Saïd C. Azoury

The use of acellular dermal matrices in chest wall reconstruction.

Summary: Surgeons are faced with increasingly complex and larger chest wall defects as a result of a variety of pathologies, the majority of which are oncologic. Skeletal reconstruction of these resulting defects and subsequent soft-tissue coverage remain a challenge for thoracic and plastic and reconstructive surgeons. A variety of techniques and grafts have been utilized to support the thoracic cage. This review focuses on the use of acellular dermal matrices in thoracic skeletal reconstruction, with a focus on the indications, published data, and surgical techniques for utilizing acellular dermal matrices in chest wall reconstruction.

Pyoderma Gangrenosum After Breast Surgery: Diagnostic Pearls and Treatment Recommendations Based on a Systematic Literature Review.

BackgroundPyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to determine distinguishing characteristics of PG in the setting of breast surgery that can facilitate timely diagnosis and appropriate treatment. MethodsPubMed, EMBASE, Scopus, and Web of Science databases were systematically searched for articles with cases of PG occurring after breast surgery. Forty-three relevant articles, including 49 case reports, were identified. ResultsPG manifested bilaterally in 30 of 34 cases (88%) in which bilateral surgery was performed. Abdominal wounds were present in 6 of 7 cases in which an abdominal donor site was used for breast reconstruction. Nipples were spared from wound involvement in 33 of 37 cases (89%) in which nipples were present after surgery. Presence of fever was noted in 27 cases (55%) and leukocytosis in 21 cases (43%). A total of 33 patients (67%) underwent wound debridement. Successful medical treatment most commonly involved steroids (41 cases, 84%) and cyclosporine (10 cases, 20%). ConclusionsPertinent clinical features were identified that may aid in timely diagnosis and treatment of PG after breast surgery. Appearance of discrete wounds involving multiple surgical sites that surround but spare the nipples should raise suspicion for PG rather than infection or ischemia, even with concomitant fever and leukocytosis. Wound debridement should be minimized and skin grafting considered only after medical therapy is initiated. Cognizance of these features may enable prompt therapeutic intervention that minimizes morbidity and improves outcomes.

Inguinal Hernia Repair During Extraperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy.

INTRODUCTION One third of men undergoing radical prostatectomy have a comorbid inguinal hernia (IH). Previous studies have shown that adding total extraperitoneal (TEP) IH repair to extraperitoneal laparoscopic radical prostatectomy (LRP) lacks adverse effects. However, outcomes of extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALP) and TEP are unknown. We compared RALP+TEP with LRP+TEP and also with RALP alone. METHODS Eleven RALP+TEP cases were retrospectively compared with 26 LRP+TEP cases and 22 control RALP without TEP. Outcomes compared between groups included operative time, estimated blood loss (EBL), discharge hematocrit (hct), time to diet advancement, length of hospital stay (LOS), postoperative complications, and hernia recurrence. RESULTS Unilateral TEP added 32 minutes to RALP and 31 minutes to LRP, whereas bilateral TEP added 80 minutes to RALP and 36 minutes to LRP. There were no differences between RALP+TEP and LRP+TEP or RALP without TEP controls in regard to EBL, discharge hct, time to diet advancement, LOS, or postoperative complications. One patient developed an anterior mesh seroma, which resolved without intervention. No IH recurrences were noted on the mean follow-up of 33 months in the RALP group and 50 months in the LRP cohort. CONCLUSIONS Unilateral and bilateral TEP added operative time to RALP but had equivalent outcomes to both LRP+TEP and RALP alone. This is likely due to the similar surgical space used for RALP and TEP, which obviates the need for substantial further dissection. For men with prostate cancer and comorbid IH, combined RALP+TEP appears to be an appropriate surgical combination.

Chest Wall Reconstruction: Evolution over a Decade and Experience with a Novel Technique for Complex Defects

BackgroundChest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects. MethodsA retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared. ResultsFrom December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47). ConclusionsIn the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.

Fibroblast Growth Factor Receptor 2 (FGFR2) Mutation Related Syndromic Craniosynostosis

Craniosynostosis results from the premature fusion of cranial sutures, with an incidence of 1 in 2,100-2,500 live births. The majority of cases are non-syndromic and involve single suture fusion, whereas syndromic cases often involve complex multiple suture fusion. The fibroblast growth factor receptor 2 (FGFR2) gene is perhaps the most extensively studied gene that is mutated in various craniosynostotic syndromes including Crouzon, Apert, Pfeiffer, Antley-Bixler, Beare-Stevenson cutis gyrata, Jackson-Weiss, Bent Bone Dysplasia, and Seathre-Chotzen-like syndromes. The majority of these mutations are missense mutations that result in constitutive activation of the receptor and downstream molecular pathways. Treatment involves a multidisciplinary approach with ultimate surgical fixation of the cranial deformity to prevent further sequelae. Understanding the molecular mechanisms has allowed for the investigation of different therapeutic agents that can potentially be used to prevent the disorders. Further research efforts are need to better understand screening and effective methods of early intervention and prevention. Herein, the authors provide a comprehensive update on FGFR2-related syndromic craniosynostosis.

Postoperative abdominal wound infection – epidemiology, risk factors, identification, and management

Surgical site infections (SSIs) complicate the postoperative course of a significant proportion of general abdominal surgical patients and are associated with excessive health care costs. SSIs increase postoperative morbidity and mortality, and may require hospital admission, intravenous antibiotics, and even surgical reintervention. Risks associated with SSIs are related to both host and perioperative factors. However, a vast majority of these infections are preventable. More recently, quality initiative programs such as American College of Surgeons National Sur- gical Quality Improvement Program are expanding their roles to help better monitor adherence to improvement measures. Indeed, standardizing preoperative antibiotic prophylaxis timing is perhaps the most persuasive example and this has been integral to reducing postoperative SSI rates. Herein, the authors provide an update on the epidemiology, risk factors, identification, and management of wound infections following abdominal surgery.

Abdominal Wall Miscellaneous

Methods: From March 2008 to June 2013, a total of 11 hepatic cirrhotic patients with intractable ascites and umbilical hernia received mesh repair. All the patients were placed a Jackson-Pratt drain in lower abdominal cavity for ascites decompression. The drain tube was placed for one month and the amount of ascites drainage was around 1000 ml per day. Patients were followd up one to six months after operation ..Burst abdomen, incisional hernias and stomal hernias : a Swedish population-based register study