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BACKGROUND: This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q© version 2.0. RESULTS: A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001). CONCLUSION: Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Mamoplastia , Retalho Perfurante , Artérias Epigástricas/cirurgia , Humanos , Mamoplastia/efeitos adversos , Morbidade , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Reto do Abdome/transplante , Estudos Retrospectivos , Telas CirúrgicasRESUMO
BACKGROUND: Complex regional pain syndrome (CRPS) is a rare but feared complication in hand surgery. Although multimodal therapy concepts are recommended, there is only low evidence on efficacy of such approaches. Furthermore, recommendations regarding therapy duration are lacking. Aim of this study was to validate the efficacy of an International Classification of Functioning, Disability and Health (ICF)-based multidisciplinary rehabilitation concept for treatment of CRPS of the hand and to find correlations between therapy duration and outcome measures. METHODS: Patients with CRPS of the hand after occupational trauma that underwent an ICF-based rehabilitation program between 2010 and 2014 were included in this retrospective study. Besides demographic data, outcomes included pain (VAS), range of motion assessed by fingertip-to-palm-distance (PTPD) and fingernail-to-table-distance (FTTD) as well as strength in grip, 3-point pinch and lateral pinch. All measures were gathered at admission to and discharge from inpatient rehabilitation therapy as well as at follow-up. Statistical analysis included paired t-test, ANOVA and Pearson's correlation analysis. RESULTS: Eighty-nine patients with a mean age of 45 years were included in this study. Duration of rehabilitation therapy was 53 days on average. All outcomes improved significantly during rehabilitation therapy. Pain decreased from 6.4 to 2.2. PTPD of digit 2 to 5 improved from 2.5, 2.8, 2.6, and 2.3 cm to 1.3, 1.4, 1.2, and 1.1 cm, respectively. FTTD of digit 2 to 5 decreased from 1.5, 1.7, 1.5, and 1.6 cm to 0.6, 0.8, 0.7, and 0.7 cm, respectively. Strength ameliorated from 9.5, 3.7, 2.7 kg to 17.9, 5.6, 5.0 kg in grip, lateral pinch, and 3-point pinch, respectively. Improvement in range of motion significantly correlated with therapy duration. 54% of patients participated at follow-up after a mean of 7.5 months. Outcome measures at follow-up remained stable compared to discharge values without significant differences. CONCLUSION: The ICF-based rehabilitation concept is a reliable and durable treatment option for CRPS of the hand. Range of motion improved continuously with therapy duration and thus may serve as an indicator for optimum length of therapy.
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Síndromes da Dor Regional Complexa/reabilitação , Duração da Terapia , Mãos/fisiopatologia , Adulto , Feminino , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. METHODS: Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Pseudoartrose , Humanos , Pseudoartrose/cirurgia , Coxa da Perna , CicatrizaçãoRESUMO
The complex regional pain syndrome (CRPS) still represents an incompletely etiologically understood complication following fractures of the distal radius. The incidence of CRPS following fractures of the distal radius varies between 1 % and 37 %. Pathophysiologically, a complex interaction of inflammatory, somatosensory, motor and autonomic changes is suspected, leading to a persistent maladaptive response and sensitization of the central and peripheral nervous systems with development of the corresponding symptoms. Decisive for the diagnostics are a detailed patient medical history and a clinical hand surgical, neurological and pain-related examination with confirmation of the Budapest criteria. Among the types of apparatus used for diagnostics, 3phase bone scintigraphy and temperature measurement have a certain importance. A multimodal therapy started as early as possible is the most promising approach for successful treatment. As part of a multimodal rehabilitation the main focus of therapy lies on pain relief and functional aspects.
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Síndromes da Dor Regional Complexa/diagnóstico , Síndromes da Dor Regional Complexa/terapia , Manejo da Dor/métodos , Medição da Dor/métodos , Fraturas do Rádio/terapia , Traumatismos do Punho/terapia , Causalidade , Terapia Combinada/métodos , Síndromes da Dor Regional Complexa/epidemiologia , Técnicas de Diagnóstico Neurológico , Humanos , Exame Físico/métodos , Prevalência , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/epidemiologia , Resultado do Tratamento , Traumatismos do Punho/diagnóstico , Traumatismos do Punho/epidemiologiaRESUMO
INTRODUCTION: Topical negative pressure therapy (TNPT) has been established for surgical wound therapy with different indications. Nevertheless, there is only sparse evidence regarding its therapeutic superiority or cost-effectiveness in the German DRG system (G-DRG). This study was designed to analyse the cost-effectiveness of TNPT in the G-DRG system with a focus on daily treatment costs and reimbursement in a general surgery care setting. PATIENTS/MATERIALS AND METHODS: In this retrospective study, we included 176 patients, who underwent TNPT between 2007 and 2011 for general surgery indications. Analysis of the cost-effectiveness involved 149 patients who underwent a simulation to calculate the reimbursement with or without TNPT by a virtual control group in which the TNP procedure was withdrawn for DRG calculation. This was followed by a calculation of costs for wound dressings and TNPT rent and material costs. Comparison between the "true" and the virtual group enabled calculation of the effective remaining surplus per case. RESULTS: Total reimbursement by included TNPT cases was 2,323â,70.04 . Costs for wound dressings and TNPT rent were 102,669.20 . In 41 cases there was a cost-effectiveness (27.5%) with 607,422.03 with TNP treatment, while the control group without TNP generated revenues of 442,015.10 . Costs for wound dressings and TNPT rent were 47,376.68 . In the final account we could generate a cost-effectiveness of 6759 in 5 years per 149 patients by TNPT. In 108 cases there was no cost-effectiveness (72.5%). CONCLUSION: TNPT applied in a representative general surgery setting allows for wound therapy without a major financial burden. Based on the costs for wound dressings and TNPT rent, a primarily medically based decision when to use TNPT can be performed in a balanced product cost accounting. This study does not analyse the superiority of TNPT in wound care, so further prospective studies are required which focus on therapeutic superiority and cost-effectiveness.
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Análise Custo-Benefício/economia , Grupos Diagnósticos Relacionados/economia , Cirurgia Geral/economia , Programas Nacionais de Saúde/economia , Tratamento de Ferimentos com Pressão Negativa/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bandagens/economia , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Mecanismo de Reembolso/economia , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.
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Queimaduras/terapia , Serviços Médicos de Emergência/normas , Algoritmos , Procedimentos Clínicos/normas , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , Garantia da Qualidade dos Cuidados de Saúde/normas , Choque Hemorrágico/terapiaRESUMO
BACKGROUND: Survival rates even in advanced tumour stage have been improved for some tumour entities due to progress in adjuvant and neoadjuvant therapeutic strategies. Nevertheless, painful, exulcerated or bleeding wounds can impair quality of life for palliative patients. Increasing evidence in palliative treatment has raised options for plastic-reconstructive surgery to be applied for treatment of local wounds which can improve quality of life for the remaining lifetime for the palliative patients in our institutions. METHODS: In this review the role of plastic surgery in the palliative treatment concept is highlighted as well as conservative and operative treatment options are discussed. With regard to the limited evidence, an analysis of the currently available literature was performed and data reviewed. These data were added to a case series of patients of our hospital. RESULTS: The analysis of the literature revealed only few data which all indicate an improvement of quality of life due to reconstructive procedures in the palliative situation. There are some studies dealing with plastic surgical operations in advanced tumour diseases. Plastic surgery procedures become relevant after failure of conservative treatment wound care. The most frequent entities are soft tissue sarcomas, squamous cell carcinomas and breast cancer. Safe and simple flaps should be preferred, but free flaps and tendon transfer are optional procedures, and resection of the thoracic wall can be justified in palliative indications with sufficient soft tissue coverage. The indications for major limb amputation should be restricted to selective cases because quality of life is highly reduced. Radiation is possible even after tissue transfer in some cases, and radiation-induced dermatitis with ulcerations can be treated additionally. DISCUSSION: Opportunities and limitations in plastic and reconstructive surgery should be continuously presented in tumour boards, to clarify these important procedures for palliative patients to all members of the tumour board. There is an increasing impact of plastic surgery for improving the quality of life in palliative patients in a multimodal therapeutical concept.
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Comportamento Cooperativo , Comunicação Interdisciplinar , Neoplasias/cirurgia , Cuidados Paliativos/métodos , Procedimentos de Cirurgia Plástica/métodos , Quimiorradioterapia Adjuvante , Terapia Combinada , Humanos , Terapia Neoadjuvante , Qualidade de Vida , Retalhos Cirúrgicos/cirurgiaRESUMO
BACKGROUND: Multimodal treatment options for ultra-low neoplasms of the rectum or anal cancer include chemotherapy, radical abdominoperineal resection and/or radiation. Primary wound closure increases the risk of perineal wound complications that require secondary revision. Perineal wound complications may trigger delay of adjacent tumor therapy and thus have an impact on rate of local recurrence and long-term survival for rectal cancer. Simultaneous primary reconstruction of the perineal defect has been shown to reduce the incidence of perineal wound complications as well as hospital stay which enables timely adjacent therapy and may improve prognosis. PATIENTS AND METHODS: This study was designed to retrospectively evaluate wound complications after abdominoperineal resection by comparing a group with and one without primary perineal reconstruction. Between 2005 and 2011, patients were analysed and divided into cohorts 1 and 2. Cohort 1 included n = 33 patients without primary perineal reconstruction. Cohort 2 included n = 4 patients with primary perineal reconstruction. Risk factors were identified for increased wound complications and delay of adjacent therapy. RESULTS: Subgroup analysis revealed that 18 out of 33 patients of cohort 1 had wound complications. In five cases, prolonged wound healing resulted in a delay of adjacent therapies. Four patients suffered from progression of tumour, 2 out of these 4 patients had a history of delayed adjacent therapy. The main risk factor for prolonged wound healing due to postoperative complications was a history of neoadjuvant treatment resulting in a rate of 64.7â%. Cohort 2 undergoing primary reconstruction presented without wound complications or delay in adjuvant therapy. DISCUSSION: A primary perineal reconstruction after APRE can reduce the rate of perineal wound complications. Furthermore, neoadjuvant treatment was shown to carry a major risk for wound complications. Patients after radio-/chemotherapy should undergo a primary reconstruction to prevent procedure-related perioperative morbidity. Subsequently, delays in adjuvant therapy, and prolonged hospital stay can be inhibited. Moreover, quality of life can be increased. The interdisciplinary approach aims at identifying high-risk patients for perineal wound complications who may benefit from primary reconstruction in order to reduce rate of wound complications with potential impact on rate of local recurrence. All these measures contribute to an optimized surgical standard.
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Abdome/cirurgia , Neoplasias do Ânus/cirurgia , Comportamento Cooperativo , Comunicação Interdisciplinar , Períneo/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/prevenção & controle , Neoplasias Retais/cirurgia , Cicatrização/fisiologia , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Ânus/diagnóstico , Neoplasias do Ânus/patologia , Quimiorradioterapia , Estudos de Coortes , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/diagnóstico , Neoplasias Retais/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: Lymphedema microsurgery is an emerging treatment modality, with dissimilar long-term outcomes. One of the main technical challenges in lymphatic microsurgery is the identification and availability of suitable donor vessels for anastomosis. Tissue engineering using biomaterials has demonstrated promise in addressing vessel quality issues in other fields, but its application in microsurgery is still limited. METHODS: Decellularized cellulose tubes were developed and bioengineered by decellularizing stems of Taraxacum-Ruderalia. The microscopic structure, mechanical properties, and residual DNA content of the cellulose tubes were evaluated. Human and murine skin fibroblasts and dermal lymphatic endothelial cells were isolated and cultured for recellularization studies. Biocompatibility, proliferative capacity, and ex-vivo endothelialization of the cellulose tubes were assessed as potential interposition grafts. Finally, the engineered cellulose tubes were assessed as interposing xenografts for lymphovenous anastomoses (LVA) in an ex-vivo swine limb model. RESULTS: The decellularized cellulose tubes exhibited a suitable microscopic structure, mechanical properties, and low residual DNA content. The tubes showed adequate biocompatibility, supported cell proliferation, and facilitated spontaneous ex-vivo endothelialization of lymphatic endothelial cells. In the swine limb model, LVA using the engineered cellulose tubes was successfully performed. CONCLUSION: This translational study presents the use of decellularized cellulose tubes as an adjunct for micro and supermicrosurgical reconstruction. The developed tubes demonstrated favorable structural, mechanical, and biocompatible properties, making them a potential candidate for improving long-term outcomes in lymphedema surgical treatment. The next translational step would be trialing the obtained tubes in a microsurgical in-vivo model.
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BACKGROUND: Negative-pressure-wound-therapy (NPWT) has become a widely used tool for the coverage and active treatment of complex wounds, including burns. This study aimed to evaluate the effectiveness of NPWT in acute burns of upper and lower extremities and to compare results to the standard-of-care (SOC) at our institution. METHODS: Patients that were admitted to our institution between May 2019 and November 2021 with burns on extremities between 0.5 % and 10 % of the total body surface area (%TBSA) were included and randomized to either NPWT or SOC (polyhexanide gel, fatty gauze, and cotton wool). Treatment was performed until complete wound healing. Patients that required skin grafts, received additional NPWT after grafting independent on the initial group allocation. RESULTS: Sixty-five patients suffering from burn injury between May 2019 and November 2021 were randomized into treatment with NPWT (n = 33) or SOC (n = 32); of these, 33 patients (NPWT) and 28 patients (SOC) had complete data sets and were included in the analysis. Both groups were similar regarding age (39.8 ± 13.7 vs. 44.8 ± 16.2 years,p = 0.192), total burn size (3.1 ± 2.3 vs. 3.4 ± 2.8 %TBSA,p = 0.721) and treated wound size (1.9 ± 1.2 vs. 1.5 ± 0.8 %TBSA,p = 0.138). We found no differences regarding healing time (11.0 ± 4.9 vs. 8.6 ± 3.8,p = 0.074, and significant differences in a number of dressing changes throughout the study (2.4 ± 1.5 vs 4.2 ± 1.9,p < 0.001). The Kaplan-Meier time-to-event analysis exhibited no statistically significant difference in the time to healing or skin grafting (p = 0.085) in NPWT group compared with SOC group. The median time to healing or skin grafting was 10(8-11) days for NPWT and 9(7-11) days for SOC. The hazard ratio for healing or skin graft was HR= 0.64(0.38-1.08). The results of the time-to-event analysis as well as the Kaplan-Meier curve on the PPS confirmed this result. We found no differences in secondary surgical operations 15.2 vs 21.4 % pain or functional outcomes. CONCLUSIONS: In this study, we found no significant difference between the two groups in terms of time to detect wound healing. We also found no difference regarding further operations for wound closure, pain and/or scarring. However, dressing changes were significantly less frequent for patients that were treated with NPWT, which may be a psychological and logistical advantage.
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Queimaduras , Tratamento de Ferimentos com Pressão Negativa , Transplante de Pele , Cicatrização , Humanos , Queimaduras/terapia , Tratamento de Ferimentos com Pressão Negativa/métodos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Estudos Prospectivos , Transplante de Pele/métodos , Bandagens , Resultado do TratamentoRESUMO
BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancy (PSM). Usually, treatment is performed as an extensive one-step approach. We investigated the feasibility of delayed HIPEC, if the one-step procedure was interrupted precociously. METHODS: 42 patients with PSM who underwent CRS and delayed HIPEC from 2006-2008 were studied. HIPEC was performed 5 days after treatment with mitomycin, cisplatin and hyperthermia. Perioperative complications and toxicity were analyzed. RESULTS: Delayed HIPEC was successfully completed in 40 of the 42 patients. In 2 cases, HIPEC was omitted because of complications during chemotherapy (anastomotic leakage and retroperitoneal edema). Minor and major surgical complications occurred in 18 and 9 of the 40 patients treated with HIPEC (45 vs. 22.5%), respectively. Toxicity grade II-IV (WHO criteria) was observed in 4 of them (10%). Median stay in the intensive care unit was 9 days (range 2-31) while the mean hospitalization time was 24 days (range 14-59). In this series, there was no mortality. CONCLUSION: Postponement of HIPEC after CRS (two-step approach) is feasible. Analysis of morbidity and mortality showed no significant difference to the one-step approach reported in the literature and no disadvantages for the patient. The two-step approach is an alternative option for patients who had to discontinue the one-step approach due to unpredictable intraoperative complications.
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Quimioterapia do Câncer por Perfusão Regional/métodos , Neoplasias Peritoneais/tratamento farmacológico , Neoplasias Peritoneais/cirurgia , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Cisplatino/administração & dosagem , Terapia Combinada , Feminino , Humanos , Hipertermia Induzida/métodos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Mitomicina/administração & dosagem , Neoplasias Peritoneais/terapia , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: After ilioinguinal radical lymph node dissection (RLND), the therapy for lymph fistulas constitutes a challenge. Risk factors for the genesis of lymph fistulas have not been sufficiently evaluated. We investigated possible factors that could influence the development of lymph fistulas in patients suffering from malignant melanoma after iloinguinal RLND. PATIENT AND METHODS: The analysis was related to patients with intransit and lymphonodal metastasised malignant melanoma of the lower limb, who underwent RLND and isolated limb perfusion (ILP). Prospective data acquisition from patients undergoing ilioinguinal RLND and ILP in a one-step approach was performed. The association of lymph fistulas to risk factors was calculated using chi-squared, linear-by-linear test and ROC curves. As possible risk factors we investigated the presence of prior surgery and diabetes mellitus type II in the medical history, chemotherapeutics, patient age and the body mass index (BMI). RESULTS: Postoperative lymph fistula occurred in 11 of 108 patients (10.2%). A significant association to lymph fistulas was found in BMI (30.2± 7.0 kg/m (2), p<0.02). Other parameters, such as prior surgery (82% vs. 71%), diabetes mellitus type II (9% vs. 11.7%), chemotherapeutics and patient age (mean 67.8 vs. 62.4 years) showed no influence. CONCLUSION: Our results indicate that the incidence of lymph fistulas after RLND and ILP of malignant melanoma of the lower limb was associated with an increased BMI. Thus, for the prevention of lymph fistulae, an initially alternative wound-closure dressing like vacuum assisted closure (V.A.C.) dressing could be of clinical relevance for obese patients.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia do Câncer por Perfusão Regional/efeitos adversos , Fístula/etiologia , Perna (Membro) , Excisão de Linfonodo/efeitos adversos , Doenças Linfáticas/etiologia , Melanoma/tratamento farmacológico , Neoplasias Cutâneas/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Índice de Massa Corporal , Quimioterapia Adjuvante , Feminino , Humanos , Canal Inguinal/cirurgia , Doenças Linfáticas/patologia , Doenças Linfáticas/prevenção & controle , Masculino , Melanoma/patologia , Melanoma/prevenção & controle , Melfalan/administração & dosagem , Melfalan/efeitos adversos , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa , Estadiamento de Neoplasias , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Neoplasias Cutâneas/patologia , Carga Tumoral , Fator de Necrose Tumoral alfa/administração & dosagemRESUMO
BACKGROUND: There is some evidence that sentinel lymph node (SLN) biopsy guided by dye injection and/or radioisotopes can improve staging of inguinal lymph nodes (LNs) in anal cancer. This study was performed to investigate the feasibility of fluorescence detection of SLN and lymphatic mapping in anal cancer. METHODS: Twelve patients with anal cancer without evidence for inguinal LN involvement were included in the study. Intraoperatively, all patients received a peritumorous injection of 25 mg indocyanine green (ICG) for fluorescence imaging of the SLN with a near-infrared camera. For comparison, conventional SLN detection by technetium-(99)m-sulfur radiocolloid injection in combination with blue dye was also performed in all patients. The results of both techniques and the effect on the therapeutic regimen were analyzed. RESULTS: Overall, ICG fluorescence imaging identified at least one SLN in 10 of 12 patients (detection rate, 83%). With the combination of radionuclide and blue dye, SLN were detected in 9 of 12 patients (detection rate, 75%). Metastatic involvement of the SLN was found in 2 of 10 patients versus 2 of 9 patients. Patients with metastatic involvement of the SLN received extended radiation field with inguinal boost. CONCLUSIONS: ICG fluorescence imaging allows intraoperative lymphatic mapping and transcutaneous SLN detection for selective biopsy of inguinal SLN in anal cancer. This technique should be further evaluated in comparative studies with larger patient numbers.
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Neoplasias do Ânus/patologia , Verde de Indocianina , Linfonodos/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Ânus/diagnóstico por imagem , Neoplasias do Ânus/cirurgia , Corantes , Estudos de Viabilidade , Feminino , Humanos , Linfonodos/diagnóstico por imagem , Linfonodos/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Prognóstico , Cintilografia , Compostos Radiofarmacêuticos , Biópsia de Linfonodo Sentinela , Coloide de Enxofre Marcado com Tecnécio Tc 99m , Adulto JovemRESUMO
The axillary nodal status is accepted as the most powerful prognostic tool available for early stage breast cancer. In the past radical removal of level I and level II lymph nodes at axillary node dissection (ALND) has been the most accurate method to assess nodal status, and it is the universal standard; however, it is associated with several adverse long-term sequelae. New diagnostic technologies have helped to individualize diagnostic evaluation and therapy of breast cancer thus improving efficacy and minimizing morbidity of treatment. Lymphatic mapping with sentinel lymph node biopsy has emerged as an effective and safe alternative to the ALND for detecting axillary metastases. Many issues such as indications or technique of performing sentinel node biopsy have been evaluated. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Sentinel node biopsy is now minimally invasive, highly accurate method of axillary staging, and has replaced routine axillary lymph node dissection as the new standard of care in breast cancer. New technologies for axillary nodal staging include innovative imaging techniques such as single photon emission computerized tomography (SPECT) and modern histopathologic evaluation of sentinel nodes using molecular biologic approaches.
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Neoplasias da Mama/patologia , Feminino , Previsões , Humanos , Metástase Linfática , Estadiamento de Neoplasias , Biópsia de Linfonodo Sentinela/tendênciasRESUMO
Secondary lymphedema (SL)is a frequent and devastating complication of modern oncological therapy and filarial infections. A lack of a reliable preclinical model to investigate the underlying mechanism of clinical stage progression has limited the development of new therapeutic strategies. Current first line treatment has shown to be merely symptomatic and relies on lifetime use of compression garments and decongestive physiotherapy. In this study, we present the development of a secondary lymphedema model in 35 rats using pre- and intraoperative fluorescence-guided mapping of the lymphatics and microsurgical induction. In contrast to the few models reported so far, we decided to avoid the use of radiation for lymphedema induction. It turned out, that the model is nearly free of complications and capable of generating a statistically significant limb volume increase by water displacement measurements, sustained for at least 48 days. A translational, accurate lymphatic dysfunction was visualized by a novel VIS-NIR X-ray ICG-Clearance-Capacity imaging technology. For the first-time SL stage progression was validated by characteristic histological alterations, such as subdermal mast cell infiltration, adipose tissue deposition, and fibrosis by increased skin collagen content. Immunofluorescence confocal microscopy analysis suggested that stage progression is related to the presence of a characteristic α SMA+/HSP-47+/vimentin+ fibroblast subpopulation phenotype. These findings demonstrate that the in-vivo model is a reliable and clinically relevant SL model for the development of further secondary lymphedema therapeutic strategies and the analysis of the veiled molecular mechanisms of lymphatic dysfunction.
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Corantes Fluorescentes/química , Linfedema/patologia , Microcirurgia/efeitos adversos , Actinas/metabolismo , Animais , Colágeno/metabolismo , Modelos Animais de Doenças , Progressão da Doença , Feminino , Fibroblastos/citologia , Fibroblastos/metabolismo , Verde de Indocianina/química , Linfedema/etiologia , Microscopia de Fluorescência , Ratos , Ratos Endogâmicos Lew , Pele/patologia , Vimentina/metabolismoRESUMO
BACKGROUND: Sentinel lymph node (SLN) biopsy with radioisotope and blue dye has been used successfully for axillary staging in breast cancer. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping and SLN biopsy. METHODS: Thirty women with breast cancer had a periareolar injection of ICG for fluorescence detection of SLN using a near-infrared camera. Twenty also received (99m)Tc-labelled sulphur radiocolloid for SLN scintigraphy. All patients underwent axillary lymph node dissection. Detection rate and sensitivity of both methods were the study endpoints. RESULTS: Visualization of lymphatic vessels by fluorescence detection depended on the dose of ICG. ICG imaging identified SLNs in 29 of 30 women (detection rate 97 per cent). Nineteen of 21 patients had metastatic SLN involvement (sensitivity 90 per cent) with false-negative results in two. Among the 20 patients who had both methods, ICG fluorescence and radiocolloid identified SLNs in 20 and 17 patients respectively. Metastatic lymph nodes were diagnosed in 12 and ten of 13 patients (sensitivity 92 and 77 per cent). False-negative rates were 8 and 23 per cent respectively. CONCLUSION: ICG fluorescence allowed transcutaneous imaging of lymphatic vessels and SLN detection, thus combining the advantages of radioisotope and blue dye methods.
Assuntos
Neoplasias da Mama/patologia , Mama/patologia , Corantes , Verde de Indocianina , Biópsia de Linfonodo Sentinela/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Lobular/patologia , Carcinoma Lobular/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Excisão de Linfonodo/métodos , Metástase Linfática , Mastectomia/métodos , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND AIMS: A right hemicolectomy is a technically demanding procedure and the quality of the operation influences the short- and long-term outcomes. An increasing number of certified centers employ surgeons who are specialized in this procedure. Residency training is obligatory, but trainee surgeons often cannot perform technically demanding procedures because of economical and certification requirements imposed on the center. This study was performed to evaluate the suitability of right hemicolectomy as a training procedure. MATERIAL AND METHODS: Between 2009 and 2013, 133 patients received a right hemicolectomy during cancer treatment. Patient data were analyzed in two cohorts: cohort 1 contained 90 patients who were operated by a resident under supervision, and cohort 2 included 43 patients who were operated by a specialized senior surgeon. Outcome and safety were evaluated by mortality rate, anastomotic leakage, complication rate, and operation time. The resection status and the number of resected lymph nodes were surrogate parameters for oncological quality. Gender, age, American Society of Anesthesiologists classification, body mass index, and general risk factors were compared in both cohorts. RESULTS: There was no significant difference in the rate of anastomotic leakage between the two groups (p = 0.799). Oncological criteria were met in both cohorts and the oncological quality was similar between groups. Furthermore, there were no significant differences in risk factors, operating time, postoperative complications, and mortality between the groups. CONCLUSION: Oncological open right hemicolectomy is a safe and suitable training procedure for residency training under standardized conditions.
Assuntos
Adenocarcinoma/cirurgia , Colectomia/educação , Neoplasias do Colo/cirurgia , Internato e Residência , Complicações Pós-Operatórias/epidemiologia , Adenocarcinoma/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Neoplasias do Colo/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos RetrospectivosRESUMO
Deficiency of either the mitogen-activated protein kinase p38 or the nuclear receptor PPARgamma results in disrupted vasculogenesis and abnormal development of the murine placenta. In addition, PPARgamma regulates differentiation of human trophoblasts. Here we tested the hypothesis that p38 plays an important role in the regulation of PPARgamma in primary human trophoblasts. We initially confirmed that cultured trophoblasts derived from normal term human placentas express p38 as well as its functional phosphorylated form. Whereas PPARgamma did not alter p38 expression, p38 inhibitors diminished the transcriptional activity of PPARgamma in primary trophoblasts. In addition, inhibition of p38 resulted in marked attenuation of PPARgamma-stimulated hCG production by cultured trophoblast. Our data support an effect of p38 on PPARgamma protein stability because p38 inhibition led to reduced expression of PPARgamma protein without a significant effect on PPARgamma mRNA, and this reduction was blocked by the protease inhibitor MG-132. Together, these data indicate that p38 regulates PPARgamma expression and activity in term human trophoblasts. Cross talk between p38 and PPARgamma signaling may play a role in modulating differentiation and function of the human placenta.
Assuntos
PPAR gama/metabolismo , Trofoblastos/metabolismo , Proteínas Quinases p38 Ativadas por Mitógeno/metabolismo , Células Cultivadas , Gonadotropina Coriônica/farmacologia , Inibidores de Cisteína Proteinase/farmacologia , Feminino , Humanos , Leupeptinas/farmacologia , PPAR gama/genética , Transcrição Gênica , Trofoblastos/efeitos dos fármacos , Proteínas Quinases p38 Ativadas por Mitógeno/antagonistas & inibidores , Proteínas Quinases p38 Ativadas por Mitógeno/genéticaRESUMO
BACKGROUND: Nerve tubes are used for bridging of short nerve gaps and for coating of primary end-to-end nerve sutures. This article provides an overview of available implants and their application. Also it presents a retrospective planning study aiming to determine the static 2-point discrimination after primary peripheral nerve repair with and without the use of a nerve tube. The results have been used to determine the sample size of a prospective randomised trial. PATIENTS AND METHODS: 54 peripheral nerve injuries of 41 patients were treated by primary end-to-end nerve sutures with or without the additional use of a nerve tube (n=28 and n=26, respectively). 38 digital nerves and 16 median and ulnar nerves were affected. Nerve tubes were used for the repair of 15 digital nerves and 13 median and ulnar nerves. Clinical follow-up was performed 46 months after surgery (patients without nerve tubes) and 18 months after surgery (patients with nerve tubes), respectively. Static 2-point discrimination (2PD) was measured by double-tip compasses (weight: 18 g) and patients were examined for clinical signs of neuroma. Further examinations included grip strength as a percentage value compared with the uninjured hand and, in case of finger injuries, the range of motion in the proximal and distal interphalangeal joints, Strickland score, DASH score and implant-associated complications. RESULTS: In patients with primary end-to-end sutures for finger injuries, there were no statistically significant differences between treatment with and without nerve tubes regarding 2PD, grip strength, DASH- or Strickland score. However, 2PD values of patients with nerve tubes had an increased spread. Average 2PD in digital nerves was 4.5 mm (3-15; SD: 3.9) without nerve tubes and 5.5 mm (3-15; SD: 5) with nerve tubes. Average 2PD after lesions of the median and ulnar nerves was 10 mm (3-15; SD: 5.9 and 5.4, respectively) in both groups. CONCLUSION: The additional use of a nerve tube showed no superiority in this planning study. The expected average 2PD is 5 mm after digital nerve injuries and 10 mm after lesions of the median or ulnar nerves.
Assuntos
Traumatismos dos Nervos Periféricos/cirurgia , Nervos Periféricos/transplante , Mãos , Humanos , Nervo Mediano , Estudos Prospectivos , Estudos RetrospectivosRESUMO
INTRODUCTION: Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis. PATIENTS AND METHODS: In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire. RESULTS: No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14. DISCUSSION: The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.