a pre-operative expressive writing intervention could improve surgical wound healing. A randomized controlled trial was conducted with 76 patients undergoing elective laparoscopic bariatric surgery. Patients were randomized either to write about their thoughts and feelings about distressing events (expressive writing) or to write objectively about how they spent their time (time management), for 20 minutes on 3 consecutive days, beginning two weeks before surgery. In both groups, 24 hour wound fluid was analysed for pro-inflammatory cytokines, and hydroxyproline was collected in ePTFE tubes at the wound site over 14 days. Contrary to our hypothesis, patients who wrote about time management had significantly more hydroxyproline at their wound sites than did expressive writing patients ( t (34) = −2.433, p = .020; 95% CI −4.611 to −0.413) and higher TNF-alpha ( t (29) = −2.423, p = .022, 95% CI −0.424 to −0.036). Many patients in the expressive writing group wrote about pre-surgical anxiety while those in the time-management group wrote about plans for preparing for surgery. These results may differ to laboratory studies due to patients’ high pre-operative anxiety about their surgery, a situation in which time management may be better than expressive writing for managing stress.

A retrospective analysis of early and late term complications in patients who underwent application of retention sutures for gastrointestinal tract malignancies.

Complications associated with wound healing after abdominal tumor operations continue to be a significant problem. This study aimed to determine the significance of retention sutures in preventing these complications. For this purpose, early and late term results of patients who underwent application of polydioxanone (PDS) and additional retention sutures for abdominal closure were retrospectively evaluated. Clinical files of 172 patients who were operated due to gastrointestinal tract malignancies in our clinic between January 2007 and January 2011 were retrospectively analyzed. Patients in whom the fascia was repaired only with PDS (Group 1) were compared to patients in whom the fascia was repaired with PDS and retention sutures (Group 2) in terms of age, gender, postoperative evisceration-wound infection (<1 month), incisional hernia (>1 month), incision type, co-morbid factors, and operative time. There was no significant difference between the two groups in terms of age or gender (p=0.680 and p=0.763). No significant difference was detected in terms of postoperative incisional hernia (p=0.064). Evisceration and post-operative wound infection were significantly lower in Group 2 as compared to Group 1 (p=0.008 and p=0.002). Operative time was significantly longer in Group 1 than in Group 2 (p<0.0001). Co-morbid features were significantly higher in Group 2 than in Group 1 (p<0.0001). There were no significant differences between the groups in terms of incision type (p=0.743). In the presence of co-morbid factors that disrupt wound healing in surgical patients with gastrointestinal malignancy, retention suture can be safely used as a supplement for optimal wound care.

A brief relaxation intervention reduces stress and improves surgical wound healing response: A randomised trial

Psychological stress has been shown to impair wound healing, but experimental research in surgical patients is lacking. This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients. This randomised controlled trial was conducted at a surgical centre. Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy; exclusion criteria were cancellation of surgery, medical complications, and refusal of consent. Seventy five patients were randomised and 15 patients were excluded; 60 patients completed the study (15 male, 45 female). Participants were randomised to receive standard care or standard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery. In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing. Change in perceived stress from before surgery to 7-day follow-up was assessed using questionnaires. Intervention group patients showed a reduction in perceived stress compared with the control group, controlling for age. Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients (difference in means 0.35, 95% CI 0.66-0.03; t(43)=2.23, p=0.03). Changes in perceived stress were not associated with hydroxyproline deposition. A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients. The intervention may have particular clinical application for those at risk of poor healing following surgery.

Extracorporeal Shock Wave Treatment Improves Incisional Wound Healing in Diabetic Rats

Impaired wound healing in surgical patients with diabetes increases the incidence of infection, prolongs hospitalization, and even increases the rate of mortality. Low-energy extracorporeal shock wave treatment (ESWT) was reported to accelerate chronic wound healing by promoting revascularization and tissue regeneration; however, it is not known if ESWT could also improve healing of acute surgical incisional wounds in diabetes. In this study, using a rat model of diabetes, we investigated the effect of low-energy ESWT on collagen content in wound tissues and its efficacy in incisional wound healing. A single dorsal incisional wound was inflicted in streptozotocin-induced diabetic rats, and they received ESWT at different time post-wounding. Rats were sacrificed on days 7 and 14 post-wounding. Wound breaking strength, hydroxyproline content, histological characteristics and the expression of transforming growth factor beta 1 (TGF-β1) were analyzed. As a result, the wound breaking strength was significantly enhanced and the hydroxyproline content in wound tissues was increased at each time point examined. The number of fibroblasts was signicantly increased, and the new collagen fibers were more abundant at the wound site after ESWT. Furthermore, the expression of TGF-β1 was up-regulated after ESWT on day 7 post-wounding. These results suggest that low-energy ESWT can increase collagen content, enhance wound breaking strength and improve the healing of incisional wound in diabetic rats. The increased collagen content may be attributed, at least in part, to the up-regulation of TGF-β1 expression in wound tissues.

Incidence and Risk Factors of Stomal Complications in Patients Undergoing Cystectomy With Ileal Conduit Urinary Diversion for Bladder Cancer

In this study we examined the incidence and associated factors of stomal complications in patients undergoing radical cystectomy with ileal conduit urinary diversion for bladder cancer. In addition, we evaluated the treatment and outcomes of surgical procedures in patients in whom stoma related complications developed. From 2001 to 2005 a total of 137 patients underwent ileal conduit diversion after cystectomy or exploration for bladder cancer, had complete clinical followup and were followed for at least 12 months after surgery. The incidence of stomal complications (including parastomal hernia, stomal stenosis and stomal prolapse) is reported with correlations made to age, race, gender, body mass index, smoking history, alcohol consumption, preoperative laboratory values (creatinine, hematocrit), operative estimated blood loss and surgical complications. In addition, management of stomal complications is reported. Of the 137 patients 21 stomal complications (15.3%) occurred in 20 patients (14.6%). The most common complication was parastomal hernia in 19 patients (13.9 %). Stomal stenosis developed in 1 patient (0.7%) and stomal prolapse developed in 1 patient with a parastomal hernia (0.7%). There were no significant differences in gender, age, race, preoperative laboratory values or history of abdominal/pelvic radiation therapy between patients with or without complications. However, patients in whom complications developed had a significantly higher mean body mass index compared to those without complications (30.8 vs 26.5 kg/m(2), respectively, p = 0.012). Operative outcomes, extent of disease and length of postoperative followup were also similar between patients with or without stomal complications. In addition, there were no significant differences in lifestyle factors (eg smoking, alcohol abuse) in patients in whom complications developed. Stomal complications associated with ileal conduit urinary diversion are not uncommon and occur in almost 15% of patients, with the most common problem being parastomal hernia. Evaluation of possible risk factors demonstrates that obesity may be a contributing factor in the development of stomal complications, particularly in the elderly. Furthermore, our experience suggests that subsequent repairs of parastomal hernias are only moderately successful.

Guidelines for the treatment of venous ulcers

1. Co-chaired this panel2. University of South Florida, Tampa, FL3. Healthpoint Ltd., Fort Worth, TX4. University of California, San Francisco, CA5. University of Texas Medical Branch, Galveston, TX6. University of Cardiff, Cardiff, Wales, UK7. University of Pennsylvania, Philadelphia, PA8. Private practice, Warren, PA9. Private practice, Tamarac, FL10. University of Pittsburgh, Pittsburgh, PA11. St. Louis University, St. Louis, MO, and12. Washington University, St. Louis, MO

Pain and wound healing in surgical patients

Human and animal laboratory studies have shown that stress delays healing of standardized punch biopsy wounds. This 5-week prospective study of 17 women who underwent elective gastric bypass surgery addressed the association between postsurgical pain intensity and subsequent healing of a standard 2.0-mm punch biopsy wound. Participants were assessed 1 week before surgery, within 3 hr before surgery, 1 to 3 days postsurgery, and at weekly intervals for 4 weeks following surgery. Patient ratings of greater acute postsurgical pain, averaged over Days 1 and 2 postsurgery, and greater persistent postsurgical pain, averaged over 4 weekly postsurgery pain ratings, were significantly associated with subsequent delayed healing of the punch biopsy wound. Presence of depressive symptoms on the day of surgery, pre-existing persistent pain, and medical complications following initial discharge from the hospital were not related to wound healing. Depressive symptoms on the day of surgery and pre-existing persistent pain did predict persistent postsurgical pain intensity. These findings extend the previous laboratory models of wound healing to a surgical population, providing the first evidence that pain plays an important role in postsurgery wound healing, a key variable in postsurgical recovery.

Improving Surgical Wound Healing with Basic Fibroblast Growth Factor after Radiation

Delayed wound healing in surgical patients who have received previous irradiation continues to be a significant problem. We investigated whether radiation decreases basic fibroblast growth factor (bFGF) production in skin and whether supplemental bFGF can improve irradiated postsurgical soft tissue healing. Experimental study in the porcine skin flap model. Pigs were subjected to orthovoltage radiation (1,300 cGy). To test whether radiation alters bFGF production in skin, semiquantitation of bFGF message was compared in irradiated and nonirradiated skin by reverse transcription-polymerase chain reaction (RT-PCR). To determine whether supplemental bFGF can improve postsurgical soft tissue healing after radiation, bFGF was given intravenously or intracuticularly preoperatively. To investigate whether additional oxygen tissue levels would modify the effects of supplemental bFGF, one test group received hyperbaric oxygen. Six weeks later, 108 skin flaps (random and arterial) were created in 27 pigs and monitored over 2 weeks. Tissues were analyzed for flap viability, vascularity, endothelial cell apoptosis by caspase-3 activation, and histologic analysis. Radiation statistically increased endothelial cell apoptosis in porcine skin by 650%. Radiation also significantly reduced bFGF message by 75% in porcine skin by RT-PCR analysis. Supplemental intravenous bFGF in irradiated tissue significantly increased skin flap viability by 25% compared with controls (P < .001). Intravenous bFGF also significantly reduced gastrointestinal side effects from irradiation by 50% compared with controls. BFGF treatment induced a trend to decrease endothelial cell apoptosis in irradiated skin, but this was not statistically significant. Histologically, the intravenous bFGF-treated flaps had similar cellularity, fibroblasts, and extracellular acid mucopolysaccharides as controls. When bFGF was administered by intracuticular injection with and without hyperbaric oxygen, skin flap survival and flap vascularity were similar to controls. Decreased local levels of bFGF in skin may play an important role in the delayed healing of irradiated wounds. Radiation appears to decrease bFGF production by significantly reducing bFGF message in irradiated tissue. Supplemental intravenous bFGF reduced irradiated soft tissue injury and improved random skin flap viability in this porcine model. More studies are needed to investigate the effects of bFGF in the surgical healing of irradiated wounds.

The effects of noise stress on leukocyte function in rats.

It has been reported that exposure to increased noise levels impairs wound healing in surgical patients and in rats. The purpose of the present study was to determine if exposure to noise stress would alter the biological function of neutrophils, macrophages, and lymphocytes, leukocytes that are involved in wound healing. Rats were exposed to 80 db of "rock" music for 24 hr, during which time the control animals were maintained in their usual environment. Leukocyte subpopulations were obtained and stimulated in vitro. Neutrophils and macrophages from noise-exposed animals secreted significantly less superoxide anion and interleukin-1 than cells from control animals. Lymphocyte function was not altered following noise stress. We conclude that short-term exposure of rats to noise stress alters some of the biological functions of leukocytes.

Synthesis of Type I Collagen in Healing Wounds in Humans

To quantify wound healing in surgical patients, samples of wound fluid were collected through a silicone rubber tube for 7 postoperative days and their concentrations of the carboxyterminal propeptide of type I procollagen (PICP) and the aminoterminal propeptide of type III procollagen (PIIINP) were measured with specific radioimmunoassays. The mean concentration of PICP in would fluid on day 1 was 207 +/- 92 (SD) micrograms/L, and on day 2 908 +/- 469 micrograms/L (p less than 0.001, signed rank test). On day 7, the mean concentration reached was 380 times higher than that of day 1 (79,330 +/- 54,151 micrograms/L). Only one peak of PICP antigenicity, corresponding to the intact propeptide as set free during synthesis of type I procollagen, was detected on Sephacryl S-300 gel filtration analysis of wound fluid samples. The mean concentration of PIIINP was 70 +/- 61 micrograms/L on day 1, 86 +/- 88 micrograms/L on day 2, and 180 +/- 129 micrograms/L on day 3 (p less than 0.001 when compared with day 1). Finally on day 7, a 250-fold concentration (17,812 +/- 9839 micrograms/L), compared with day 1, was reached. Methods described in the present paper allow separate and repetitive quantification of the synthesis of both type I and type III procollagen during human wound healing.

Aminoterminal propeptide of type III procollagen in healing wound in humans.

For quantitative analysis of wound healing in surgical patients, samples of wound fluid were collected through a silicone rubber tube and their concentration of the aminoterminal propeptide of type III procollagen was measured with a specific radioimmunoassay. Peritoneal fluid, collected through an abdominal drain, and serum were also analyzed. At day 1 after operation, the mean concentration of the propeptide was 30 times higher than the mean preoperative serum level (2.5 micrograms/L). A significant increase (p less than 0.001) occurred at day 3 in the wound and at day 2 in peritoneal fluid. At day 5 the mean wound concentration (2670 micrograms/L) was 1000 times higher than the serum level. In serum a small but significant increase (p less than 0.05) was found at days 5 and 30. The increase in wound fluid resulted from the intact, liberated propeptide, indicating that the results reflect the synthesis of type III collagen deposited in the wound. This procedure offers a quantitative tool for wound healing studies. Other extracellular matrix components can also be measured, the sequential pattern of their appearance can thus be assessed, and disturbances and treatment effects in wound healing can be detected.

Impaired wound healing in surgical patients with varying degrees of malnutrition.

The relationship between nutritional state and wound healing was examined in 66 adult surgical patients. Wound-healing response was assessed by measuring the collagen content (hydroxyproline) of fine tubes of Gore-tex inserted subcutaneously along standardized needle track arm wounds. After a period of 7 days, the tubes were removed and it was found that there was a higher hydroxyproline content in the tubing of 36 normally nourished patients than there was in the tubing of 21 patients with mild protein energy malnutrition (p less than 0.01) and 9 patients with moderate to severe protein energy malnutrition (p less than 0.01). There was no difference in the wound-healing response between the two latter groups of patients who had significantly different degrees of malnutrition. The results suggest that a definite abnormality in the wound-healing response exists in malnourished surgical patients, but it occurs earlier in the course of the illness than previously supposed.

STEROID THERAPY AND WOUND HEALING IN SURGICAL PATIENTS.

STEROID THERAPY AND WOUND HEALING IN SURGICAL PATIENTS.