Effectiveness of 1α-25-dihydroxyvitamin D3 active substance on anastomosis safety in the rat femoral artery end-to-end anastomosis experimental model: Macroscopic and histological analyses.

Under inflammatory conditions, macrophage dominance affects the degree of inflammation. We assessed the effects of the active vitamin D (calcitriol) administration on inflammatory processes and macrophage dominance and aimed to determine the potential positive macroscopic and histological effects in supermicrosurgical arterial anastomosis model of rats. Forty rats were divided into five groups: control surgery (Group 1), surgery with preoperative (Group 2), post-operative (Group 3), perioperative (Group 4) systemic calcitriol and surgery with local calcitriol (Group 5). Eighty femoral artery anastomoses were planned in both legs of rats. Systemic calcitriol was administered intraperitoneally daily to the animals in the relevant groups. Preoperative vessel diameter measurements were taken before anastomosis. Three weeks post-surgery, post-operative vessel diameter measurements were taken, anastomosis patency was assessed and vascular segments were collected for histological examination, which included assessment of M1 and M2 macrophage depolarisation, leucocyte infiltration, intima-media ratio and luminal gap scoring. Systemic calcitriol administration (pre-, post- or perioperative) significantly improved the vessel diameter (p < 0.001); there was no significant difference among Groups 2-4. Histological findings revealed that Groups 3 and 4 had lower intima-media ratios (p < 0.05 and p < 0.01), higher M2-M1 macrophage ratios (p < 0.01 and p < 0.001) and lower leucocyte infiltration (p < 0.05, p < 0.01 and p < 0.001). Local calcitriol administration had no vasodilatory effects or resulted in positive histological outcomes. Although the administration of calcitriol pre- and post-operatively increased the vessel diameter, the latter appeared to have a more favourable impact on the histological analyses.

Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis.

BACKGROUND: Various techniques have been described for performing microsurgical anastomosis with providing high patency rates. Although the total anastomotic time may not be an issue when dealing with a single set of anastomoses, using a faster technique may save significant amount of time in cases of transferring flaps with shorter critical ischemia time or where multiple anastomoses are required. This study compares the total anastomosis time between four different combinations of commonly used suturing and knot tying techniques. METHODS: Twenty-four rats were divided into 4 groups. Simple interrupted suture with conventional knot tying technique (SIS-CT) was used in group I, continuous suture technique with conventional knot tying (CST) was used in group II, simple interrupted suture with airborne knot tying technique(SIS-AT) was used in group III, and continuous-interrupted suture with airborne knot tying technique(CIS-AT) was used in group IV for microsurgical anastomosis. Total anastomosis time and patency rates with each technique and samples from anastomotic sites were analyzed. RESULTS: The mean time required for microvascular anastomosis of the femoral artery was 1075 s in group I, 799 s in group II, 844 s in group III, and 973 s in group IV. The difference between four groups was statistically significant. The anastomoses in group II and group III were completed in the shortest period of time. Intergroup comparison revealed that the difference between group II and group III was not statistically significant, however, total anastomosis time for completion of the anastomosis was significantly longer for group I, followed by group IV. Thrombosis rates and histological analysis revealed no significant differences among four groups. CONCLUSION: CST and SIS-AT techniques can significantly reduce microsurgical anastomosis time and provide high patency rates. Also, the time needed to complete an anastomosis was significantly shorter for CIS-AT when compared to SIS-CT.

Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects.

Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap. METHODS: This retrospective study analyzed data of 23 patients undergoing adipofascial flap reconstruction after distal leg trauma between June 2017 and January 2020. A reconstructive approach with an adipofascial flap followed by a skin graft was used in all patients. Patients were divided into two treatment groups, and in only one treatment group, an acellular dermal matrix was placed above the adipofascial flap during the first stage of the reconstruction. Negative pressure wound therapy was applied to both groups. Surgical technique, outcomes, and complications were discussed. RESULTS: All patients achieved complete healing, and no flap loss was reported. Minor complications occurred in four patients; all were treated conservatively on outpatient basis. The surgical and aesthetic results were evaluated as satisfactory from both patients and professionals. However, the group treated with acellular dermal matrix showed a lower complication rate, and resulted significantly more satisfied with the overall results and in several domains of the questionnaire administered postoperatively (P < 0.05). CONCLUSIONS: The adipofascial flap is a safe and effective approach for the reconstruction of small-to-medium-sized defects of the distal lower extremity. Our two-stage reconstructive approach maximizes the pearls offered by the established technique; the dermal matrix guarantees a layered reconstruction optimizing the surgical and aesthetic outcomes of the skin graft with minimal donor site morbidity.

The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up.

BACKGROUND: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. METHODS: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. RESULTS: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). CONCLUSIONS: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.

Experience in reconstruction of esophagus, epiglottis, and upper trachea due to caustic injuries in pediatric patients and establishment of algorithm.

BACKGROUND: Unintentional swallowing of corrosive agents cause problems in the pediatric population. Swallowing dysfunction can be seen after injuring the pharynx and/or epiglottis which leads to the obstruction of esophagus. An algorithm was established taking into account the injury to the epiglottis and restoring gastrointestinal continuity with isolated or combine free and or supercharged jejunum flap, or supercharged colon transposition flap. METHODS: Seventeen patients between the ages of 3 and 16 (mean age: 7.7) were treated between 1985 and 2019. Three different procedures were performed based on endoscopic findings; for patients with no or minimal damage to epiglottis, pedicled colon transposition was done in 12 cases. For patients with epiglottic scarring or edema, a two-stage reconstruction was performed. In the first stage, free jejunum flap was implemented to the pharynx to facilitate food passage, followed by a pedicled jejunum in two cases, or a pedicled colon transposition in two cases to provide gastrointestinal continuity. For one patient with severe epiglottic scarring, a free jejunal flap was used as a diversion conduit in the first stage, followed by supercharged colon transposition to restore gastrointestinal continuity. RESULTS: Supercharged intestinal flaps were harvested with 3-4 cm of extra intestinal tissue than the measured thoracic portion in each individual in order to reach the hypopharyngeal region. The size of the free jejunal flaps were 10 cm. Oral feeding was initiated on the eighth postoperative day. Partial loss of the anterior wall of the jejunal flap was seen in one case, in which a free anterolateral thigh-vastus lateralis musculocutaneous flap was used for reconstruction. The mean follow-up time was 5.1 years and there was no stricture in the final outcome. CONCLUSION: A competent epiglottis is essential for proper swallowing reflex. Meticulous microsurgical dissection and performing supercharged intestinal flaps provide a complication-free end result.

Risks of Laparoscopic Harvest of Free Intestinal Flaps for Esophageal Reconstruction.

BACKGROUND: Performing ablative surgery using an laparoscope is a common practice. However, its use in the harvest of a segment of intestine for reconstruction has 2 major challenges: risk of damage to the vascular pedicle of the flap as well as to the vessels of other parts of the intestine that remain in the peritoneal cavity and risk of damage to the intestinal flap while pulling it out through a small opening in the abdominal wall. The aim of this study was to report advantages and disadvantages of harvesting free intestinal flaps using the laparoscopic method, explaining the challenges faced and lessons learned from this experience. PATIENTS AND METHODS: Free intestinal flaps were harvested by laparoscopy in 12 patients aged 28 to 63 years. There were 9 free jejunal flaps for the reconstruction of the cervical esophagus and 3 ileocolic flaps for the reconstruction of both the cervical esophagus and voice reconstruction. RESULTS: In 1 patient, laparoscopy was converted to laparotomy due to previous colectomy, which resulted in compromised circulation to the rest of the colon. One jejunal flap had leakage at its pharyngeal end; therefore, a pectoralis major myocutaneous flap was used for closure. In addition, 1 ileocolic flap had partial loss of its anterior wall, and a free anterolateral flap was used as a patch for closure. Furthermore, it was very difficult to harvest 1 free jejunal flap due to the thick and fat mesentery. CONCLUSION: Prolonged operative times, unexpected leakage at the anastomosis sites, partial loss of flaps, possible risk of vascular pedicle damage or venous compromise, demanding pedicle dissection in obese patients, and requirement of conversion to laparotomy are the major drawbacks of harvesting free intestinal flaps by laparoscopy.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm.

BACKGROUND: Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm. METHODS: From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery. RESULTS: The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants. CONCLUSION: Immediate reexploration is mandatory to salvage the flap.

Management of Medially Displaced Sub-Condylar Mandibular Fractures in Pediatric Population Using Novel Atraumatic Approach.

ABSTRACT: The appropriate treatment of pediatric mandibular condyle fractures is subject to much debate and concern among surgeons, with improper treatment potentially resulting in a number of adverse outcomes. Such outcomes include the disruption of mandible growth, decreased posterior facial height, facial asymmetry, and temporomandibular joint ankylosis. Several surgical and nonsurgical approaches to these fractures have been described in the literature; however, each one carries its own risk of various complications. In this study, the authors illustrate a new atraumatic approach for mild to moderately displaced subcondylar fractures, with least possible complications and unexpected outcomes. In this study, 6 patients (2 female and 4 male) with unilateral medially displaced condylar base and neck fractures, angulated between 30 and 45 degrees, were treated using a novel intraoral approach. The follow-up period varied from 12 to 18 months. All patients achieved normal occlusion and had painless functioning of the temporomandibular joint with proper mouth opening (>35 mm) without any recurrence at long term follow up. This minimally invasive approach could eliminate the possibility of major complications and be considered a safe and feasible surgical technique for certain cases of pediatric mandibular condyle fracture.

A New Experimental Lymphedema Model: Reevaluating the Efficacy of Rat Models and Their Clinical Translation for Chronic Lymphedema Studies.

BACKGROUND: Our aim was to create a new rodent hind limb lymphedema model lacking the fibrosis effect induced by radiotherapy and subjected to the inhibition of lymphangiogenesis via sirolimus (rapamycin) to maintain a chronic lymphedema model and investigate its reliability for human treatment modalities. METHODS: Forty-two Sprague-Dawley rats were randomly assigned to 7 groups: (1) surgery control, (2) vehicle-surgery control, (3) vehicle control, (4) rapamycin control, (5) surgery with 1 mg/kg per day rapamycin, (6) surgery with 1.5 mg/kg per day rapamycin, and (7) surgery with 2 mg/kg per day rapamycin. All surgeries were performed on the right hind limbs, with the left hind limbs also considered as a control. The drug and its solvent were administered daily into the relevant groups intraperiteonally. The presence of lymphedema was investigated by weekly limb circumference measurements, microcomputed tomography, fluorescence lymphography using indocyanine green dye, and microscopic evaluation at the end of the sixth week to determine any histological changes in the hind limbs. RESULTS: In group 1, lymphedema was observed for 2 weeks (P = 0.032), whereas in groups 5, 6, and 7, lymphedema lasted for 3 weeks (P < 0.05.) Fluorescence using indocyanine green revealed that the edema was totally resolved after 6 weeks of surgery by a well-developed superficial lymphatic organization instead of the normal distinct vessel structure. Histologically, groups 1, 5, 5, and 7 demonstrated a significant increase in both the number of macrophages (P < 0.001) and newly formed lymphatic vessels in the right side surgically treated hind limb (P < 0.05). CONCLUSIONS: Despite the extreme surgical destruction and lymphangiogenesis inhibition in the rat model, the sustained lymphedema did not last >3 weeks. Because of the rapid neolymphangiogenesis in murines and a different wound healing mechanism, they should not be considered as an appropriate model for research on human lymphedema in first place.

Pharyngoesophageal reconstruction with free jejunum or radial forearm flap as diversionary conduit: Functional outcomes of patients with persistent dysphagia and aspiration.

BACKGROUND: A diversion loop provides an alternative pathway for food intake from the bucco-gingival sulcus into the thoracic esophagus. Therefore, the bolus does not pass via pharynx where choking may occur in case of severe dysphagia. The data about outcomes and complications of the diversionary procedure are short and they refer to small cohort with brief follow-up. METHODS: This retrospective study analyzed data of 48 patients, mean aged 34.3 years (range, 22-58 years), undergoing the creation of a diversion loop in two stages. Patients complained of aspiration, choking, and dysphagia. Swallowing disorders were caused by corrosive injury, radiation damage, or neurologic injury, and were investigated through laryngoscopy and esophagography. A diversion loop was created in 45 cases with free jejunal flap and in 3 cases with radial forearm flap. Complications, functional outcomes, and revision rate were reviewed. The mean follow-up was 26.3 months. RESULTS: We reported one failure (2%) and one partial necrosis of the free flaps. The most frequent complication was hematoma (8%). One case of esophagocutaneous fistula (2%) and two cases of stricture (4%) were also observed. Forty-two patients (87%) took all of the daily diet from their mouths through the diversionary conduit. A poor functional outcome was significantly associated with pre-operative radiotherapy (p < .0001). CONCLUSIONS: The diversion loop offers an alternative route for alimentation. Patients are freed from their choking obsession; moreover, they are rehabilitated into society without the drawbacks of permanent jejunostomy feeding. The technique was upgraded with caudal marginal mandibulectomy to improve the outcomes. Patients undergoing a diversionary procedure due to radiation damage should be carefully informed about the expected functional results.

Lower Body Lift After Bariatric Surgery: 323 Consecutive Cases Over 10-Year Experience.

BACKGROUND: Lower body lift is a widespread procedure for massive weight loss patients aimed to improve the contour of the lower trunk, gluteal region and proximal lower extremity. The data about complications are confusing, and there is a lack of uniform studies for massive weight loss patients. A simple formula to carry out a reliable procedure in a short time with a low complication rate should be advocated. METHODS: This retrospective study analyzed data of 323 patients undergoing lower body lift after bariatric surgery over a 10-year period. Selection criteria, careful preoperative marking, reliable intra- and postoperative care and a few surgical tips are discussed. All the complications (both major and minor) and the aesthetic satisfaction were evaluated. Risk factors assessed were patient age, tobacco consumption, current BMI, operative time and combined surgery. RESULTS: The overall complication rate was 42%. We recorded a lower rate of major complications and skin dehiscence; no infection and no skin necrosis were observed. The most frequent complication was seroma (35%). A complication development was straight related to age (p = 0.0177) and tobacco use (p = 0.0336). Patients' satisfaction about overall aesthetic was high. CONCLUSIONS: We present our case load and describe an easy recipe to perform a safe surgery without undermining and liposuction in short operative times. The reasonable overall complication rate and the surprisingly lower rate of dehiscence and skin necrosis combined with a pleasant aesthetic result make the lower body lift an easy and safe procedure, when applied to the appropriate patient population. 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.

Varenicline increases random flap survival in rats submitted to nicotine.

Smoking is a leading cause of flap failure. Varenicline-assisted smoking cessation has shown beneficial effects on vascular endothelial function. The aim of this study was to determine whether varenicline conveys beneficial effects for skin flap survival. Twenty-four rats were randomly divided into four groups of six. The rats in the control group received normal saline subcutaneous injections, and those in the nicotine group received subcutaneous nicotine injections. The rats in the varenicline group received varenicline intraperitoneally, and those in the nicotine-varenicline group received both nicotine and varenicline. At the end of week 3, the dorsal skin flaps were raised in all rats. On postoperative day 7, the flaps were evaluated by direct observation, microangiography, and light microscopy. The mean necrotic area of the flaps was significantly greater in the nicotine group than in the control group (49.2 ± 4.71 vs. 22.03 ± 0.93%, respectively, p < .01) and significantly higher in the nicotine-varenicline group than in the varenicline group (22.4 ± 1.23 vs. 9.2 ± 0.59%, respectively, p < .01). However, no significant difference was observed between the control and nicotine-varenicline groups (p = .934). Microangiographically, vascularity was lowest in the nicotine group and highest in the varenicline group. Histologically, larger areas of necrosis, more severe inflammation and less vessel formation were observed in the nicotine group. Healing, exhibited by a greater number of vessels, was evident in the varenicline-applied groups. Varenicline appears to increase the microcirculation of random flaps, as shown by decreased flap necrosis and increased vascularity.

Jejunum/DIEP Composite Flap: A Novel Rat Model of Viscerocutaneous Flap Prefabrication.

Background Reconstruction of complex pharyngoesophageal defects presents a major challenge, particularly in soft tissue deficient and previously scarred surgical sites. In recent years, the free jejunum flap method has emerged as a reliable means of esophageal reconstruction. However, it may require cutaneous coverage with an additional flap in extensively scarred, secondary reconstructions. Prefabrication of an intestinal/cutaneous composite flap can potentially solve this problem. Materials and Methods Total 28 Sprague Dawley rats were used in the study protocol. A vascularized jejunal segment was transposed beneath the deep inferior epigastric perforator (DIEP) flap. Contact with underlying abdominal fascia was prevented using a silicone sheet. Animals were distributed into five groups based on the timing of deep inferior epigastric vessel ligation to determine the time required for successful revascularization. The viability and the vascular anatomy of the prefabricated structures were analyzed using histology and microangiography. Results A jejunum/DIEP composite flap was successfully prefabricated based on mesenteric vessels. The skin component survived intact after 5 days of contact with serosal surface of the jejunal segment. Conclusion The clinical application of this technique can provide an alternative means of single-stage esophageal reconstruction, especially in patients with soft tissue deficiency and donor vessel unavailability.