An Update on Tissue Contraction in Immediate Breast Reconstruction Using an Adjustable Implant Partially Filled With Air.

Background With the use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) techniques, utilizing a prepectoral underfilled adjustable saline implant allows for tissue contraction and thickening of the flap. This procedure allows for immediate reconstruction using an adjustable implant as a spacer with less risk of skin flap compromise and improves cosmetic outcomes. Methods A retrospective chart review of patients presenting to a single surgeon from September 2013 to September 2021 for breast reconstruction utilizing an underfilled prepectoral adjustable implant following SSM or NSM was performed. Baseline patient demographics, clinical information, postoperative complications, conversion to silicone implant, and contraction distance were recorded and analyzed. Results Fifty-four patients underwent prepectoral breast reconstruction using a Spectrum™ adjustable implant following an NSM or SSM. Tissue contraction and skin flap elevation were observed in all patients. The amount of tissue contraction averaged 4.4 cm (mean). Seven patients (12.96%) developed seromas. Four patients (7.41%) developed hematomas in the early postoperative period. Two patients (3.67%) developed capsular contracture. Two patients (3.67%) had a displaced port. After converting the air to saline, 25 patients (46.29%) opted for a secondary reconstructive procedure to exchange the saline implants for silicone gel implants. Conclusion Tissue contraction reduces the need for skin excision in ptotic breasts undergoing reconstruction procedures following NSM or SSM. The partially filled implant initially functions as a spacer to prevent flap adherence to the pectoral muscle and minimizes tension on the flap to promote flap thickening, elevation around the underfilled implant, and maximizes breast projection and overall aesthetic outcome.

Apigenin Targets MicroRNA-155, Enhances SHIP-1 Expression, and Augments Anti-Tumor Responses in Pancreatic Cancer.

Pancreatic cancer (PC) is a deadly disease with a grim prognosis. Pancreatic tumor derived factors (TDF) contribute to the induction of an immunosuppressive tumor microenvironment (TME) that impedes the effectiveness of immunotherapy. PC-induced microRNA-155 (miRNA-155) represses expression of Src homology 2 (SH2) domain-containing Inositol 5'-phosphatase-1 (SHIP-1), a regulator of myeloid cell development and function, thus impacting anti-tumor immunity. We recently reported that the bioflavonoid apigenin (API) increased SHIP-1 expression which correlated with the expansion of tumoricidal macrophages (TAM) and improved anti-tumor immune responses in the TME of mice with PC. We now show that API transcriptionally regulates SHIP-1 expression via the suppression of miRNA-155, impacting anti-tumor immune responses in the bone marrow (BM) and TME of mice with PC. We discovered that API reduced miRNA-155 in the PC milieu, which induced SHIP-1 expression. This promoted the restoration of myelopoiesis and increased anti-tumor immune responses in the TME of heterotopic, orthotopic and transgenic SHIP-1 knockout preclinical mouse models of PC. Our results suggest that manipulating SHIP-1 through miR-155 may assist in augmenting anti-tumor immune responses and aid in the therapeutic intervention of PC.

Portal Hypertension Due to a Traumatic Arteriovenous Fistula in a Patient With a Celiac Artery Aneurysm.

This article describes a rare case of a traumatic splenic arteriovenous fistula (AVF) causing portal hypertension in a patient presenting with abdominal pain, diarrhea, and melena. A 78-year-old was admitted to the hospital with abdominal pain. The patient's history was notable for prior laparotomy and left nephrectomy for a gunshot wound. Workup demonstrated portal hypertension with a dilated splenic vein with aneurysmal changes and a saccular celiac artery aneurysm. Celiac angiogram demonstrated a communication between celiac and portal circulation. The patient underwent laparotomy with ligation of the splenic artery and resection of the celiac artery aneurysm. In conclusion, splenic AVFs are relatively rare in clinical practice. Once the diagnosis is established, operative intervention is required to avoid complications of portal hypertension. Surgical ligation has been used in this case with a successful outcome.

The Role of Minimally Invasive Surgery in Appendectomy Within a Hernia.

We present three cases where an inflamed incarcerated appendix was in a femoral, inguinal, and an umbilical hernia. All three patients underwent an appendectomy laparoscopically. The hernias in two of the patients (femoral and inguinal) were left unrepaired as the primary goal was to relieve the patients' symptoms and achieve source control. The hernia was repaired primarily in the patient with an umbilical hernia intraoperatively. At three months follow-up, none of the patients had a clinically visible hernia.

Overwhelming Post-Splenectomy Infection Syndrome: Variability in Timing With Similar Presentation.

Overwhelming post-splenectomy infection (OPSI) syndrome is a rare and well-known entity that rapidly progresses with poor outcomes. Two patients underwent splenectomy after trauma and later presented with flu-like symptoms and thrombocytopenia, which then progressed to fulminant sepsis and death. The first patient had sepsis 20 days post-splenectomy, and the second patient underwent splenectomy 15 years before presentation. Both patients expired within 24 hours of the onset of symptoms. Even with no specific criteria for diagnosis, prompt identification of the overwhelming post-splenectomy infection is necessary; however, the prognosis is usually poor, even with aggressive treatment.

Fallopian Tube Tumor Mimicking Primary Gastrointestinal Malignancy.

A 67-year-old female patient positive for a mismatch repair gene mutation and history of serous carcinoma of the fallopian tube presented with a lower gastrointestinal bleed. Clinical workup was suggestive of a primary gastrointestinal malignancy. Pathological review after right hemicolectomy revealed the primary tumor was a fallopian tube carcinoma. Over the next few years, she presented with upper and lower gastrointestinal bleeds from a recurrent metastatic disease, which was from the primary fallopian tube cancer. Although serous carcinoma of the fallopian tube is not an uncommon diagnosis, it is unusual for it to present with symptoms of recurrent gastrointestinal bleed mimicking a primary gastrointestinal malignancy.

Pelvic Rectal Stercoral Perforation Resulting in Diffuse Pneumatosis.

An 83-year-old woman with oral corticosteroid use for chronic autoimmune conditions presented with abdominal pain and constipation for the previous seven days. CT of the abdomen and pelvis revealed a large fecaloma with diffuse pneumatosis involving the retroperitoneum, subcutaneous tissue, and mediastinum. An emergent exploratory laparotomy revealed perforation of the rectum below the peritoneal reflection into the retroperitoneum. An end-colostomy with Hartmann's operation was then performed intra-operatively. Despite operative treatment complicated by prolonged intubation, the patient succumbed to multiorgan failure and expired.

Healing of Bilateral Nipple Areolar Complex Necrosis by Secondary Intention.

Complete necrosis of the nipple, areola, or both is a uncommon complication of reduction mammaplasty, especially if it happens bilaterally. This case involving a young, black female illustrates that, in a large open wound of the breast, it would be ideal to leave it to heal by secondary intention as adding a skin graft would only speed up the healing process and not improve the result with the additional risk of keloid at the donor site. This open wound of the breast was treated with progressive surgical debridement while assessing the affected area in order to preserve as much tissue as possible due to the sensitive nature of the wound along with wet to dry dressing changes and antibiotic solution treatment. Our report suggests an additional approach to the standard of care involving a free flap to improve aesthetic outcomes.

Laparoscopic Approach for Gallstone Ileus in Geriatric Patients.

We report two patients who presented with small bowel obstruction secondary to gallstones in the ileum. Both patients were geriatric women with multiple comorbidities. The first patient was a 73-year-old woman who presented with a gallstone eroding and obstructing the duodenum (Bouveret's syndrome) secondary to gallbladder cancer with diffuse metastatic spread to the liver. The stone was disimpacted endoscopically using lithotripsy. The patient presented two days later after the stone had migrated downstream into the small bowel causing obstruction requiring surgical intervention. Second patient was an 81-year-old woman who presented with small bowel obstruction caused by a gallbladder stone impacted in the distal ileum. Both patients were managed laparoscopically with a mini laparotomy to extract the affected segment of bowel loop via small incision on the anterior abdominal wall at the port site with enterolithotomy. Both patients were discharged by postoperative day four with no complications. We conclude that, in elderly patients with multiple comorbidities presenting with gallstone ileus, laparoscopic approach provides early recovery with minimal pain.

Idiopathic Pneumatosis of Small Bowel and Bladder.

An 81-year-old woman presented with multiple episodes of loose bowel movements. CT scan of the abdomen and pelvis revealed pneumatosis cystoides intestinalis and asymptomatic emphysematous cystitis. The patient had an extensive workup with no obvious identified pathology to explain diffuse pneumatosis of the small bowel and bladder. Her symptoms improved with symptomatic management, empirical antibiotics, and no surgical intervention.

Fulminant Ischemic Pancolitis: A Severe Variant of Ischemic Colitis.

We present the case of a 75-year-old female with abdominal pain and a sudden change in mental status. She progressed rapidly with manifestations of acidosis without episodes of bloody bowel movements or diarrhea. The patient underwent emergent exploratory laparotomy, and a diagnosis of fulminant ischemic pancolitis was made with visual confirmation of infarcted colon from cecum to proximal rectum leading to subtotal colectomy and ileostomy. Postoperatively, the patient showed improved acidosis and mental status; unfortunately, over the subsequent days, the patient declined and was transferred to hospice and palliative care.

Fat Graft Size: Relationship Between Cannula and Needle Diameters.

Background It is generally believed that trauma to fat grafts is detrimental and affects the survival of the graft. In addition, it has been shown that smaller fat particle size corresponds to better survival; however, smaller cannula openings correspond to slower and more difficult fat graft harvesting. Objectives This study documents the relationship between cannula size, harvested fat cell size, and injection needle size. A means of reducing fat particle size following aspiration with larger diameter cannulas is also discussed. Methods Fat was harvested from five patients undergoing elective liposuction. Each fat sample was placed in a syringe and injected through progressively smaller needles until obstruction under low pressure was obtained. The minimal needle size was documented for each sample. Results Fat harvested with a liposuction cannula results in different size fat particles ranging up to the size of the cannula. Particles obtained from 3- and 4-mm cannulas can be injected without obstruction through a 16-gauge needle. Particles obtained from a 2-mm cannula can be injected without obstruction through an 18-gauge needle. Particles obtained from a 1-mm cannula can be injected without obstruction through a 20-gauge needle. Particles obtained from a 1-mm cannula could not be injected without obstruction through a 22-gauge needle. Conclusions There is a relationship between cannula opening size and the resultant fat graft size. Fat particles are somewhat compressible but should not be forced through needles or cannulas that are too narrow. It may be beneficial to harvest fat with larger cannulas and cut the particles to smaller sizes for injection.

Amyand's Hernia: Perforated Appendix in an Incarcerated Inguinal Hernia.

Amyand's hernia is an unusual condition characterized by the presence of a normal or inflamed appendix located within an inguinal hernia. We present a rare situation wherein a 56-year-old male patient presented with an incarcerated inflamed appendix in a right inguinal hernia. He was emergently taken to the operating room, with diagnostic laparoscopy changed to open, due to incarcerated cecum and terminal ileum. The incarcerated segment had to be resected with primary anastomosis. The inflamed and purulent contents were washed out, and the hernia defect was left unrepaired due to the presence of abscess in the inguinal canal.