Showing papers on "Surgical wound published in 1989"

The Bilobed Flap for Nasal Reconstruction

Abstract: • Four hundred consecutive surgical wounds on the nose were studied for wound management. The most commonly used flap was the bilobed double transposition flap that is especially useful for reconstruction of defects on the lower third of the nose. While the standard design often results in tissue protrusions or pincushioning, improvements in the design are outlined herein to achieve the best results for defects on the nose. (Arch Dermatol.1989;125:957-959)

Primary repair of colon wounds. A prospective trial in nonselected patients.

Abstract: 102 patients with penetrating intraperitoneal colon injuries were entered into a prospective study. Colon wound management was undertaken without regard to associated injuries or amount of fecal contamination. Primary repair was performed in 83 patients, segmental resection with anastomosis in 12, and resection with end colostomy in 7. There were no suture line failures in the primary repair group, and one suture line failure in the anastomosis group. The one failure was in a patient who underwent repeated explorations for bleeding before the leak occurred. The septic complication rate was 33% of the entire series and was unrelated to primary repair. Logistic regression analysis to identify risk factors for sepsis included transfusion greater than or equal to 4 units (p less than 0.02), more than two associated injuries (p less than 0.04), significant contamination (p less than 0.05), and increasing colon injury severity scores (p less than 0.02). The method of colon wound management, location and mode of injury, presence of hypotension (BP less than 90), and age did not significantly contribute to sepsis. We conclude that nearly all penetrating colon wounds can be repaired primarily or with resection and anastomosis, regardless of risk factors.

Repair of incisional hernia.

Abstract: Because wound infection is a major cause of incisional hernia, the question posed is whether or not repairs of incisional hernias are at a higher risk for wound infection also. To answer this, we analyzed the incidence of wound infection after repair of incisional hernias during a 30 month period and compared it with the infection rate in all other clean procedures performed during the same period. All repairs of incisional hernias were performed upon patients with completely healed incisions without clinical signs of infection. Patients undergoing concomitant procedures upon the gastrointestinal tract were excluded. During the 30 month period, 995 clean operations were performed. In the 80 repairs of incisional hernias, there were 13 infections proved by culture, yielding an over-all infection rate of 16 per cent. In the remaining 915 clean procedures, there were 14 wound infections (1.5 per cent, p less than 0.0001). Of these 915 clean operations, 241 were repairs of inguinal hernias. Two infections occurred in this subgroup (0.8 per cent, p less than 0.0001, compared with repairs of incisional hernias). In patients undergoing repairs of incisional hernias with previously documented wound infections, 41 per cent had infected repairs. By comparison, only 12 per cent of patients without a prior infection had infections develop in the hernial repair (p less than 0.05). The infection rate for patients not receiving prophylactic antibiotics (21 per cent) was almost twice the rate for those receiving antibiotics (11 per cent), p = 0.07. We concluded that repair of incisional hernias has a significantly higher rate of infection than do other clean general surgical procedures. Herniorrhaphy of a wound that was previously infected is at a higher risk for reinfection, despite complete healing of the skin and absence of clinical signs of infection. Perioperative antibiotic prophylaxis may be indicated, but randomized studies are needed. For reporting and surveillance purposes, repairs of incisional hernias should not be classified as clean surgical procedures.

Wound complications of adjuvant radiation therapy in patients with soft-tissue sarcomas.

Abstract: Adjuvant radiation therapy by the brachytherapy technique has been suggested by us to diminish local recurrence following resection of extremity and superficial truncal soft-tissue sarcoma. However, loading of the catheters with radioactive sources on the first through the fifth postoperative days results in a 48% significant wound-complication rate. Our previous animal experiments would suggest that delay of application of radiation to one week after wounding is accompanied by significant improvement in wound-breaking strength, new H3 hydroxyproline accumulation, and improved force-tension curves. As part of our ongoing prospective randomized trial of the effects of brachytherapy on local control, one change was made: the catheters were loaded five or more days after operation. Wound complications were then reviewed in 50 patients following this single change in brachytherapy delivery. Of the 21 patients receiving brachytherapy, 14% had significant wound complications; 10% of the 29 patients who did not receive radiation had wound complications of similar severity. This decrease in wound complications represents a major improvement over our prior experience and suggests that the timing of radioactive source loading in the postoperative period is a major factor in radiation-induced wound-healing delay.

Histoacryl: Its Use in Aesthetic Facial Plastic Surgery

Abstract: • Since their discovery in 1949, cyanoacrylates have evoked interest as being a possible ideal "tissue glue." Several different forms of these compounds have been developed in order to try to reduce or eliminate tissue toxicity. Butyl-2-cyanoacrylate (Histoacryl) appears to be the closest ideal material as it induces low tissue reactivity and toxicity. It has been used extensively for middle ear surgery with little or no adverse effects. A historical review of tissue adhesives and a discussion of technical considerations is outlined. A clinical trial of 100 patients treated with Histoacryl on various surgical wounds revealed no significant adverse effects with wound healing, graft rejection, or infection over a six-month period. Histoacryl appears to offer many advantages and few disadvantages over conventional suture techniques. ( Arch Otolaryngol Head Neck Surg 1989;115:193-197)

Enhanced growth of tumour cells in healing colonic anastomoses and laparotomy wounds.

Abstract: In the past, it has been noted that experimental tumour cells innoculated into the peritoneal cavity or into the lumen of the bowel will grow at a recently formed colonic anastomosis. However, it has previously been unclear whether the healing process enhances tumour growth or whether the presence of a suture line merely allows the tumour cells to gain access to the tissues. In the present study, using the hooded Lister rat, we have confirmed these findings by showing that growth of the syngeneic MC28 sarcoma and OES5 breast carcinoma occurs preferentially at colonic anastomoses and laparotomy wounds after intraperitoneal injection, and at colonic anastomoses after intraluminal injection. In previous studies using the MC28 sarcoma and the OES5 breast carcinoma injected by the intracardiac route (so that tumour cells reach normal and healing tissues in approximately equal numbers) we have shown that tumour growth is enhanced in healing wounds but not in the surrounding normal tissues when cells reach a healing colonic anastomosis or laparotomy wound within 2 h of its formation. Furthermore, by studying the distribution of radiolabelled tumour cells after intracardiac injection, we have calculated that the probability of a tumour cell leading to a deposit in a healing anastomosis or laparotomy wound is increased 1,000 fold compared to normal tissue. No previous studies have combined the data for intracardiac, intraluminal and intraperitoneal injection of tumour cells using the same animal model. We conclude that the same phenomenon of tumour growth enhancement in colonic anastomoses and laparotomy wounds reported after intracardiac injection of tumour cells may well be enhancing tumour growth after intraperitoneal and intraluminal injection. If these results can be extrapolated to man, then tumour cells spilled at surgery for colorectal cancer (or indeed any other cancer) may well encounter an environment which favours their growth and so the healing process itself may contribute to the genesis of local recurrence of malignant disease.

Expulsive Choroidal Hemorrhage in Rabbits: A Histopathologic Study

Abstract: • Expulsive hemorrhage is a catastrophic complication of intraocular surgery that can result in total loss of vision. Suprachoroidal effusion and hemorrhage may precede the development of expulsive hemorrhage; however, the relationship remains unclear. After sedation with intravenous pentobarbital sodium, 11 rabbits were given lactated Ringer's solution and heparin sodium intravenously. The right eyes were proptosed, and the central cornea, lens, and anterior vitreous were removed. After surgery, all 11 eyes (100%) developed choroidal effusion, choroidal hemorrhage, or expulsive hemorrhage. The rabbits were killed at various intervals after surgery so that the eyes could be enucleated and processed for light microscopy. Histologic examination revealed four sequential stages of expulsive hemorrhage as follows: (1) There was engorgement of the choriocapillaris. (2) Suprachoroidal effusion occurred mainly near the posterior pole. (3) As the effusion enlarged, stretching and tearing of choroidal vessels as well as tearing of the vessels and attachments at the base of the ciliary body occurred. (4) Massive extravasation of blood, primarily from the torn vessels at the ciliary body base, resulted in suprachoroidal hemorrhage and expulsion of blood through the surgical wound. This experimental model may provide new information relating to the cause and prevention of expulsive choroidal hemorrhage.

Wound perfusion with bupivacaine: objective evidence for efficacy in postoperative pain relief.

Abstract: Conflicting reports exist for the efficacy of intermittent wound perfusion with bupivacaine in the relief of postoperative pain. A study was devised to assess postoperative pain relief objectively using a Patient Controlled Analgesic Device (PCAD) during continuous wound perfusion with bupivacaine or saline. Thirty consecutive patients undergoing cholecystectomy were randomised to receive continuous postoperative wound perfusion with 0.5% bupivacaine for 24 h followed by normal saline for a further 24 h or vice versa. During the study period, conventional analgesia was provided using a PCAD set to deliver (and record the number of) on-demand bolus doses of intravenous pethidine 0.2 mg/kg at half-hourly intervals as required. Pethidine requirements were higher on the first postoperative day, regardless of which solution was given, but bupivacaine perfusion almost halved mean linear analogue pain scores compared to those recorded with saline. Likewise, the number of bolus doses of pethidine demanded was reduced by an average of 68% compared to those recorded during saline perfusion on day 1 (P = 0.01) and by 82% on day 2 (P = 0.01). When assessed by objective criteria, perfusion of surgical wounds with bupivacaine after cholecystectomy produces better pain relief than wound perfusion with saline.

Inhibition of tumor-cell attachment to extracellular matrix as a method for preventing tumor recurrence in a surgical wound.

Abstract: Studies with four different transplantable murine tumors demonstrated that surgical instruments contaminated by contact with a tumor mass could produce tumors in a surgical wound. Eighty-seven per cent of mice with wounds made by invisibly contaminated scissors developed tumors. Irrigation with water did not prevent tumor growth. Before spilled tumor cells can invade and grow into a recurrence in the wound site, they must first attach to underlying extracellular matrix. We have devised a simple in vitro assay to identify inhibitors of tumor-cell attachment to develop therapeutic compounds that can prevent tumor-cell reimplantation. Various test compounds, including proteases (trypsin and Dispase), known modulators of matrix metabolism (proline analogues, cycloheximide, heparin, cortisone, cortexolone, and heparin-steroid combinations), large molecular weight polymers (agarose, dextran, polyethylene oxide), and synthetic fibronectin peptides were tested for their ability to inhibit mouse melanoma (B16-F10) cell attachment to gelatinized dishes. Most of these compounds had little or no effect on tumor-cell adhesion when cells were plated in serum-containing medium. However we identified three compounds that inhibited tumor-cell attachment in a reversible fashion: (1) a specific inhibitor of collagen deposition (L-azetidine-2-carboxylic acid); (2) a bacterial neutral protease (Dispase); and (3) synthetic fibronectin peptides that contained the arginine-glycine-asparate (RGD) sequence that is responsible for cell binding. Dispase and the RGD-containing peptides also inhibited cell implantation and prevented tumor formation in a surgical wound. We propose that inhibitors of attachment might be used either alone or with other biologic modifiers to prohibit implantation of free tumor cells at the time of surgery and thus, to prevent local tumor recurrence.

Use of transcutaneous electrical nerve stimulation for postoperative pain.

Abstract: This study examined the effects of transcutaneous electrical nerve stimulation (TENS) on incisional pain caused by the procedure of cleaning and packing an abdominal surgical wound. Seventy-five subjects (mean age 56.9 years) were randomly assigned to one of three intervention groups: TENS, placebo-TENS, or no-treatment control. The appropriate experimental treatment was administered during the routine dressing change which took place two mornings after surgery. Using an 11-point, visual analogue pain scale, subjects described pain experienced during the dressing change. Subjects who received TENS reported a significantly lower level of pain after dressing change than did those subjects who received either placebo-TENS or no-treatment. Drug administration variables did not contribute significantly to level of reported pain.

Lower limb prosthesis having removable rigid amputation stump dressing

Abstract: A lower limb prosthesis assembly is provided for immediate post-operative applications which includes a weight-bearing prosthetic device in conjunction with a removable, size-adjustable rigid dressing for placement around a patient's amputation stump. The weight-bearing prosthetic device includes a foot-ankle assembly attached to an adjustable endoskeletal shank having adjustment means, medial and lateral uprights extending upwardly from the endoskeletal shank, and an open ended quadrilateral thigh socket attached to and located between the medial and lateral uprights. The thigh socket includes a proximal ischial weight-bearing shelf for supporting the patient without contacting the open wound of the amputation stump. The rigid dressing includes a substantially stump-shaped rigid cast portion for placement around the stump which is open-ended at the top and shaped to enclose and secure around the stump at its bottom to apply mild compression for suppressing edema of the stump. The cast portion has (a) two vertical half shells wherein each half shell has two vertically-separatable overlapping sections which are slidably adjustable for adaption to different size stumps, (b) sizing means on the cast portion for adjusting it in size circumferentially and for holding the overlapping sections together, and (c) locking means for securing the two half shells together around the amputation stump. The invention is intended to be used immediately after an amputation, as early as the first post-operative day. This provides a prosthetic device which is prefabricated, adjustable, economical and easy to use without creating any problems in the healing of the terminal surgical wound.

Cultured allogenic keratinocyte grafts in the management of wound healing : prognostic factors

Abstract: . Cultured allografts derived from neonatal fore-skin provide a potent stimulus to wound healing in a wide variety of wounds. Their application is a simple outpatient procedure involving no discomfort for the patient. In contrast to autografting, no biopsy is necessary, and growth of newborn keratinocytes in cultures is more rapid than that of adult cells. Use of cultured allogeneic cells offers immediate graft availability and the possibility of stockpiling and preserving the graft for future use. Cultured epidermal allografts may be valuable in accelerating healing by second intention in surgical wounds, as well as being a helpful addition to chronic ulcer management. In venous disease, the outcome is at least comparable to other forms of skin grafting. Ulcers due to connective tissue disorders fared less well and deep chronic ulcers (down to fascia or tendon) were not significantly improved by cultured allograft application. Surprisingly, patient age did not influence outcome.

A clinical trial of tissue adhesive (histoacryl) in skin closure of groin wounds.

Abstract: The use of tissue adhesives has been widely studied since the 1960s. Since then they have found use in specialties like plastic surgery, neurosurgery, ENT surgery and dental surgery. Several papers have reported their safe use, both clinically and experimentally, particularly of the newer homologue n-butyl/2-cyanoacrylate (Histoacryl). In this study 43 patients (46 wounds) whose operations involved a groin incision were randomised into two groups for skin closure either with Dexon subcuticular suture (23 wounds) or Histoacryl glue (23 wounds). We found that both sets of wounds healed well with no wound infections or excessive inflammation when assessed at one week and four weeks. However the glued wounds had consistently better cosmesis scores (mean score 4.71 at four weeks) compared to the subcuticular Dexon wounds (mean score 4.00 at four weeks) and P value of less than 0.05. We feel that there is a place for tissue adhesives in skin closure for some general surgical wounds.

Sartorius muscle coverage for the treatment of complicated vascular surgical wounds.

Abstract: Sartorius muscle flaps were evaluated in 14 patients treated for complicated groin wounds related to vascular surgical procedures. Particular risk factors for poor wound healing were present in 8 patients, including diabetes, obesity, or poor nutrition in 3 patients; prior radiotherapy to the groin in 2; reoperative groin exposure in 3. Eleven of 14 patients had multiple indications for sartorius flap coverage, including hemorrhage in 5 patients, groin wound sepsis in 3, graft sepsis in 2, wound necrosis in 5, exposure of a reconstruction in 4, treatment of a lymphocele in 1, and treatment of groin irradiation in 2. Nine flaps were proximal sartorius segments rotated into the groin, four were distal muscle reflected into the groin, and one was a mobilized mid-portion of the muscle. Early successful wound healing occurred in all patients, but complications included muscle bed infection in 1 patient, late recurrence of lymphocele in 1, and recurrent groin sepsis in 1. Hemorrhage did not recur, and existing reconstructions were salvaged in all patients. The sartorius flap is a well-tolerated method for achieving autogenous tissue coverage for the problem groin wound, and there is no long-term functional deficit from anatomic loss of the sartorius muscle.

Penetration of antibiotics into the surgical wound in a canine model.

Abstract: The dose and timing of antimicrobial agents given for surgical wound prophylaxis should be based on the concentration-time profile of the drug in tissue at the site of contamination. However, concentrations of antimicrobial agents in surgical wounds are difficult to determine accurately. Since a surgical wound is a unique extravascular compartment with increased vascular permeability and a high surface area/volume ratio, antibiotic concentrations in sera and surgical wounds should be similar. To test this hypothesis, the pharmacokinetics of single intravenous doses of cefazolin (40 mg/kg) and gentamicin (4 mg/kg) in sera and surgical wounds in a clinically relevant surgical model using dogs were compared. Drug concentrations were determined in interstitial fluid in muscle biopsies taken randomly from wound surfaces and serial wound fluid samples collected after the incisions were closed. Protein binding of cefazolin and gentamicin in sera and wound fluids was low (less than or equal to 29 +/- 9%) in this canine model. Cefazolin and gentamicin equilibrated rapidly (less than or equal to 30 min) between serum and the surgical wound, and concentrations in the two sites declined in parallel. Values for the area under the concentration-time curve, mean residence time, and terminal half-life in serum and the surgical site for each drug were similar. Cefazolin concentrations in serum underestimated the time during which concentrations in surgical wounds exceeded the susceptibility breakpoint MIC for important pathogens by an average of 58 min (range, 26 to 109 min; P = 0.036); for gentamicin, the underestimation averaged 30 min (range, 10 to 60 min; P = 0.036). These data support the concept that the concentration-time profiles of antimicrobial agents in serum may prove valuable clinically as guides to determining the and timing of antibiotic administration necessary for effective antimicrobial prophylaxis in surgery. Further studies are needed to determine the surgical wound pharmacokinetics of highly protein-bound antibodies.

Use of dynamic compression plates for treatment of tibial diaphyseal fractures in foals: nine cases (1980-1987).

Abstract: The medical records of 9 foals less than 4 months old, with fracture of the tibial diaphysis, were reviewed. Open reduction was accomplished by use of 3 approaches; however, a cranial approach was preferred and was used in 7 foals. Two dynamic compression plates were implanted in all foals except the first of this series. The technique of plate luting was used in 7 foals and appeared to improve the ability of implants to resist failure. Complications after surgery included partial or complete failure of fracture fixation (n = 3 foals), osteomyelitis (n = 2 foals), angular limb deformity (n = 2 foals), minor dehiscence of the surgical wound (n = 3 foals), and mild extensor deficits of the injured limb (n = 4 foals). One foal was euthanatized 12 hours after surgery because of complete loss of fracture fixation. All other foals were discharged 10 to 295 days after surgery. One or both plates were subsequently removed in 7 foals. Follow-up information was obtained 6 to 36 months after discharge. Excellent results were reported for 6 foals, and good or fair results were reported for the remaining 2 foals.

Surgical antibiotic irrigations.

Abstract: Instillation of antibiotic solutions into surgical wound sites seems empirically attractive since relatively high concentrations of antibacterial agents can be applied directly to the probable site of infection. However, systemic effects provided by antibiotic assimilated from sites of application are responsible for much of the activity and toxicity of antibiotic irrigations. The most appropriate drugs and dosages for use as prophylactic antibiotic irrigations have not been determined. Most controlled trials conducted in recent years have utilized various cephalosporins in concentrations of 1 to 4 g/L. In some of these trials, surgical irrigation has been found as effective as prophylactic intravenous antibiotics, which are the proven and accepted standard. Reported cases of toxicity associated with antibiotic irrigations are few in number, excepting neomycin, which has caused postoperative respiratory depression/apnea, permanent deafness, and renal failure.

Preincisional intraparietal Augmentin in abdominal operations.

Abstract: A total of 624 consecutive eligible patients undergoing abdominal operations received a single preoperative dose of amoxycillin/clavulanic acid (1.2 g Augmentin) for the prophylaxis of surgical wound infection. They were randomised to have the antibiotic injected intravenously at induction of anaesthesia (n = 328) or infiltrated subcutaneously along the line of the proposed incision (n = 296). The incidence of wound infections was considerably lower in the group given the antibiotic into the abdominal wall (8.4% compared with 15.9%--chi 2 = 7.90, P = 0.005). No significant differences were found in the incidence of other major or minor infective or non-infective postoperative complications between the groups. It is concluded that preincisional intraparietal injection is more effective than intravenous injection of Augmentin for the prophylaxis of surgical wound infection.

Wound infection caused by Branhamella catarrhalis.

Abstract: Branhamella catarrhalis was isolated from sputum, tracheal secretions, and a nonhealing and infected thoracic surgical wound in a 59-year-old woman who had a history of a chronic, interstitial fibrosis and who had undergone an open lung biopsy procedure. The patient's upper respiratory tract was the likely source of the organism. To our knowledge, this is the first report of a wound infection caused by B. catarrhalis.

Emergence of Isolates Resistant to Ampicillin

Abstract: • Clinical isolates ofStreptococcus faeciumdemonstrating ampicillin resistance were recovered from eight pediatric patients. Sites of isolation included blood, surgical wound, bile drainage, urine, burns, and peritoneal fluid. Seven patients had prolonged hospitalization, and all had been treated with broad-spectrum antibiotics prior to isolation of the resistant enterococcus. One isolate was from an ill, bacteremic patient; the others were in mixed culture and were not considered causes of disease. The isolates were not epidemiologically related. Minimal inhibitory concentrations for various antibiotics included ampicillin (16 to 32 mg/L), penicillin (128 mg/L), gentamicin (16 mg/L), and vancomycin (2 mg/L). Three isolates demonstrated high-level resistance (>2000 mg/L) to streptomycin; none did so to gentamicin. In vitro synergy testing performed on seven available isolates for ampicillin and gentamicin demonstrated no synergy to this combination. None produced β-lactamase. Combined antibiogram and plasmid data showed at least five distinct patterns. These strains present a new clinical problem in their high level of resistance to ampicillin and to the combination of ampicillin and gentamicin. (AJDC. 1989;143:1033-1037)

Clinical experience with cefmetazole sodium in the United States: an overview

Abstract: The clinical development programme for cefmetazole sodium included over 4000 patients treated by 78 investigators. Cefmetazole therapy was compared with that of cefoxitin sodium (cefoxitin) for the treatment of urinary tract, skin and soft tissue, lower respiratory, abdominal, and gynaecological infections (with cefoxitin-sensitive pathogens) and for the prevention of postoperative wound infection in patients undergoing surgical procedures. Both cefmetazole and cefoxitin were administered intravenously in all studies. Cefmetazole was as effective as cefoxitin in the treatment of the infections studied. In the surgical wound infection prophylaxis studies, multiple-dose cefmetazole therapy was more effective than multiple-dose cefoxitin therapy in patients undergoing lower gastrointestinal surgery; this difference approached statistical significance. Both multiple-dose and single-dose cefmetazole therapy were as effective as multiple-dose cefoxitin treatment in the other types of surgery studied. Clinical laboratory findings and adverse medical events reported among cefmetazole patients were similar to those observed in patients treated with cefoxitin.