The Cleft Aesthetic Rating Scale for 18-Year-Old Unilateral Cleft Lip and Palate Patients: A Tool for Nasolabial Aesthetics Assessment.

OBJECTIVE: To develop a reliable and easy-to-use method to assess the nasolabial appearance of 18-year-old patients with unilateral cleft lip and palate (CLP). DESIGN: Retrospective analysis of nasolabial aesthetics using a 5-point ordinal scale and newly developed photographic reference scale: the Cleft Aesthetic Rating Scale (CARS). Three cleft surgeons and 20 medical students scored the nasolabial appearance on standardized frontal photographs. SETTING: VU University Medical Center, Amsterdam. PATIENTS: Inclusion criteria: 18-year-old patients, unilateral cleft lip and palate, available photograph of the frontal view. EXCLUSION CRITERIA: history of facial trauma, congenital syndromes affecting facial appearance. Eighty photographs were available for scoring. MAIN OUTCOME MEASURES: The interobserver and intraobserver reliability of the CARS for 18-year-old patients when used by cleft surgeons and medical students. RESULTS: The interobserver reliability for the nose and lip together was 0.64 for the cleft surgeons and 0.61 for the medical students. There was an intraobserver reliability of 0.75 and 0.78 from the surgeons and students, respectively, on the nose and lip together. No significant difference was found between the cleft surgeons and medical students in the way they scored the nose ( P = 0.22) and lip ( P = 0.72). CONCLUSIONS: The Cleft Aesthetic Rating Scale for 18-year-old patients has a substantial overall estimated reliability when the average score is taken from three or more cleft surgeons or medical students assessing the nasolabial aesthetics of CLP patients.

Photographic assessment of burn size and depth: reliability and validity.

OBJECTIVE: The aim of this study was to examine the reliability and validity of using photographs of burns to assess both burn size and depth. METHOD: Fifty randomly selected photographs taken on day 0-1 post burn were assessed by seven burn experts and eight referring physicians. Inter-rater reliability in both groups (experts vs. referrers) was calculated. The validity of burn size assessment was calculated using live assessment as the gold standard, and of burn depth using clinical assessment in combination with laser Doppler imaging as the gold standard. The validity of the photographically-assessed indication for surgery was calculated using laser Doppler imaging and actual treatment as the gold standard. Finally, agreement in referral indication was calculated. RESULTS: Using photographs, burn size could be assessed reliably and validly by experts (ICCs of 0.83 and 0.87), but not by referrers (ICCs of 0.68 and 0.78). Photographic assessment of burn depth was neither reliable nor valid, with ICCs respectively of 0.38 and 0.28 for experts and 0.24 and 0.13 for referrers. The indication for surgery could also not be assessed validly. Agreement between assessors regarding referral indication was low. CONCLUSION: Burn size, but not burn depth, can be assessed reliably and validly by experts using photographs of the burn wound. We recommend exploring other forms of telemedicine, like live interactive video, to investigate whether this leads to an improved burn depth assessment where clinical assessment is not possible. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.

Single-stage breast reconstruction using Strattice™: A retrospective study.

INTRODUCTION: Strattice™, a porcine acellular dermal matrix, has emerged as a product to augment implant-based breast reconstruction. It aims to resolve problems related to poor tissue coverage of the implant. Presently, evidence justifying the use of Strattice in breast reconstruction is lacking. The objective of this study is to assess the clinical outcomes of a patient cohort that underwent single-stage implant-based breast reconstruction with the additional use of Strattice. METHODS: We conducted a retrospective chart review of patients who underwent single-stage breast reconstruction with the use of Strattice. All cases of breast reconstruction after oncologic or prophylactic mastectomy between 2010 and 2014 in one of eight different centres in the Netherlands were included. Patient demographics, treatment characteristics and clinical outcome data were collected. The outcomes were presented using descriptive statistics, and the associations were evaluated using Fisher's exact test. RESULTS: Eighty-eight patients who underwent either unilateral (60 patients) or bilateral (25 patients) (n = 110 breasts) single-stage breast reconstruction with the use of Strattice were identified. The indication for mastectomy was therapeutic in 69.1% (76) of cases and prophylactic in 30.9% (34) of cases. The reported minor complications included seroma (20.9%), skin necrosis (20.0%), wound dehiscence (11.8%), erythema/inflammation (14.5%) and infection (11.8%). In 22 breasts (22.7%), reoperation was necessary, with explantation of the implant in 11 breasts (11.8%). CONCLUSIONS: In this cohort, the total complication rate was very high (78%). Although most complications were minor, reoperation was performed in 22.7%, with explantation of the implant in 11.8% of breasts. We suggest that patient selection, experience of the surgeon and handling of early complications are factors playing a crucial role in the success of the operation. The use of a Strattice sheet in single-stage implant-based breast reconstruction may be a promising technique, but more evidence from prospective, randomized studies is necessary to justify its use. LEVEL OF EVIDENCE: IV.

An economic evaluation of the use of TNP on full-thickness wounds.

OBJECTIVE: Topical negative pressure (TNP) (vacuum therapy) is frequently used in the management of acute, traumatic, infected and chronic full-thickness wounds. This prospective clinical randomised trial compared the costs of TNP with conventional therapy (moist gauze) in the management of full-thickness wounds that required surgical closure. METHOD: The direct medical costs of the total number of resources needed to achieve a healthy, granulating wound bed that was 'ready for surgical therapy' were calculated. RESULTS: Fifty-four patients admitted to a department of plastic and reconstructive surgery were recruited into the trial. Cost analysis showed significantly higher mean material expenses for wounds treated with TNP (414euros+/-229euros [SD]) compared with conventional therapy (15euros+/-11euros; p<0.0001 ), but significantly lower mean nursing expenses (33euros+/-31 euros and 83euros+/-58euros forTNP and conventional therapy respectively; p<0.0001). Hospitalisation costs were lower in theTNP group (1788euros+/-1060euros) than in the conventional treatment group (2467euros+/-1336euros; p<0.043) due to an on average shorter duration until they were'ready for surgical therapy'. There was no significant difference in total costs per patient between the two therapies (2235euros+/-1301euros for TNP versus 2565euros+/-1384euros for conventional therapy). CONCLUSION: TNP had higher material costs. However, these were compensated by the lower number of time-consuming dressing changes and the shorter duration until they were 'ready for surgical therapy', resulting in the therapy being equally as expensive as conventional moist gauze. DECLARATION OF INTEREST: This work was partly supported by the Plastic and Reconstructive Surgery Esser Foundation, and KCI Medical, Houten,The Netherlands. The authors have no conflicts of interest.

Exposure of circumflex branches in the tilted, beating porcine heart: echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass.

OBJECTIVE: In off-pump coronary surgery, exposure of posterior vessels via sternotomy causes deterioration of cardiac function. Changes in ventricular geometry, valve competence, and hemodynamics after retraction of the beating heart were studied. Subsequently, the modifying effect of right or left heart bypass was investigated. METHODS: In six 80-kg pigs, an ultrasound probe was attached to the backside of the left ventricle and the heart was fully retracted with a suction tissue stabilizer. Five pigs underwent additional pump support. RESULTS: During retraction, the right ventricle was squeezed between the pericardium and interventricular septum, thereby decreasing its diastolic cross-sectional area by 62% +/- 6% (P <.001) while, concomitantly, right ventricular end-diastolic pressure increased to 165% +/- 19% (P =.004) of basal values. Stroke volume and mean arterial pressure decreased by 29% +/- 6% and 23% +/- 8% (P =.007 and P =.02, respectively). Left ventricular shape became somewhat elliptic without changes in preload pressure, and its diastolic cross-sectional area decreased by 20% +/- 3% (P =.001). All valves were competent. Right heart bypass restored left ventricular cross-sectional area, stroke volume, and mean arterial pressure. In contrast, left heart bypass increased blood pressure only marginally. CONCLUSIONS: Ninety-degree anterior displacement of the beating porcine heart caused primarily right ventricular dysfunction as a result of mechanical interference with diastolic expansion without concurring valvular incompetence. Right heart bypass normalized stroke volume and mean arterial pressure by increasing left ventricular preload; in contrast, left heart bypass failed to restore systemic circulation.

A novel one-shot anastomotic stapler prototype for coronary bypass grafting on the beating heart: feasibility in the pig.

OBJECTIVE: The nonpenetrating, arcuate-legged clip has proved its ability to provide a high-quality microvascular anastomosis. This study assessed the feasibility of constructing a coronary end-to-side anastomosis on the beating heart with a novel mechanical, sutureless anastomotic device that applies 12 circumferential clips simultaneously. METHODS: In 14 consecutive pigs (70-90 kg), the left internal thoracic artery (diameter, 3 mm) was grafted to the left anterior descending coronary artery (diameter, 3 mm) by means of a one-shot anastomotic stapler prototype. Endothelial denudation, medial necrosis, and intimal hyperplasia were analyzed quantitatively and compared with those seen in conventionally sutured anastomoses (n = 4). RESULTS: In 8 of 14 anastomoses, the one-shot anastomotic stapler successfully applied all 12 clips circumferentially across the everted arteriotomy edges. In the remaining, either 1 (n = 4) or 3 and 4 adjoining malaligned clips had to be replaced manually with a single-clip applicator. Coronary occlusion was limited to approximately 3 minutes. At follow-up, all anastomoses were patent angiographically. At 2 days, in 2 of 7 cases, a local coronary dissection was observed, and there was a considerable loss of endothelial cells and medial damage. At 28 days, however, minimal intimal hyperplasia was seen at the anastomotic lining, although more pronounced when compared with conventionally sutured anastomoses. CONCLUSIONS: The one-shot anastomotic stapler prototype enabled short-occlusive (3 minutes), sutureless end-to-side grafting on the beating porcine heart. In spite of early endothelial and medial damage and 2 local dissections, all anastomoses remained patent with minimal intimal hyperplasia at 4 weeks.

Temporary luminal arteriotomy seal: III. Postmortem arteriosclerotic human coronary artery.

BACKGROUND: Recently, we described a temporary luminal arteriotomy seal that provided a bloodless arteriotomy without obstructing recipient artery blood flow during bypass grafting in nonarteriosclerotic porcine arteries. This postmortem study assessed the sealing properties in irregular arteriosclerotic human coronary arteries. METHODS: Three hearts were obtained from donated corpses within 24 hours of death. The coronary arteries were pressure-perfused at 60 mm Hg with citrated porcine blood. At 15 anastomosis sites in four different coronary arteries, an end-to-side anastomosis was created using a 200-microm-thick polyurethane seal. Adequacy of sealing was determined at perfusion pressures of 60, 40, and 20 mm Hg. RESULTS: After insertion, the arteriotomy was sealed instantaneously in 10 of 15 anastomoses. After repositioning, complete sealing with a bloodless operative field was obtained in all cases. Low intracoronary transmural pressure did not impede sealing. In 8 of 15 anastomoses, minor leakage without obscuring the arteriotomy edges was observed during anastomotic suturing. Histologic examination revealed no intimal tear or dissection caused by the anastomotic procedure. CONCLUSIONS: In postmortem-obtained arteriosclerotic human coronary arteries, the temporary luminal arteriotomy seal provided optimal visualization of the coronary anastomosis site in combination with persistent distal perfusion.

Temporary luminal arteriotomy seal: II. Coronary artery bypass grafting on the beating heart.

BACKGROUND: This study assessed the feasibility of applying a temporary luminal arteriotomy seal during end-to-side coronary artery bypass grafting on the beating heart. METHODS: In 18 consecutive pigs, the left internal mammary artery was grafted to the left anterior descending coronary artery, and the arteriotomy was temporarily sealed luminally by a 200-microm-thick polyurethane seal. Endothelial denudation, medial necrosis, and intimal hyperplasia were measured quantitatively and compared with conventionally sutured anastomoses (n=4 pigs). RESULTS: Insertion and retrieval of the seal required 28+/-12 and 11+/-6 seconds, respectively. Including the arteriotomy, coronary artery occlusion was limited to about 80 seconds. The seal provided a bloodless arteriotomy in all anastomoses with unimpeded coronary artery blood flow. Endothelial denudation was limited to two thirds of the circumference of the coronary artery. No medial necrosis was found. Intimal hyperplasia at the suture line was small, although more pronounced when compared with conventionally sutured anastomoses. CONCLUSIONS: In off-pump, beating-heart coronary artery bypass grafting, the temporary luminal arteriotomy seal provided a bloodless arteriotomy with negligible obstruction to coronary artery blood flow, and with a minimum of arterial wall damage. It is conceivable that this seal may expand the indications for coronary surgical procedures without cardiopulmonary bypass.

A review of topical negative pressure therapy in wound healing: sufficient evidence?

BACKGROUND: Topical negative pressure (TNP) therapy has become a useful adjunct in the management of various types of wounds. However, the TNP system still has characteristics of a "black box" with uncertain efficacy for many users. We extensively examined the effectiveness of TNP therapy reported in research studies. DATA SOURCES: A database search was undertaken, and over 400 peer-reviewed articles related to the use of TNP therapy (animal, human, and in vitro studies) were identified. CONCLUSIONS: Almost all encountered studies were related to the use of the commercial VAC device (KCI Medical, United States). Mechanisms of action that can be attributed to TNP therapy are an increase in blood flow, the promotion of angiogenesis, a reduction of wound surface area in certain types of wounds, a modulation of the inhibitory contents in wound fluid, and the induction of cell proliferation. Edema reduction and bacterial clearance, mechanisms that were attributed to TNP therapy, were not proven in basic research.

Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospective randomised trial.

BACKGROUND: Vacuum-assisted closure wound therapy (vacuum therapy) has been used in our department since 1997 as a tool to bridge the period between debridement and definite surgical closure in full-thickness wounds. We performed a prospective randomised clinical trial to compare the efficacy of vacuum therapy to conventional moist gauze therapy in this stage of wound treatment. METHODS: Treatment efficacy was assessed by semi-quantitative scoring of the wound conditions (signs of rubor, calor, exudate and fibrinous slough) and by wound surface area measurements. Tissue biopsies were performed to quantify the bacterial load. Besides this, the duration until 'ready for surgical therapy' and complications encountered during therapy and postoperatively were recorded. RESULTS: Fifty-four patients were included (vacuum n=29, conventional n=25). With vacuum therapy, healthier wound conditions were observed. Furthermore, a tendency towards a shorter duration of therapy was found, which was most prominent in late-treated wounds. In addition, the wound surface area reduced significantly faster with vacuum therapy. Surprisingly, these results were obtained without a decrease in the number of bacteria colonising the wound. Complications were minor, except for one case of septicaemia and one case of increased tissue necrosis, which compelled us to stop vacuum therapy. For the treatment of full-thickness wounds, vacuum therapy has proven to be a valid wound healing modality.

Jejunal intussusception of a gastric lipoma: a review of literature.

Gastrointestinal intussusception is an uncommon condition caused by a pendunculated, gastric tumor being forced through the pyloric sphincter and into the duodenum. An extremely rare case of gastrojejunal intussusception caused by a giant gastric lipoma is described in this article. The patient presented with anemia and weight loss. Initial gastroduodenal endoscopy failed to establish the diagnosis but abdominal ultrasound and computed tomography revealed signs of intussusception possibly associated with a lipoma of the small bowel. At laparotomy a pendunculated, submucosal, gastric lipoma, measuring 10 x 5 cm was found to have been intussuscepted into the jejunum. It was reduced and removed through a gastrotomy. Recovery was uneventful.