17 Self-fixing scaffold membrane prevents postoperative adhesion by scavenging ROS productionLi, Sicheng; Liu, Ye; Huang, Jinjian; Wu, Xiuwen; Ren, Jianan
doi: 10.1093/bjs/znaf024.023pmid: N/A
AimThis study focuses on the investigation of formation mechanism and prevention technologies for postoperative abdominal adhesions by combining bioengineering technology with the target therapy on abdominal adhesion mechanism.MethodsA tissue engineering anti-adhesion membrane (SC-Xg) was prepared by cross-linking xanthan gum (Xg) with sodium citrate (SC) through dehydration condensation reaction for in vivo implantation to prevent postoperative abdominal adhesions. The physicochemical properties of SC-Xg were characterized by Fourier transform infrared spectroscopy, scanning electron microscopy, rheometry, and swelling experiments to screen for suitable material formula ratios. Moreover, the biocompatibility of SC-Xg was assessed by co-culture with cells and fluorescence staining of live/dead cells. Through cellular experiments, we explored the possible mechanisms of sodium citrate inhibition of oxidative stress. Based on in vivo implantation of SC-XG membrane to mouse IBM, the safety and efficacy of SC-Xg in preventing postoperative abdominal adhesions were further confirmed using histopathological staining and ELISA assays.ResultsWe developed a sodium citrate-based cross-linked xanthan gum tissue engineering membrane (SC-Xg) through a dehydration condensation reaction for the prevention of abdominal adhesion formation after abdominal surgery. The mechanical properties of xanthan gum were optimized by using different amount of sodium citrate for cross-linking. The SC-XG membrane showed the antioxidant properties, good self-fixation ability, biocompatibility, and biodegradability, and was easy to prepare for applications. In vitro and in vivo experiments confirmed the clinical translational potential of SC-Xg by shielding the surgical site, inhibiting oxidative stress and inflammatory response by activating Nrf2, and significantly reducing adhesion formation.ConclusionsSC-Xg membrance inhibits oxidative stress in the injured peritoneum and prevents the formation of adhesions.
31 Concerning a case: innovative approach to managing sepsis from an infected breast prosthesisBlay, Lidia; Malagón, Paloma; Vilà, Jordi; Aranda, Daniel; Pascual, Iciar; Claret, Rosa; Cardona, Pere Joan; Carrasco, Cristian; Humaran, Daniel; Julián, Joan Francesc
doi: 10.1093/bjs/znaf024.027pmid: N/A
We present a 45-year-old patient with right breast neoplasia and BRCA2 genetic mutation. She is discussed in a multidisciplinary breast cancer committee and was considered to be a candidate for bilateral skin and nipple sparing mastectomy with sentinel lymph node biopsy. The surgery was performed endoscopically through lateral incisions of 3.5 cm in the axillary midline. During surgery, the presence of retroareolar tumor cells was found, requiring a new retroareolar resection to ensure the anterior margin and to maintain the nipple-areola complex. The immediate postoperative course was favorable and the patient was discharged after 48 hours. In outpatient follow-ups, drainage is monitored, and necrotic tissue is observed exclusively in the nipple during ambulatory check-ups, with satisfactory progress. At 15 days drainage is removed in the right breast, but the patient reconsults at 48 hours due to pain in the breast, erythema in the drainage orifice and slight increase in volume in the lower outer quadrant and center of the breast. Drainage is performed by puncture and purulent material is analized and the patient is admitted with intravenous antibiotherapy. During 5 days the patient presented progressive worsening with increased erythema, pain, fever and sepsis in analytical (>20 000 leukocytes and CRP >400 mg/l) so it is proposed to explant the prosthesis. The patient refuses to have the prosthesis removed and requests conservative management, refusing the explant even with the vital risk involved. In front of a competent patient, an attempt of ‘prosthesis conservative’ management was decided, performing surgery with intense washing of the mastectomy cavity, Friedrich of necrotic plaque with direct suture and prosthesis placement with previous drainage, washed with betadine, prontosan and antibiotherapy + sensitive antifungals according to initial antibiogram. She was hospitalized for 10 days with antibiotics and endovenous antifungal well tolerated, with progressive improvement and discharge with oral antibiotics and control in external consultations. The patient maintains good evolution with normalization of her septic status and good aesthetic result. The pathological anatomy showed free surgical margins.
43 A challenging management of a Y graft mycotic pseudoaneurysm in a simultaneous pancreas-kidney transplant recipientGeropoulos, Georgios; Colucci, Nicola; Amin, Irum; Russell, Neil; Kosmoliapsis, Vasilis
doi: 10.1093/bjs/znaf024.038pmid: N/A
IntroductionThe incidence of allograft artery mycotic pseudoaneurysms after kidney and pancreas transplantation is less than 1%. Natural history of vascular mycotic aneurysms is characterized by their tendency to rupture causing major bleeding, leading to graft loss and increased mortality rate.Case ReportA 45-years old patient was transferred to the intensive care unit of our hospital following a massive upper gastrointestinal bleeding, pyrexia and hemodynamic compromise. Medical background included a simultaneous pancreas-kidney transplant (SPK) back in 2020, followed by rejection and repeated pancreatic transplant (PTA) alone one year after. Abdominal computerized tomography imaging showed a thrombosed graft superior mesenteric artery, with concomitant active bleeding from the splenic limb of the arterial Y graft, due to a mycotic pseudoaneurysm ruptured into the bowel. The bleeding was initially managed with an endovascular stenting of the right common iliac artery, determining an inevitable graft ischemia. Blood cultures isolated Bacteroides sp. so, the patient was started on board spectrum antibiotics (piperacillin/tazobactam) based on the culture sensitivities. Following resuscitation, the patient went to theatre two days after for a graft pancreatectomy, including the aneurysmal Y graft. An iliac artery vascular repair was then performed. The endovascular stent was removed during the procedure. The cultures of the pancreatic graft, vessels and stent were positive for enterococcus faecium, leading to adding vancomycin to the already existed antibiotic regimen. The patient received in total four weeks of intravenous and oral antibiotics. His postoperative course was uneventful and was discharged on the 14th postoperative day.Educational HighlightsPancreatic graft arterial pseudoaneurysms is an uncommon as well as quite serious complication following a combined kidney and pancreas transplantation. Initial management of pseudoaneurysms should rely on early diagnosis while endovascular repair could be an acceptable bridging therapy along with long term antibiotics. Surgical management involve removing the infected vessels and perform arterial reconstruction aiming preservation of the graft. However, in some cases graft pancretectomy is deemed necessary to control the ongoing resistant sepsis or findings of ischemic graft.
44 Gram stain and intraabdominal infection: narrative revisionVázquez, Alba Manuel; Pérez, Inés Rubio; Badía Pérez, Josep María; Sánchez, Carmen González; Garriga, Xavier Guirao
doi: 10.1093/bjs/znaf024.031pmid: N/A
AimOur aim is to determine whether Gram staining can confirm the presence of pathogens in an intra-abdominal infection (IAI), identify filamentous forms or provide information for the initiation of antibiotic treatment and/or drainage of a collection. It also intended to assess whether the Gram stain result may support the diagnosis of primary or secondary peritonitis.MethodsA narrative literature review was conducted. Articles published in English or Spanish since 1990 were included. Experimental studies, peritoneal dialysis and liver cirrhosis were excluded. SINTAXIS: ‘Intraabdominal Infections’ (diverticulitis, colonic; Appendicitis; cholecystitis, acute; Peptic Ulcer Perforation; Intestinal Perforation; secondary peritonitis; Abdominal Abscess; Postoperative complications) AND (‘Gentian Violet’ OR ‘Gram's stain).ResultsForty papers were found and eight were selected for review (7 retrospective and 1 prospective observational studies). The usefulness of Gram staining was discussed in acute cholecystitis, liver abscess, secondary peritonitis, blood stream infections and soft tissue infections, but no uniform criteria were found in the patients included. According to studies, we cannot conclude that Gram stain is useful in IAI. It does not seem to predict the outcome of cultures or influence the duration and selection of antimicrobial therapy, whereas it may be slightly more useful for fungi due to its higher negative predictive value. Gram stain positivity seems to mean an increased risk of SSI in certain pathologies and closer outpatient monitoring could be applied in these cases. Microbiological characterization of the Gram stain in certain pathologies (soft tissue infection, blood stream infection) may point to an intra-abdominal origin of the primary infection.ConclusionsConsidering the heterogeneity of the studies reviewed, no clear conclusions can be drawn about the usefulness of Gram staining in IAI.
25 Hepatic abscess secondary to migration of fish bone impaction from the duodenum: a challenging managementVera, Blanca Monje; Asensio, Luis; Recarte, Maria; Del Castillo, Federico; Suarez, Belen; Fondevila, Constantino; Rubio-Perez, Ines
doi: 10.1093/bjs/znaf024.036pmid: N/A
IntroductionForeign body ingestion is a common condition. Over 80% of cases are accidental and even unnoticed by the patient, 10–20% need endoscopic treatment for extraction, and only 1% of cases need surgical intervention. There is a wide range of possibilities and complications in the gastrointestinal tract related to foreign body impaction. A very uncommon complication is perforation of bowel with migration of the foreign body and underlying insidious infection. These situations usually require a surgical approach to resolve the problem. We present the case of a patient with a liver abscess secondary to fishbone impaction in the duodenum with migration into the liver.Case ReportA 79-year-old male with a medical history of duodenal ulcer, hiatal hernia, and benign prostatic hyperplasia arrived to the Emergency Department (ED) with shortness of breath, fever and general malaise. On laboratory exams he presented leukocytosis and high C reactive protein (CRP). A simple Chest X-ray reported pleural effusion. Blood cultures informed of a S. intermedius. As his first diagnostic approach was pneumonia, he was admitted to the Pneumology Department. During admission, a thoraco-abdominal CT scan was performed. It informed of a liver abscess (2.5 × 2.3 cm) with a foreign body of linear morphology in the middle, probably a fishbone. This foreign body had one end located in the first duodenal portion and the other end at the edge of the hepatic abscess (segment IV), close to the falciform ligament. The patient was finally diagnosed with a liver abscess with pleural effusion in the infectious context. He received empirical antibiotic treatment and conservative management. After clinical improvement, the patient was discharged. However, he returned to the ED again due to a poor general condition. An abdominal CT scan was performed which reported enlargement of the liver abscess, with increased inflammation around it. Gastroenterologists performed an endoscopy to try and remove the fishbone, but it was unsuccessful due to scar tissue blocking access. Percutaneous drainage of the abscess was performed to achieve source control with the isolation in cultures of the same S. intermedius as in blood. The patient received targeted antibiotic treatment after source control and he was scheduled for elective surgery. The operative findings described a fibrous tract leading from the duodenum to the liver: it was opened, and the fishbone removed. The tract was resected, and the duodenal orifice was closed. The patient recovered uneventfully.Educational HighlightsThe range of clinical manifestations of foreign body impaction can be acute or insidious. In this case, a high level of suspicion was needed for diagnosis, as symptoms were atypical and initially ruled as pneumonia. It is important to remember that source control is the main objective when treating abdominal infections. If conservative management is not effective, optimization of the patient and medical treatment to reduce inflammation can be a wise strategy before surgery. The optimal treatment of abdominal foreign bodies is a challenging condition and treatment must be tailored to each patient and presentation.
18 iNPWT versus standard dressing on groin surgical incisions after revascularization surgery: PICO-vasc randomised trialLorenzo, Laura Rodriguez; Cañas, Elena Gonzalez; Madrazo Gonzalez, Zoilo; Salto, Eduardo Arrea; Gimenez Gaibar, Antonio; Radua, Jana Merino
doi: 10.1093/bjs/znaf024.004pmid: N/A
ObjectiveThis study assessed the potential benefit of applying incisional negative pressure wound therapy (iNPWT) in patients undergoing revascularisation due to peripheral arterial disease.DesignA prospective, randomised, controlled trial was conducted comparing the inguinal application of iNPWT versus standard surgical dressing. Patients were enrolled from February, 2021 to November, 2022.MethodsOne hundred and thirty-three groin incisions were randomised (66 intervention group, 67 control group). Randomisation sequence was carried out by permuted blocks and allocation assigned by opening opaque envelopes once the revascularisation procedure finished. Wound healing and complication rates were assessed at postoperative days 5, 14 and 30. The primary and secondary endpoints were: 30-day postoperative surgical site infection (SSI) and surgical site occurrence (SSO) rates, defined as surgical wound complication other than SSI. Postoperative SSI was defined according to the Center for Disease Control and Prevention (CDC) criteria. SSO included: wound dehiscence, seroma or lymphocele, haematoma, and lymphorrhagia. The study was registered at ClinicalTrails.gov database (NCT04840576) and reported according to the CONSORT guidelines.ResultsiNPWT did not alter the 30-day inguinal SSI and SSO rates (16.7% versus 20.9%, P = 0.53 and 37.9% versus 44.8%, P = 0.42, respectively). The use of iNPWT showed a reduction in early-SSO rate (19.7% versus 35.8%, RR 1.45, 95% c.i. 1.047–2.013), wound dehiscence (0% versus 6%, P = 0.044) and postoperative seroma (4.6% versus 19.4%, P = 0.014).ConclusionInguinal postoperative use of iNPWT proved to be an effective preventive tool, with significant reductions in early-SSO rate, wound dehiscence, seroma, but did not alter the 30-day SSI and SSO rates.
14 Conventional versus instillation NPWT in the treatment of surgical site infections—an interim analysis of ongoing prospective trialPopivanov, Georgi; Penchev, D; Chipeva, S; Stefanov, D; Konaktchieva, M; Kjossev, K; Paycheva, Ts; Dimitrov, P; Marangozov, S; Mutafchiyski, V
doi: 10.1093/bjs/znaf024.020pmid: N/A
AimApproximately 9 million HAIs occur yearly worldwide or 5–15% of all admissions. According to a recent systematic review the cumulative incidence of SSIs is 11%. According to the Middle East Expert Forum, NPWT with instillation (NPWTi) offers the following benefits over the conventional NPWT ‘reduction in bioburden, decreased time to wound closure, reduced infection rates, decreased length hospital stay and fewer additional surgical procedures’. However, the quality of the published literature is low and sound evidence for the benefit of NPWTi is still lacking. The present study aims to compare the effectiveness of NPWT and NPWTi using an improvised system with continuous lavage with saline and chlorhexidine in superficial and deep SSIs after conventional laparotomy or laparoscopic abdominal surgery.Material and MethodsThe study analyzes a prospective database encompassing 17 January 2018–25 December 2023. All patients underwent surgical debridement and lavage with 3–5 l saline under anesthesia. Systemic antibiotics were administered according to the antibiogram. In conventional NPWT, the wound was filled with black foam (Granufoam®, KCI) and covered with plastic folio. A continuous pressure of 125 mmHg was applied using the hospital suction system. In NPWTi, the whole wound was filled with Granufoam®. The instillation was performed via gravity from i.v. bag through a drain put within the foam. Chlorhexidine 0.1% 300 ml in 700 ml saline was used for continuous instillation three times daily (3 l per day) on the background of continuous pressure of 125 mmHg. Double masking was applied (Investigator and Outcomes Assessor). Primary outcomes were the rate of wound closure and 30-day infection recurrence rate. Secondary outcomes were hospital stay, number of OR visits, and time to wound closure (suture or flap). The study is registered in ClinicalTrials.gov with ID: NCT06014788.ResultsOut of 4765 operated patients for the last five years, the HAIs and SSIs were 3.1% (n = 149) and 2.6% (n = 125). The distribution of ESKAPEE pathogens was following: E. faecium—34.4%, S. aureus—8%, K. pneumoniae—10.4%, A. baumanii—8%, P. aeruginosa—11.2%, Enterobacter—7.2%, E. coli—32.8%. A total of 62 consecutive patients (standard NPWT—41, NPWTi—21) have been included. Conventional NPWT managed the first consecutive 30 cases. The next 21 were treated with either conventional NPWT or NPWTi at the discretion of the operating surgeon, whereas the last 11 were treated with NPWTi. There was deep SSI in 32 cases—19 in NPWT and 13 in NPWTi. The mean age was 60.8 versus 57 years. The rate of wound closure was 93% versus 91%, the 30-day infection recurrence rate was 2% versus 10%, and the complication rate was 2% versus 10%. The secondary outcomes were as follows: hospital stay—19.3 versus 20.8 days, number of OR visits—3.71 versus 2.9, and time to wound closure (suture or flap)—11.8 versus 11.6 days. None of the abovementioned differences was statistically significant.ConclusionThe interim analysis of this prospective ongoing trial demonstrates no significant benefit of NPWTi in comparison to the conventional NPWT in superficial or deep SSIs after laparotomy.