Encephaloduroateriosynangiosis (EDAS) in the management of Moyamoya syndrome in children with sickle cell disease.

BACKGROUND: Encephalo-duro-arterio-synangiosis (EDAS) in Moyamoya syndrome (MMS) treatment has been well described in the literature, however in MMS caused by sickle cell anaemia (SCA), EDAS use remains controversial with poor long-term follow-up. We present a case-series of SCA patients who have undergone EDAS for SCA-related MMS and describe their post-operative course as well as provide a literature review of the role of EDAS in the treatment of sickle cell anaemia. METHODS: A retrospective review of all the paediatric EDAS procedures conducted in our institution for SCA from 2007 to 2015. Two patients underwent behavioural screening. RESULTS: A total of eight patients with MMS secondary to SCA underwent EDAS. Unilateral EDAS was performed without complication in seven patients. One patient underwent bilateral EDAS but with a two-year gap in between procedures. Follow-up magnetic resonance angiography demonstrated no progression of Moyamoya collaterals or further ischaemic events with regression of collaterals clearly visible in one patient. All patients have demonstrated a return to normal school activities. CONCLUSIONS: EDAS is a well-tolerated revascularisation procedure for children with MMS. The prevention of further infarcts in our group with sickle cell disease has allowed these children to resume normal school activities.

Moyamoya angiopathy - Is there a Western phenotype?

Moyamoya disease (MMD) is a chronic cerebrovascular disease involving progressive bilateral stenosis of the intracranial segments of the internal carotid arteries. It results in the development of a rich, but friable collateral supply, prone to rupture. The disease is well described in Japanese literature and was originally thought to be a predozminantly Eastern disease. However, the recent literature describes a Western phenotype that may present with a different clinical course. This review aims to describe the variations in the epidemiology of the MMD between Eastern and Western populations, the possible reasons for them and highlight their implications for clinical practise and future research.

Lower third chest wall reconstruction in a bilateral sequential lung transplant recipient.

Reconstruction of the sternum following deep sternal wound infection (DSWI) can be challenging, and despite advances in reconstructive surgery, DSWI remains a significant cause of morbidity and mortality in cardiothoracic patients. Transplantation patients present an additional, unique challenge for the reconstructive surgeon. These patients are often on immunosuppressant therapy, with multiple comorbidities, and cannot tolerate prolonged operations for reconstruction. They often have a prior extensive surgical history, which may limit donor options; and their wounds are often in the lower third of the sternum, which is a challenging location to reconstruct with locoregional tissues.We report a case of successful lower third chest wall reconstruction in a bilateral lung transplant recipient with a combination of bilateral pectoralis advancement flaps and omentoplasty.

Invasive cutaneous squamous cell carcinoma resulting in arm amputation. Case discussion and literature review.

Skin cancer is one of the most common cancers in the world. Specifically incidence of non-melanoma malignancy in the UK has increased by 56% in the last decade. Cutaneous squamous cell carcinoma (cSCC) is a type of non-melanoma skin cancer that if caught early can be successfully treated. Conservative excision surgery is the most common treatment modality with high cure rates even if tumours are advanced. Radical surgery is rarely required, and amputations, especially when the distal part of the upper extremity is involved, are very uncommon. Here, we describe a case of an invasive cutaneous squamous cell carcinoma of the elbow that required trans-humeral arm amputation.

The management of deep sternal wound infection: Literature review and reconstructive algorithm.

Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.

Dupuytren's Fasciectomy: Surgical Pearls in Planning and Dissection.

Fasciectomy remains the mainstay of surgical treatment for Dupuytren's disease at many units worldwide, particularly in cases of recurrence after aponeurotomy or enzymatic fasciotomy. In some series, this has been reported as high as 48% in 3 years. The lead author has since abandoned the use of collagenase altogether. In this innovation article, we describe simple maneuvers to aid the planning and dissection of a Dupuytren's fasciectomy. We describe techniques to enable efficient dissection of the cord and minimize problems when designing skin flaps. We also highlight technical points in revision cases.

A retrospective comparison of 3M™ Micropore™ with other common dressings in cosmetic breast surgery.

BACKGROUND: Surgical site infection has considerable cost implications for healthcare providers. Evidence suggests that the use of Micropore™ tape as a dressing for surgical incisions may be associated with reduced/comparable rates of infection in surgical wounds. 3M™ Micropore™ tape is significantly cheaper than conventional wound dressings. The purpose of this study was to compare differences in the rate of wound healing problems including superficial incisional surgical site infection (SSI) and wound healing problems following cosmetic breast procedures between Micropore™ tape and other common wound dressings. METHODS: A clinical database was utilised to identify all patients undergoing elective breast surgery at a UK private cosmetic surgery group between May and November 2017. The patients were divided into 2 groups: those whose wounds were dressed with 3M™ Micropore™ tape post-operatively and those dressed with other common wound dressings. Data was analysed to assess the prevalence of post-operative wound healing problems (superficial incisional surgical site infection and delayed wound healing) in each group. RESULTS: 1216 patients were identified in our database, 659 patients receiving Micropore™ and 557 patients receiving conventional wound dressings. The overall prevalence of wound healing problems in the Micropore™ tape and conventional wound dressing group were 12% and 10% respectively, with no statistical difference (p = 0.3913). There was no statistical significance between the use of antibiotics and prevalence of wound healing problems in either group. CONCLUSION: The results of our study suggest that there is no difference between the use of Micropore™ tape and other conventional wound dressings in the prevalence of post-operative wound healing problems in cosmetic breast surgery. Our findings support the routine use of Micropore™ tape in post-operative dressing for clean, non-contaminated, directly closed, elective surgical wounds. We suggest a larger scale, prospective, randomized study should be conducted to confirm these initial findings.

Loss of domain leading to intra-operative cardiorespiratory arrest during open repair of a giant inguinoscrotal hernia and hydrocele.

We present the case of a 73-year-old man with a longstanding, giant inguinoscrotal hernia and hydrocele treated by an open approach, complicated intra-operatively by loss of domain leading to cardiorespiratory arrest. Surgery involved a midline approach by the general surgeons. Protruding viscera were mobilised, freed from adhesions, and returned to the abdominal cavity with closure of the internal ring, followed by reconstruction of the penis and scrotum by the plastic surgery and urology teams. Following abdominal closure, the patient developed severe cardiorespiratory instability attributed to large fluid shifts and increased intra-abdominal pressure due to loss of domain. The abdomen was therefore left open, and an ABThera negative pressure therapy system was employed. Two days later the abdomen was closed without tension. The remainder of the patient's post-operative recovery was unremarkable.

Traumatic abdominal wall hernia secondary to seatbelt injury: a case successfully managed by delayed surgical mesh repair and complicated by intervening pregnancy.

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia occurring secondary to blunt trauma. We report a case of seatbelt-associated TAWH in a 20-year-old woman who was presented to hospital via ambulance following a road traffic collision with a distended abdomen, peritonitis and free gas, with an associated TAWH identified on CT imaging. The patient underwent delayed surgical repair of her hernia using biological mesh, without recurrence, with a clinical course complicated by pregnancy. We use this report to demonstrate late repair as a safe and effective option for management of TAWH in pregnancy, with active surveillance and a multidisciplinary approach by the obstetric, plastic surgery and trauma teams.

Severe soft tissue infection masquerading as necrotising fasciitis in a 31-year-old woman with a background of right thigh arteriovenous malformation.

A 31-year-old woman with a history of a right thigh arteriovenous malformation presented with an acute history of right thigh pain and swelling. This rapidly progressed to gross sepsis. She was intubated, requiring inotropic support and renal replacement therapy. She was considered disproportionately unwell, with the impression one of necrotising fasciitis (NF). She was taken to theatre for emergency exploration and debridement. There was no evidence of NF to note in theatre. Tissue samples cultured group C Streptococcus, with histopathological examination confirming group C Streptococcal soft tissue infection. Thereafter, she was treated with high-dose intravenous antibiotics, use of a negative pressure wound therapy system, and multiple returns to theatre for repeat debridement. Her condition gradually improved, and she was stepped down to a surgical ward 3 weeks after admission. Nine weeks after initial presentation, she underwent skin grafting for wound closure. She returned to work 7 months later.