Indocyanine green-guided liposuction for patients presenting with residual nonpitting edema after lymphovenous anastomosis.

INTRODUCTION: Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction. PATIENTS AND METHOD: Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry. RESULTS: The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12). CONCLUSION: Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%.

Role of intraoperative radiotherapy in the treatment of sacral chordoma.

BACKGROUND CONTEXT: Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT). PURPOSE: The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT. STUDY DESIGN: This is a retrospective case series. PATIENT SAMPLE: The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015. OUTCOME MEASURES: The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences. METHODS: We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared. RESULTS: A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement. CONCLUSIONS: Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT.

Xenotransplantation of human adipose-derived stem cells in the regeneration of a rabbit peripheral nerve.

Adipose tissue-derived mesenchymal stem cells (AdMSCs) are useful in the regeneration of neural tissues. Furthermore, xenotransplantation of human adipose tissue-derived mesenchymal stem cells (hAdMSCs) into animal models has already been tested and the results encouraged us to study peripheral nerve regeneration in rabbits, in order to test the feasibility of a xenotransplantation of hAdMSCs. ANIMALS AND METHOD: To promote end-to-end nerve fiber contacts of a 4-cm gap in the peroneal nerve of white New Zealand rabbits, an autologous vein conduit was used and three groups of animals were evaluated. In Group I, the gap was repaired with a vein conduit refilled with fibrin. Group II was similar, but the animals were treated with cyclosporine A. In Group III, a fibrin scaffold with hAdMSCs was placed inside the autologous vein conduit, and animals were treated with cyclosporine A. Neurofilament immunohistochemistry results showed 100% nerve regeneration at the vein guidance channel 90 days after the surgery in the hAdMSC-transplanted group but lesser neural regeneration in the neurofilaments of groups I and II. The analysis of variance (ANOVA) test showed statistically significant differences among all groups (p < 0.04). Group III exclusively tested positive for human monoclonal anti-mitochondrial antibody. Electron microscopy images showed tiny bundles, with a predominance of nonmyelinated axons. Myelinated axons caused irregular thickness of the myelin sheath, which was especially observed in group III. CONCLUSIONS: Xenotransplantation of hAdMSCs into a fibrin scaffold promoted nerve regeneration through a vein conduit that connected a 4-cm gap created at the peroneal nerve of rabbits. Animals treated with hAdMSCs presented negative inflammatory response at the regenerated nerve gaps, but it was demonstrated that hAdMSCs were incorporated to the new nerve creating neural tissue and endothelial cells. However, hAdMSCs required immunosuppression with cyclosporine A to achieve axonal regeneration.

Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial.

AIMS: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

Epiperitoneal vessels: more resources to perform DIEP flaps.

The development of the DIEP flap established an accepted concept of reconstructive surgery, but in patients who demonstrate inadequate in vivo flap perfusion, alternative surgical options to improve vascularisation are limited. We present a 42-year-old patient, with a left mastectomy whose breast was reconstructed with a DIEP flap. After anastomosis to the internal mammary vessels there was insufficient arterial perfusion of the flap. The situation was resolved by using an independent medial perforator artery emerging from the peritoneal layer (epiperitoneal vessels). This new pedicle was anastomosed end-to-end to the distal portion of the inferior epigastric artery. We consider that epiperitoneal vessels can be an emergency pedicle when needed and a possible alternative to the main pedicle of the DIEP flap.

Improving flap survival by transplantation of a VEGF-secreting endothelised scaffold during distal pedicle flap creation.

UNLABELLED: The benefits of a VEGF-secreting endothelised scaffold on the survival of distal flaps with early pedicle flap division were evaluated in a rabbit model. We bioengineered a scaffold based on a fibrin matrix in which endothelial cells, genetically modified with a VEGF-encoding adenoviral vector were embedded. We distributed subjects in four groups. CONTROL: Eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold. The pedicle was divided after a period of 5 days; and eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold but in this group the pedicle was divided after a period of 2 days. TREATMENT: Eight rabbits conditioned with VEGF-secreting endothelial cells embedded in a fibrin scaffold; the pedicle was divided after a period of 5 days. And eight rabbits conditioned with VEGF-secreting endothelial cells but the pedicle was divided after a period of 2 days. The percentages of survival were 95.62+/-4.95% for the VEGF-producing scaffold vs. 51.25+/-45.88% for a non-VEGF secreting scaffold when sectioning the pedicle after 5 days. The percentage of survival of flaps in the group grafted with the VEGF-secreting scaffold was 55.62% compared to 2.5% in the group receiving the non-VEGF scaffold when the pedicle was sectioned after 2 days. The CD 31 immunostaining studies showed a dramatic increase in angiogenesis in the flaps conditioned by the VEGF-producing scaffolds. These data revealed that endothelised VEGF-secreting scaffold during flap creation could be a suitable approach in reconstructive surgery.

Congenital infiltrating lipoma of the upper limb in a patient with von Willebrand disease.

Infiltrating lipoma is a rare variety of lipoma, characterized by an infiltration of the adipose tissue of the muscles. Infiltrating lipomas are usually classified in two groups: intermuscular infiltrating lipoma and intramuscular infiltrating lipoma. Most are acquired, and they usually appear in middle-aged individuals. Exceptionally, they are congenital. In such cases they are not related to other diseases. We report an 8-year-old boy with a congenital infiltrating lipoma of the upper limb and von Willebrand disease. Both diseases are linked to an alteration in chromosome 12, but this clinical association seems to be random rather than causal.

Aggressive basal cell carcinoma of the temporal region in a patient with Gorlin-Goltz syndrome.

Gorlin-Goltz syndrome is an autosomal dominant disorder with variable penetration characterized primarily by five major findings: multiple basal cell carcinomas presenting at a young age, pits on the palms and soles, skeletal abnormalities, jaw cysts, and ectopic calcification of the falx cerebri and other structures. When the basal cell carcinomas are located in the head and neck there is a high risk of invasion of deep structures if early and radical treatment is not performed. The authors present a 59-year-old man affected by basal cell carcinoma in the context of Gorlin-Goltz syndrome. Although patients with this syndrome can present aggressive basal cell carcinomas, it is unusual to find them involving the craniofacial bones. In this patient the basal cell carcinoma involved the middle ear, the intrapetrous aspect of the facial nerve, and the dura mater. The reconstruction of a wide three-dimensional defect, in which the brain was exposed, was achieved with local flaps and a free musculocutaneous rectus abdominis flap. Factors affecting reconstruction in the lateral cranial base are discussed.

Relationship between flow and incidence of thrombosis in polytetrafluoroethylene vascular grafts in free microvascular flaps in lambs.

We have done an experimental study in lambs in which we investigated the influence of flow rate on free microvascular flaps using polytetrafluoroethylene (PTFE) vascular grafts. We set up five surgical groups in which blood flow was progressively increased through the PTFE vascular graft. In group I (venous autograft) we observed just one vascular thrombosis which was located at the site of the anastomosis. In group II (PTFE 3 x 10 mm) all the microvascular flaps became necrosed after the third postoperative day. In group III (PTFE 3 x 10 mm) necrosis also developed in all cases, but the anastomoses remained permeable no longer than eight days. In group IV (3 x 15 mm) the permeability in the microvascular free flaps was about 40% after 21 days, and in group V (3 x 10 mm) it reached 70%. To match graft flow rates with flap survival we did a regression analysis of flow rates for groups II, III, and V and the corresponding survival periods for the flaps. There was a clear and highly significant relationship (r = 0.717, p = 0.0001). In conclusion, it is necessary to maintain blood flow through the prosthesis at a rate higher than the thrombogenic threshold. When the flow rate in the vessels through the PTFE grafts was higher, the viability of the flaps was better. The ideal surgical technique should always be based on an arteriovenous fistula distal to the PTFE vascular graft. It is necessary to maintain blood flow through a prosthesis at a rate higher than the thrombogenic threshold.