Influence of Body Mass Index on Venous Thrombotic Complications of Liver Transplants.

OBJECTIVE: To analyze venous thrombotic complications in transplanted patients as a function of their body mass index (BMI). MATERIALS AND METHODS: This single-center, observational retrospective study of individuals undergoing liver transplantation between January 2008 and December 2014 analyzed the frequency of pretransplant portal thrombosis, post-transplant venous complications (early and late portal thrombosis), deep vein thrombosis, pulmonary thromboembolism and the survival outcomes as a function of World Health Organization BMI class. RESULTS: Liver transplantation was performed in 208 patients during the study period. No statistically significant differences in study variables were found as a function of BMI in bivariate analyses (P < .05), and Kaplan-Meier survival analysis results were also nonsignificant. CONCLUSION: No differences in the rate of venous thrombotic complications or survival were found as a function of the BMI class of these liver transplant recipients. These findings are in line with previous reports that complication rates are not higher in obese patients and support the proposal that obesity should not be considered a contraindication for liver transplantation based on the risk of venous complications.

Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients.

INTRODUCTION: The deep inferior epigastric perforator (DIEP) flap is currently viewed as the gold standard in autologous breast reconstruction. We studied three-dimensional computed tomography angiography (CTA) in 145 patients undergoing free abdominal flap breast reconstruction to try to correlate deep inferior epigastric artery (DIEA) branching pattern with the type of flap performed and patient outcome. Today, reconstructive breast surgeons have become more experienced in raising DIEP flaps and operative times are becoming more acceptable. However, there remains significant interest in finding ways to aid this challenging dissection. METHODS: We retrospectively evaluated consecutive patients between January 2007 and August 2008. CTAs were analysed using the Moon and Taylor (1988) classification of the DIEA branching pattern. Data gathered included pre-operative morbidity, type of abdominal wall free flap performed, length of operation, length of stay and complications. RESULTS: Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%). CONCLUSIONS: In this large CTA series, we found a type 1 (single artery) DIEA pattern most frequently, in contrast to the predominance of the type 2 bifurcating pattern observed previously. The higher proportion of DIEP flaps performed in the type 2 pattern patients is consistent with the documented shorter intramuscular course in this group. We have found CTA useful for faster selection of the best hemiabdomen for dissection and flap loss rates in our unit have reduced from 1.5% to 0.67%.

Successful reconstruction of a gunshot segmental defect of the radius with a free vascularised fibular osteocutaneous flap.

The use of the vascularised fibular flap for bony reconstruction was first described for the mandible. It has since been used for upper limb bony defects of various aetiologies (congenital, infective, traumatic and neoplastic). Specifically gunshot segmental defects of the upper limb have been reconstructed with vascularised fibular in the humerus and radius, the common indication in these previous cases was delayed reconstruction. We describe a challenging case of a 40-year-old male with a 6.5 cm segmental radial defect caused by gunshot wounds, which was primarily reconstructed using this microvascular technique. The advantages of the vascularised fibular flap and its suitability for this type of reconstructive surgery are discussed.

Resource implications of bilateral autologous breast reconstruction--a single centre's seven year experience.

INTRODUCTION AND AIMS: Since the recent introduction of ''Payment by Results'' as part of NHS financial reforms, it has been noted that there is an imbalance between allocated Healthcare Resource Group tariffs and actual resource use for certain procedures. This study was undertaken to assess the impression that bilateral breast reconstruction using autologous flaps is under-funded. MATERIAL AND METHODS: Patients who underwent bilateral flap breast reconstruction following mastectomy between 2000 and 2006 at Addenbrooke's University Hospital were identified. Resource cost analysis for each patient was based on the following parameters: number of operating consultants, theatre running costs, and length of hospital stay. The estimated hospital costs were then compared to the national tariff for the Healthcare Resource Group ''Complex Breast Reconstruction using Flaps''. KEY RESULTS: Over the 7-year period 24 patients underwent bilateral flap breast reconstruction (7 paired latissimus dorsi and 17 paired abdominal flaps). The mean operative time was 9.4h (£4.5/min), the mean hospital stay was 10 days (£150/day) and ten patients required 2 consultants (£34/h) operating. The average total cost equated to £5 492. CONCLUSION: The allocated tariff of £4 053 is insufficient, even before the inclusion of hidden costs. Bilateral free flap breast reconstructions are grossly under-funded at present. With increasing financial pressures on NHS Trusts there may be a drive towards simpler operations, which receive proportionally greater remuneration.

Malignant peripheral nerve sheath tumour of the cervical vagus nerve in a neurofibromatosis type 1 patient.

One serious complication of neurofibromatosis type 1 (NF1) is the development of malignant peripheral nerve sheath tumours (MPNSTs). These malignancies often develop within pre-existing plexiform neurofibromas and their development is now thought to be associated with both tumour suppressor gene mutations and dysregulated growth factor signalling. Recent work demonstrates that the lifetime risk of malignant transformation is significantly greater than previously thought. Ionising radiation, a long-standing disease, particularly the presence of a large number of plexiform neurofibromas from an early age, are suggested risk factors. We present an NF1 patient who developed an MPNST of the cervical vagus nerve which was successfully treated with surgery. Close monitoring of patients with NF and a high level of suspicion towards rapidly enlarging and painful swellings is merited as these features may signify malignant transformation. Whether a positive history of MPNST in other affected family members predisposes the individual to a higher risk of malignant transformation is unclear.

Use of septal cartilage homografts in rhinoplasty.

We present a case report demonstrating the long-term survival of homologous cartilage grafts in the nose. There are no histological changes in homografts compared with autologous cartilage. The importance of an adequate technique of preservation as well as the possibility of viral transmission, are discussed. In our opinion, septal cartilage is the best reason for nasal repair, before auricular or costal cartilages. We consider the use of homologous septal cartilage a useful technique basically indicated when a cartilage graft is considered necessary, but there is insufficient autologous cartilage available.