Successful Reinnervation of the Diaphragm After Intercostal to Phrenic Nerve Neurotization in Patients With High Spinal Cord Injury.

OBJECTIVE: Our objective in this study was to extend diaphragmatic pacing therapy to include paraplegic patients with high cervical spinal cord injuries between C3 and C5. INTRODUCTION: Diaphragmatic pacing has been used in patients experiencing ventilator-dependent respiratory failure due to spinal cord injury as a means to reduce or eliminate the need for mechanical ventilation. However, this technique relies on intact phrenic nerve function. Recently, phrenic nerve reconstruction with intercostal nerve grafting has expanded the indications for diaphragmatic pacing. Our study aimed to evaluate early outcomes and efficacy of intercostal nerve transfer in diaphragmatic pacing. METHODS: Four ventilator-dependent patients with high cervical spinal cord injuries were selected for this study. Each patient demonstrated absence of phrenic nerve function via external neck stimulation and laparoscopic diaphragm mapping. Each patient underwent intercostal to phrenic nerve grafting with implantation of a phrenic nerve pacer. The patients were followed, and ventilator dependence was reassessed at 1 year postoperatively. RESULTS: Our primary outcome was measured by the amount of time our patients tolerated off the ventilator per day. We found that all 4 patients have tolerated paced breathing independent of mechanical ventilation, with 1 patient achieving 24 hours of tracheostomy collar. CONCLUSIONS: From this study, intercostal to phrenic nerve transfer seems to be a promising approach in reducing or eliminating ventilator support in patients with C3 to C5 high spinal cord injury.

Use of an extracorporeal membrane oxygenation circuit as a bridge to salvage a major upper-extremity replant in a critically ill patient.

Major replantation of the upper extremity is defined as replantation at or above the level of the wrist. Selection of appropriate candidates is complex and requires consideration of many patient- and injury-associated factors including patient age, associated injuries, patient desire, mechanism of injury, ischemia time, wound condition, and presence of multiple-level injury. With respect to age, younger patients, especially children, are deemed to have a distinct advantage over more elderly patients due to improved nerve regeneration, and many advocate making every effort to replant this population. The risks of major upper-extremity replantation are significant and include bleeding, depletion of coagulation factors, secondary infection, and sepsis. As a result, major systemic illness and significant associated injuries are accepted as contraindications to limb salvage in this patient population. Herein we describe the use of an extracorporeal membrane oxygenation (ECMO) circuit as a potential bridge for short-term preservation of the extremity in a young patient with an acute, concomitant systemic illness. In the authors' opinion, use of ECMO perfusion is a viable means of maintaining extremity perfusion over hours or even days and may lead to broadened replant criteria in patients with associated injuries.

Utilizing V-Y fasciocutaneous advancement flaps for vulvar reconstruction.

OBJECTIVES: We aimed to analyze the outcomes of patients who underwent vulvectomy with subsequent V-Y fasciocutaneous flap reconstruction. METHODS: All medical records of all patients who underwent vulvectomies with V-Y fasciocutaneous flap reconstruction from January 2007 to June 2016 were retrospectively reviewed. Patient clinical and surgical data, demographics, and outcomes were abstracted. RESULTS: Of the 27 patients, 42 flaps were transferred. A simple vulvectomy was performed in 8 (30%) patients, partial radical vulvectomy in 15 (56%), and radical vulvectomy in 4 (15%). The median area of defect was 30 cm2. Minor wound separations occurred in 9 patients (33%). Infectious complications occurred in 4 patients (15%); this included urinary tract infections in 2 (50%), postoperative fevers in 2 (50%), and sepsis in 1 (25%) patient with a UTI. There were no instances of flap necrosis, wound dehiscence, or wound infections. Black race was more likely to be associated with an infectious complication with 3 (75%) patients, compared to white race with 1 (4%) patient (p < .01). The presence of diabetes was more likely to be associated with an infectious complication in 2 (67%) patients, compared to 1 (4%) in non-diabetic patients (p < .01). No other significant association was found during analysis of demographics, medical comorbidities, vulvar pathology, or surgical factors affecting V-Y fasciocutaneous flap infectious complications or minor wound separations. CONCLUSIONS: The use of a V-Y fasciocutaneous advancement flap for vulvar reconstruction is safe and associated with mostly minor complications. Infectious complications were more frequently associated with diabetes, black race, and HIV.

Optimizing Results of Postmastectomy Radiation Therapy Utilizing the Latissimus Dorsi Flap and Tissue Expander Technique: A Single-Center Experience.

Objective: Postmastectomy radiation therapy is a well-established risk factor for complications after breast reconstruction. Even if the surgeon has a suspicion that radiation therapy may be needed, it may be beneficial to place tissue expanders during the mastectomy procedure as a temporizing measure, complete radiation therapy, and then reconstruct the breast with a latissimus flap. The purpose of this study was to examine the complication rates of the latissimus dorsi flap as compared with the complication rates of implant-based reconstruction in the setting of radiation therapy. Methods: A 16-year retrospective chart review from 2000 to 2016 was conducted. All patients who underwent temporizing tissue expander placement for radiotherapy with subsequent latissimus flap reconstruction were included in the study. Patients who did not follow up for implant exchange were excluded from the study. Results: Fifty-five patients were identified with an average age of 46.0 years (range, 27-67 years) and an average body mass index of 24.2 (range, 18.9-31.9). Five patients (9.1%) developed capsular contractures amenable to surgical intervention. One patient (1.8%) developed infection of the tissue expander, requiring removal. There were no incidences of flap failure or wound dehiscence. The average follow-up after latissimus flap reconstruction was 25.3 months (range, 3.7-121.6 months). Conclusions: We feel that the latissimus dorsi flap after postmastectomy radiation therapy represents the preferred implant-based reconstruction option to consider when the need for postmastectomy radiation therapy is anticipated. The latissimus dorsi flap remains a safe, effective solution to postmastectomy radiation therapy that every plastic surgeon should offer.

Early Clinical Outcomes of a Novel Antibiotic-Coated, Non-Crosslinked Porcine Acellular Dermal Graft after Complex Abdominal Wall Reconstruction.

BACKGROUND: Non-crosslinked porcine acellular dermal grafts (NCPADG) are currently the mainstay biomaterial for abdominal wall reconstruction (AWR) in complex hernia patients. We report early clinical outcomes using a novel rifampin/minocycline-coated NCPADG for AWR. STUDY DESIGN: A multi-institutional retrospective review was performed of patients who underwent ventral hernia repair using XenMatrix AB Surgical Graft (CR Bard, Inc [Davol]). Patient demographics, hernia and procedure characteristics, and surgical site occurrences/postoperative complications were reviewed up to 6 months after AWR. RESULTS: Seventy-four patients underwent AWR using XenMatrix AB Surgical Graft. Open AWR was performed in 52 patients (70.3%), and 22 patients (29.7%) underwent laparoscopic VHR. Median hernia size/area was 66.0 cm(2) (range 9.4 to 294.5 cm(2)). Sixteen patients (21.6%) had previous wound infections, and 16 patients (21.6%) had violation of the gastrointestinal tract during hernia repair. The most common locations of NCPADG placement were within the intraperitoneal (32.4%) and onlay (21.6%) positions, respectively. Median hospital length of stay was 4 days. Within 30 days after AWR, 6 (8.1%) patients were readmitted, postoperative seroma formation developed in 4 (5.4%) patients, 1 patient required percutaneous drainage, and surgical site infections developed in 5 (6.8%) patients. At 6 months follow-up, hernia recurrence had developed in 4 (5.4%) patients. CONCLUSIONS: Data suggest that use of a novel rifampin/minocycline-coated NCPADG was associated with a low rate of postoperative surgical site occurrences/postoperative complications during the first 30 days of follow-up in complex AWR patients. In addition, data suggest a low rate of hernia recurrence at 6-month follow-up. Additional study is warranted to determine whether early antimicrobial protection of the device translates into longer-term protection of the repair.

Renal cell carcinoma metastatic to the duodenum: treatment by classic pancreaticoduodenectomy and review of the literature.

Renal cell cancer (RCC) most commonly metastasizes to the lungs, bones, liver, renal fossa, and brain, although metastases can occur elsewhere. RCC metastatic to the duodenum is especially rare, with only a small number of cases reported in the literature. Herein, we describe a case of an 86-year-old woman with a history of RCC treated by radical nephrectomy 13 years previously. The patient presented with duodenal obstruction and anemia from a solitary duodenal mass invading into the pancreas and was treated via classic pancreaticoduodenectomy. Preoperative imaging and intra-operative assessment showed no evidence of other disease. Pathology confirmed metastatic RCC without lymph node involvement. Our case report and review of the English language literature underscore the rarity of this entity and support aggressive surgical treatment in such patients.