Normative Data of the Interorbital Distance in Thai Population.

The incidence of the patients with craniofacial anomalies was high in southeast-Asian countries, for example, fronto-ethmoidal encephalo-menigocele or craniosynostosis. These craniofacial anomalies usually involve orbits, so a surgical orbital reconstruction is always required.Various methods have been used in the past to indirectly analyze the craniofacial region. Plain skull radiography, anthropometry, and cephalometry provided the limited information of interorbital distance in terms of accuracy whereas the interorbital distance is crucial to be reconstructed, increasing or decreasing. The accurate normal interorbital distance which grows by age as other craniofacial structures is the important data in the part of interorbital and orbital reconstruction. To date, the normative data of the bony interorbital distance among Thai population have not been established.The purpose of this study is to provide normal values and the growth patterns of the bony interorbital distances and other dimensions of the orbit according to age among Thai population through the axial computed tomography. Comparisons can then be made between normal values and those for an individual patient or those for a group of patients, for example, those with front-ethmoidal meningoencephalocele, Crouzon, or Treacher-Collins syndrome, or among values for individual patients at different time intervals.A retrospective study of computed tomography (CT) scan series of 698 normal orbits from 349 skeletally normal subjects (202 men and 147 women) was enrolled. The age range of the patients was 0 to 21 years (mean, 10.2 years; SD, 5.8 years). A series of 12 measurements were obtained from the CT scans of each subject. All CT images were obtained from patients who underwent CT of the facial bone, brain, and orbits at the Department of Radiology of 3 big hospital in Bangkok-Ramathibodi, Samitivej Srinakarin, and Bangkok hospital-since 2010 to 2015.The normal measurement values in the orbital region through the CT images, as the normal periorbital growth curve, will help improving diagnostic accuracy, staging of reconstruction, precision of corrective surgery, and follow-up of the Thai patients with craniofacial abnormalities such as front-ethmoidal meningoencephalocele, hypertelorism. These data may also apply to the related population in the southeast-Asian countries.

Genetic study of the CDKN2A and CDKN2B genes in renal cell carcinoma patients.

Objectives: While recent studies have demonstrated several genetic alterations are associated with pathogenesis of RCC, the significance of cyclin-dependent kinase inhibitor 2A (CDKN2A) and cyclin-dependent kinase inhibitor 2B (CDKN2B) in tumorigenesis of RCC is less clear. We investigate the distribution of CDKN2A and CDKN2B mutations in patients with RCC and analyze the impact of CDKN2A and CDKN2B mutations on RCC. Methods: A pathological examination was conducted using thirty fresh renal tissue samples with renal masses that had undergone partial or radical nephrectomy. Multiplex ligation-dependent probe amplification (MLPA) was used to detect genetic aberrations of CDKN2A and CDKN2B in genomic DNA isolated from samples. Subsequently, CDKN2A and CDKN2B mutations were confirmed using chromosomal microarray technique. Results: Twenty-one patients were diagnosed with RCC, eight with benign diseases, including angiomyolipoma (AML) and oncocytoma, and one with mucinous adenocarcinoma of renal pelvis. Two of twenty-one patients (9.5 %) with clear-cell RCC were positive for CDKN2A and CDKN2B gene deletions. Interestingly, patients with CDKN2A and CDKN2B mutations were associated with sarcomatoid patterns of RCC (2 out of 4, 50 %). In contrast, no CDKN2A or CDKN2B deletions were detected in samples from benign renal tumors, papillary RCC, or other kidney cancers. Conclusions: This study demonstrated the potential use of CDKN2A and CDKN2B as biomarkers for the prognostic and molecular classification of renal cancer. CDKN2A and CDKN2B mutations may be associated with RCC development and sarcomatoid changes. Further research is needed to understand the underlying molecular mechanisms of CDKN2A and CDKN2B in the pathogenesis of RCC.

Ultrasound predictors of thyroid cancer.

OBJECTIVE: To identify ultrasound (US) features associated with cancer in thyroid nodules. MATERIAL AND METHOD: During a two and a half-year period, medical charts, US images, and pathological findings in 629 consecutive patients with thyroid nodules who underwent US examination as well as fine needle aspiration biopsy (FNAB) or surgical excision or both were retrospectively reviewed. Clinical and US findings associated with thyroid cancer were identified using statistical models. RESULTS: Unequivocal cytological or pathological findings were available for 578 patients. Forty-eight patients (8%) had thyroid cancer. Independent clinical and US features associated with thyroid cancer included younger age, symptoms other than palpable mass, solid nodules, fewer number of nodules, presence of calcifications, and enlarged cervical lymph nodes. The combination of all these features was most specific for the diagnosis of thyroid cancer. The absence of all these features could rule out all thyroid cancers. CONCLUSION: The risk of the thyroid cancer in patients with thyroid nodules could be estimated by using relevant clinical and US features.

New inflammatory indicators for cell-based liquid biopsy: association of the circulating CD44+/CD24- non-hematopoietic rare cell phenotype with breast cancer residual disease.

BACKGROUND: Breast cancer residual disease assessment in early-stage patients has been challenging and lacks routine identification of adjuvant therapy benefit and objective measure of therapy success. Liquid biopsy assays targeting tumor-derived entities are investigated for minimal residual disease detection, yet perform low in clinical sensitivity. We propose the detection of CD44-related systemic inflammation for the assessment of residual cancer. METHODS: Circulating CD44+/CD45- rare cells from healthy, noncancer- and cancer-afflicted donors were enriched by CD45 depletion and analyzed by immuno-fluorescence microscopy. CD44+ rare cell subtyping was based on cytological feature analysis and referred to as morphological index. AUC analysis was employed for identification of the most cancer-specific CD44+ subtype. RESULTS: The EpCam-/CD44+/CD24-/CD71-/CD45-/DNA+ phenotype alludes to a distinct cell type and was found frequently at concentrations below 5 cells per 5 mL in healthy donors. Marker elevation by at least 5 × on average was observed in all afflicted cohorts. The positive predicted value for the prediction of malignancy-associated systemic inflammation of a CD44+ rare cell subtype with a higher morphological index was 87%. An outlook for the frequency of sustained inflammation in residual cancer may be given to measure 78%. CONCLUSION: The CD44+ rare cell and subtype denotes improvement in detection of residual cancer disease and may provide an objective and alternative measure of disease burden in early-stage breast cancer.

Factors influencing loss to follow-up after elective inguinal herniorrhaphy.

OBJECTIVE: To identify risk factors associated with losses to follow-up after inguinal herniorrhaphy and to examine whether these factors are associated with higher risks for recurrence according to the literature. MATERIAL AND METHOD: Records of inguinal hernia patients who underwent elective inguinal herniorrhaphy between January 1998 and November 2006 were reviewed. Factors potentially associated with loss to follow-up included demographic variables, type of hernia, predisposing factors, type of anesthesia, surgeon experience, type of repair, and early operative complications. Loss to follow-up was defined as the absence of follow-up information three months after herniorrhaphy for at least two years. RESULTS: There were 1,451 patients with 1,727 hernia operations. Of these, 981 operations (57%) were lost to follow-up. On multivariable analysis, factors associated with loss to follow-up included younger age, male gender secondary hernia, tissue-based repair, indirect inguinal hernia, and no postoperative complications. Many of these factors were not known to be associated with increased recurrence after hernia repair CONCLUSION: Hernia repairs lost to follow-up were systematically different from those not lost to follow-up, but factors related to these losses were not clearly or uniformly associated with higher risks for recurrence according to the literature.

PSA density and prostate cancer detection.

OBJECTIVE: To evaluate the diagnostic value of prostate-specific antigen density (PSAD) and the appropriate cutoff for the detection of prostate cancer. MATERIAL AND METHOD: Between January 2008 and March 2011, 292 men with PSA levels between 4 and 10 ng/mL underwent transrectal ultrasonography (TRUS) with prostate biopsy. The diagnostic value of PSA levels and PSAD were compared using receiver operating characteristic curves. RESULTS: Prostate cancer was diagnosed in 64 (22%) of the 292 men who had PSA levels 4 to 10 ng/mL. The mean PSA level was 6.96 ng/mL. The mean age was 66 years. The area under the curve (AUC) of PSA and PSAD were 0.475 and 0.665, respectively. The sensitivity and specificity of PSAD at cutoff of 0.15 was 78% and 43%, respectively CONCLUSION: PSAD was a better discriminator of prostate cancer than PSA for PSA levels less than 10 ng/ml. Our data suggested that a different PSAD cutoff than previously recommended need to be defined for Thai people.

Impact and appropriateness of the emergency ultrasonography in a tertiary care hospital.

OBJECTIVE: To quantify the notion of the impact of ultrasonography (US) on and the appropriateness of its use in, the diagnosis and treatment of emergency conditions. MATERIAL AND METHOD: A prospective study was conducted between September 2006 andApri 2007 at a tertiary care hospital. US was performed or supervised by experienced staff radiologists during the working hours and by final year radiology residents during the off-hours. Data collection forms were filled by radiology residents. The final discharge diagnoses were obtained from medical charts and computerized records. Data collected included age, gender provisional diagnosis, ultrasound findings, the discharge diagnosis, time of ultrasound examination, other radiologic investigations and therapeutic interventions. Outcomes included the impact, appropriateness, and diagnostic accuracy of US. RESULTS: Six hundred eighteen patients underwent 702 emergency ultrasound examinations. The median age was 51 years. Approximately 50% were male. The anatomical region most commonly examined was the abdomen (80%). US had an impact on clinical management in 85% of all examinations. Appropriate use of US was seen in 64% of all examinations. The overall accuracy of US was 90%. Factors associated with higher impact included suspected urological, vascular and musculoskeletal conditions, while vague abdominal conditions were associated with less impact. CONCLUSION: The impact of US on the management of emergency conditions was high and most requests for US were appropriate. However a more efficient use of emergency US is still possible, especially for abdominal conditions.

The relative false negative rate of isosulfan blue in detecting sentinel lymph nodes in early breast cancer.

OBJECTIVE: To determine the false negative rate of the isosulfan blue injection method of SLN detection in early breast cancer, relative to that of the combined blue dye and radiocolloid injection method. MATERIAL AND METHOD: Seventy women with early breast cancer underwent the combined method of SLN detection during the period between September 2007 and December 2008. Standard criteria for each method were used to identify SLNs. Each SLN was labeled as identified by the blue dye, the radiocolloid and as being positive or negative for cancer cells. RESULTS: Subjects were 50 years old with tumors of size 2.3 cm on the average. The average number of SLNs harvested was 2.5 nodes per subject. The detection rate for the isosulfan blue method was 91% (64/70). The relative false negative rate of the blue dye was zero (0/64). CONCLUSION: Experienced surgeons who use the isosulfan blue method of SLN detection in early breast cancer can be reasonably confident that the false negative rate of the isosulfan blue method was similar to that of the combined method.

Breast cancer cells in the afferent lymphatic tracts of sentinel lymph nodes.

BACKGROUND: To identify breast cancer cells in the afferent lymphatic tracts of axillary sentinel lymph nodes (SLNs). MATERIAL AND METHOD: The authors performed a prospective study of 1 00 breast cancer patients who underwent SLN biopsy between June 2009 and January 2010. The afferent lymphatic tracts of SLNs were identified by isosulfan blue or radiocolloid or both and were examined histologically. RESULTS: One hundred three SLNs and afferent lymphatic tracts were examined. The mean age of the patients was 53.2 years (range, 24 to 78 years). The median number of SLNs was 2 (range, 1 to 7). Twenty-four (24%) patients had positive SLNs. Most patients had stage I breast cancer (67%). Three patients with positive SLNs (13%) and stages IIB-IIIC breast cancers had tumor cells in the afferent tract tissue. There were no tumor cells in the afferent tracts of negative SLNs. CONCLUSION: Only a small proportion of operable breast cancer patients have tumor cells in the afferent lymphatic tract tissue of SLNs. There was a probable trend for more advanced stage breast cancer to harbor tumor cells in the afferent lymphatic tract tissue.

Large Mammary Paget Disease without Underlying Breast Carcinoma.

Mammary Paget disease is an uncommon type of breast cancer. Redness, scaling, and thickness involving the nipple and areola are common clinical symptoms. Invasive breast cancer was found in nearly 90% of these patients. Only a few cases of mammary Paget disease with no underlying cancer have been described, with a better prognosis. Treatment options include wide excision or mastectomy. However, if the lesion is very extensive, breast reconstruction may be required. We reported a rare case of extensive Paget disease in a 65-year-old woman who had a 7-year history of a 14 × 19 cm progressively enlarging erythematous scaling lesion that covered her entire left breast. No evidence of related malignancy or metastatic lesion was seen. A left mastectomy with sentinel lymph node biopsy and immediate pedicled transverse rectus abdominis myocutaneous flap reconstruction was chosen. There is uncertainty about axillary node metastasis since multiple enlarged and palpable left axillary lymph nodes were seen. She had axillary lymph node dissection instead. A histological examination confirmed the diagnosis of Paget disease of the nipple in the absence of underlying breast cancer and there was no evidence of axillary lymph node metastasis. This article emphasizes the need to pay close attention to diagnosis, progression, and treatment of the disease.

Effect of local anaesthetic infiltration on postoperative pain after laparoscopic cholecystectomy: randomized clinical trial.

BACKGROUND: Local anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC. METHODS: Patients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed. RESULTS: Out of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007). CONCLUSIONS: Local anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery. REGISTRATION NUMBER: TCTR20201103002 (http://www.thaiclinicaltrials.org).

Short-term outcomes of two laparoscopic bariatric procedures.

OBJECTIVE: To compare the short term outcomes of laparoscopic Roux-Y gastric bypass (lap RYGB) and laparoscopic gastric banding (lap banding) for morbidly obese patients at a tertiary care hospital. MATERIAL AND METHOD: Medical records of patients who underwent laparoscopic bariatric surgery for morbid obesity between November 2003 and November 2008 were reviewed. Baseline data including demographics, anthropometric and biochemical measurements were recorded. Patients were followed postoperatively and the body weight was measured every three to six months. Follow-up biochemical measurements were also recorded. After approximately six months to one year after the initial operation, the Bariatric Analysis and Reporting Outcome System (BAROS) scores were obtained, and re-evaluated every six months. RESULTS: There were 65 patients in the series, 31 underwent lap banding and 34 lap RYGB. There were 28 men (43%) and 37 women (57%), with an average age of 31.7 years (SD, 10.5 years). Patients were followed postoperatively for a period between six months and three years. The expected weight loss was 6% greater on the average for the lap RYGB group during the first two years of follow-up. Biochemical outcomes tended to marginally favor the lap RYGB group. There was no clear difference between groups in terms of the BAROS scores. CONCLUSION: Short- term differences between the two laparoscopic operations for morbid obesity tended to marginally favor lap RYGB. However, the BAROS scores were not clearly different between the two groups. These differences seemed to attenuate with time. The effects of the two operations were similar after two years.

Predictive factors of axillary lymph node metastasis in breast cancer.

OBJECTIVE: To identify clinical, radiologic and pathologic factors significantly related to axillary lymph node (ALN) metastasis in women with operable breast cancer. MATERIAL AND METHOD: Records of women with operable invasive breast cancer treated between July 2002 and May 2006 were reviewed Data on the number of axillary nodes, number of positive nodes, preoperative clinical, mammographic, and pathologic characteristics of each breast cancer were retrieved. Multiple logistic regression analyses were used to identify significant predictors of ALN metastasis. RESULTS: Records of 590 patients were reviewed Positive ALNs were found in 302 patients (51%). Independent and significant predictors of ALN metastasis included younger age, larger tumor size, presence of lymphovascular invasion, category 5 mammograms and low mammographic breast density. The combination of age less than 60 years, low mammographic breast density, category 5 mammogram, tumor larger 1 cm., and presence of lymphovascular invasion, had a specificity for predicting ALN metastasis of over 95%. CONCLUSION: A combination of clinical, radiologic, and pathologic characteristics highly specific for predicting ALN metastasis was found This prediction rule might be useful for selecting breast cancer patients for full ALN dissection without a preliminary SLNB.

Efficacy of the Orally Disintegrating Strip Sildenafil for the Treatment of Erectile Dysfunction: A Prospective, Randomized Trial.

INTRODUCTION: Phosphodiesterase 5 inhibitors are the predominant treatment option for erectile dysfunction. AIM: This study evaluates the efficacy and safety of sildenafil orally disintegrating strips for the treatment of erectile dysfunction. METHODS: One hundred twenty erectile dysfunction patients were enrolled in a prospective, randomized, controlled crossover study and allocated into 2 groups of 60 participants. Patients were either treated with sildenafil strips or tablets for 8 weeks after which they crossed over into the alternate treatment formulation for another 8 weeks following a 4-week wash-out period. Each participant was assessed 8 times throughout the study period and their formulation preference registered at the end of the study. MAIN OUTCOMES AND MEASURES: Changes in the abridged International Index of Erectile Function (IIEF-5) score and Erection Hardness Score (EHS) resulting from sildenafil orally disintegrating strip or tablet treatments were the primary end points, with differences in onset of action, duration of action, and incidence of adverse events between the 2 formulations included as secondary end points. RESULTS: Both sildenafil formulations were effective in treating patients with erectile dysfunction. There was significant improvement of erectile function in term of IIEF-5 score and EHS from both formulations. The number and type of adverse events were also comparable. Likewise, there were no statistically significant differences between the earliest onset of action times and longest duration of action times. However, the results showed a 7.1-minute earlier onset of action time for orally disintegrating strips that may be considered as clinically meaningful by some patients. CONCLUSION: Sildenafil orally disintegrating strips are a safe and effective alternative to the conventional tablet formulation for the treatment of erectile dysfunction. Sangkum P, Sirisopana K, Matang W, et al. Efficacy of the Orally Disintegrating Strip Sildenafil for the Treatment of Erectile Dysfunction: A Prospective, Randomized Trial. Sex Med 2021;9:100453.

Biopsy rate and positive predictive value for breast cancer in BI-RADS category 4 breast lesions.

OBJECTIVE: To examine the biopsy rate and positive predictive value (PPV) for breast cancer in lesions categorized as BI-RADS (Breast Imaging reporting and Data System) category 4. MATERIAL AND METHOD: The medical records of patients with BIRADS 4 breast lesion diagnosed at the breast diagnostic center Ramathibodi Hospital between December 1, 2004 and December 31, 2005 were retrospectively reviewed. PPV was calculated for patients who had biopsy performed or had clinical follow-up for at least two years. The radiographic and pathological findings were compared. RESULTS: The biopsy rate of 536 lesions categorized as BI-RADS 4 was 75% (403 of 536). Malignancy was found in 95 of 460 patients; or a PPV of 21%, PPVs for subcategories 4A, 4B and 4C, were 9%, 21% and 57%, respectively. The most common malignancy was invasive ductal carcinoma (67%). Patients with advanced age, having a clinically palpable breast mass of large size, with mammographic findings of architectural distortion and asymmetrical density were significantly associated with a higher risk of breast cancer. CONCLUSION: PPV for malignancy in the present study was comparable to previous studies. In subcategories 4B and 4C, the malignancy rate was higher than that in subcategory 4A.

The prognostic significance of microvessel density in intrahepatic cholangiocarcinoma.

OBJECTIVE: Intrahepatic cholangiocarcinoma (IHCC) is the second most common primary cancer of the liver Tumor angiogenesis seem to play an important role in tumor growth and prognosis of cancer patients. The purpose of the present study was to determine the prognostic value of tumor microvessel density (MVD) in patients with IHCC. MATERIAL AND METHOD: Clinicopathological prognostic factors, recurrence rate, and survival in 22 patients with IHCC who underwent liver resection for IHCC were reviewed. Tumor MVD was estimated using immunohistochemical methods. Overall probabilities of recurrence and survival were estimated using Kaplan-Meier methods. Prognostic significance ofMVD and other factors was tested using Cox proportional hazards regression. RESULTS: There was no significant association between any clinicopathologic factors (age, sex, tumor markers, and pathologic factors including MVD) and time-to-tumor recurrence. The only prognostic factor associated with survival was tumor stage. MVD was neither a significant survival predictor nor a predictor of tumor recurrence. CONCLUSION: The only factor associated with poor prognosis in patients with IHCC in the present study was higher tumor stage. MVD was not a significant prognostic factor in patients with IHCC.

Sentinel lymph node biopsy after neoadjuvant treatment of breast cancer using blue dye, radioisotope, and indocyanine green: Prospective cohort study.

BACKGROUND: The breast cancer treatment paradigm has shifted to neoadjuvant treatment. There are many advantages to neoadjuvant treatment, such as tumor downsizing, in vivo tumor biology testing, treating micrometastasis, and achieving complete pathological response (a surrogate marker for overall survival). However, in the post neoadjuvant settings, sentinel lymph node biopsy can be done using a dual staining technique to decrease the false-negative rate (FNR) and increase the detection rate. However, many hospitals are not equipped to use radioisotopes. Here we investigate the detection rate and accuracy of sentinel lymph node biopsy in post neoadjuvant treatment breast cancer, comparing radioisotope, isosulfan blue, and indocyanine green (ICG) approaches. MATERIAL AND METHODS: This prospective study includes breast cancer patients (T2-4, N1-2) who had received neoadjuvant treatment. Carcinomas were confirmed by tissue pathology. Patients who had previous surgical biopsy or surgery involving the axillary regions, and those with a history of allergy to ICG, isosulfan blue, or radioisotope were excluded from the study. RESULT: The study was done between July 1, 2019 to March 31, 2020. The mean age of participants was 53 years. Fourteen (60.87%) were post-menopause, two (8.7%) were perimenopause, and seven (30.43%) were premenopause. The clinical-stage distribution of the participants was: 2A (8.7%), 2B (34.78%), 3A (43.48%), and 3B (13.04%). The primary tumor size was 4.82 ± 2.73 cm. The lymph node size was 1.8 ± 0.96 cm. The detection rates at the individual level were 95.23% with ICG, 85.71% with isosulfan blue, and 85.71% with a radioisotope. The detection rate increased up to 100% when the ICG and blue dye methods were combined. The FNRs of sentinel lymph node biopsy at the individual level were: 10% using ICG, 30% using isosulfan blue, and 40% using radioisotope. At the lymph node level, the detection rates were 93.22% using ICG, 81.78% using isosulfan blue, and 53.87% using a radioisotope. The FNRs of sentinel lymph node biopsy at the lymph node level were 19.05% with ICG, 21.43% with isosulfan blue, and 18.03% with a radioisotope. However, the FNR was less than 10% when ICG, isosulfan blue, and a radioisotope were combined. CONCLUSION: We can perform sentinel lymph node biopsy by combining blue dye with ICG as an optional modality and achieve a comparable outcome with combine radioisotope in locally advanced breast cancer after neoadjuvant treatment.

Comparisons of complications between extended latissimus dorsi flap and latissimus dorsi flap in total breast reconstruction: A prospective cohort study.

BACKGROUND: The latissimus dorsi (LD) flap is one of the most popular techniques in breast reconstruction. Although numerous studies have not shown functional impairment of the shoulder after surgery, other studies have reported significant functional impairment, especially after extended LD flap reconstruction. The present study compared functional deficit and shoulder movement between extended LD and LD flap reconstruction. MATERIALS AND METHODS: Between December 2015 and May 2018, this study enrolled 31 patients undergoing LD flap reconstruction. Data on patient demographics, operative details, morbidities, and degree of shoulder movement were collected. Outcomes were compared between the extended LD and LD flap groups. RESULTS: Twenty-one women and 10 women underwent LD flap and extended LD flap reconstruction, respectively. The median patient age was 43 years. No demographic data differed between groups. Seroma, especially around the back incision, was the most common complication (90.5% in the LD flap and 90% in the extended LD group). Five patients in the LD flap group and one patient in the extended LD flap group showed decreased shoulder range of motion (ROM) at 6 months post-operation. Only one patient in the LD flap group showed impairment based on American Shoulder and Elbow Surgeons Shoulder Score (ASES). The results did not differ significantly between groups; however, the LD flap group showed faster functional recovery. CONCLUSION: LD flap reconstruction can be performed with a very low impact on shoulder function. We observed a slightly decreased ROM for both LD flap techniques, with no impact on functional outcome.

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

BACKGROUND: The contralateral lateral section (zone IV) of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is generally removed intraoperatively. The border of zone IV is usually identified anatomically using the Hartrampf classification. In this study, we used the indocyanine green (ICG) fluorescence method to determine the border of zone IV and find the correlation with clinical flap outcome. METHODS: The study recruited breast cancer patients who underwent a pedicled TRAM flap reconstruction. The border of zone IV was identified using the intraoperative ICG fluorescence imaging. The medial border of the removed specimen was sent for a pathological examination of vascular density. RESULTS: A total of 29 patients underwent a pedicled TRAM reconstruction. In 16 patients, the border of zone IV identified by ICG fluorescent imaging was identical to the anatomical border. The ICG imaging showed distinct perfusion patterns, which we divided into 4 categories: sequential, simultaneous, low midline scar, and delayed pattern. Overall, there were no patient with total flap loss, 1 patient had a partial flap loss and 4 patients had a fat necrosis. Neither the ICG perfusion time nor the pathological vascular density correlates with the clinical flap outcome. The delayed ICG perfusion pattern (category IV) has the highest fat necrosis rate, although it is not statistically significant. CONCLUSIONS: In this study, more than half of the patients have ICG perfusion corresponding with the Hartrampf zone, which reflected the conventional practice of zone IV pedicled TRAM flap removal. Some ICG perfusion patterns could be helpful, especially in low midline and delayed pattern.