Comparative Analgesic Efficacies of Ropivacaine and Bupivacaine for Postoperative Rectus Sheath Block in Paediatric Abdominal Surgery: A Meta-Analysis of Randomized Controlled Trial and Retrospective Cohort Studies.

Background: The optimal dose and concentration of analgesic efficacy of ropivacaine (RPV) and bupivacaine (BPV) for postoperative pain relief in paediatric abdominal surgery patients is still unclear. Therefore, this meta-analysis compared the efficacy of these analgesics, their administered modes (ultrasound-guided RSB versus LAI) for postoperative pain relief, and side effects. Methods: Three databases, PubMed, Embase, and Cochrane Database of Systematic Reviews, were exhaustively searched with predefined keywords. Eight randomized clinical trials and retrospective studies were selected. Analgesic effect, postoperative pain score, level of side effect, applied dose, and concentration of drug were analysed. Results: Drug dose ranged from 0.5-2.5 mL/kg of 0.2 to 0.5% concentrations. Male participant for RSB and LAI treatment groups varied from 40-62% and 25-83%, respectively. Mean age of RSB and LAI groups ranged from 3.8-11.65 years and 4.3-11.27 years, respectively. Our meta-analysis revealed that RSB could reduce total opioid use postoperatively (WMD = -0.02, 95% CI: -0.02, -0.02), with I 2 value of 15%. We found that the RPV (0.25%, 2.5 ml/kg) was optimal in suppressing the pain. Its lower concentration (0.2%) was ineffective, whereas higher one (0.375%) seems to increase risk of systemic toxicity. Similarly, BPV (0.25%, 2.5 mg/kg) efficaciously reduced the pain score, while its lower concentration was ineffective. The combined postoperative pain score in the RPV-treated group was found to be significantly reduced (p < 0.01) with I 2 value of 85% indicating high heterogeneity. Conclusion: Both RPV and BPV were significantly effective in reducing postoperative pain score. It appears that RSB could be a preferred choice to deliver analgesia, due to reduced opiate dose requirement and improved clinical safety without significant postoperative adverse events.

Application of Botulinum Neurotoxin Injections in TRAM Flap for Breast Reconstruction: Intramuscular Neural Arborization of the Rectus Abdominis Muscle.

Breast reconstruction after mastectomy is commonly performed using transverse rectus abdominis myocutaneous (TRAM) flap. Previous studies have demonstrated that botulinum neurotoxin injections in TRAM flap surgeries lower the risk of necrosis and allow further expansion of arterial cross-sectional diameters. The study was designed to determine the ideal injection points for botulinum neurotoxin injection by exploring the arborization patterns of the intramuscular nerves of the rectus abdominis muscle. A modified Sihler's method was performed on 16 rectus abdominis muscle specimens. Arborization of the intramuscular nerves was determined based on the most prominent point of the xyphoid process to the pubic crest. All 16 rectus abdominis muscle specimens were divided into four muscle bellies by the tendinous portion. The arborized portions of the muscles were located on the 5-15%, 25-35%, 45-55%, and 70-80% sections of the 1st, 2nd, 3rd, and 4th muscle bellies, respectively. The tendinous portion was located at the 15-20%, 35-40%, 55-60%, and 90-100% sections. These results suggest that botulinum neurotoxin injections into the rectus abdominis muscles should be performed in specific sections.

The impact of ultrasound-guided bilateral rectus sheath block in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy - a retrospective study.

BACKGROUND: Rectus sheath block (RSB) is known to attenuate postoperative pain and reduce perioperative opioid consumption. Thus, a retrospective study was performed to examine the effects of bilateral rectus sheath block (BRSB) in cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: A total of 178 patients undergoing CRS/HIPEC at our hospital were included. Patient information and anaesthesia-related indicators were collected from the electronic medical record (EMR) system. All subjects were divided into the following two groups: the G group (general anaesthesia) and the GR group (RSB combined with general anaesthesia). Patients in the GR group received 0.375% ropivacaine for BRSB before surgery. The primary outcomes included the total amount of remifentanil and rocuronium, the total consumption of dezocine after surgery, the visual analogue scale (VAS) score and the patient-controlled intravenous analgesia (PCIA) input dose at 1 h (T6), 6 h (T7), 12 h (T8), 24 h (T9) and 48 h (T10) after surgery. Other outcomes were also recorded, such as patient demographic data, the intraoperative heart rate (HR) and mean arterial pressure (MAP), and postoperative complications. RESULTS: Compared with the G group, the GR group showed a shorter time to tracheal extubation (P < 0.05), a decreased total amount of remifentanil and rocuronium (P < 0.05), and a reduced VAS score, PCIA input dose and number of PCIA boluses at 1 h, 6 h and 12 h after surgery (P < 0.05). However, at 24 h and 48 h after surgery, there were no differences in the VAS score of pain at rest or during motion between the two groups (P > 0.05). Moreover, the incidence of hypertension, emergence agitation, delayed recovery, hypercapnia, and nausea and vomiting was lower in the GR group than in the G group (P < 0.05). There were no differences in the changes in MAP and HR during the surgery between the two groups (P > 0.05). No complications associated with nerve block occurred. CONCLUSION: BRSB could provide short-term postoperative analgesia, reduce perioperative opioid consumption and reduce the incidence of postoperative complications. It is an effective and safe procedure in CRS/HIPEC.

Rectus sheath single-injection blocks: a study to quantify local anaesthetic absorption using serial ultrasound measurements and lidocaine serum concentrations.

OBJECTIVES: Rectus sheath blocks are an established option for analgesia following abdominal surgery, but pharmacokinetic data are limited. This study sought to characterise the absorption of lidocaine injectate and the pharmacokinetics of lidocaine after rectus sheath injection. METHODS: Bilateral rectus sheath single-injection blocks were given to 10 patients undergoing general or urological surgery. Afterwards, serial lidocaine serum levels and ultrasound measurements of the rectus sheath injectate reservoir were collected. KEY FINDINGS: Injectate within the rectus sheath was visible with ultrasound up to 12 h after injection. However, the rate of drug absorption exceeded that of injectate disappearance. Peak serum concentration occurred within 30 min with average peak concentrations of 1.65 µg/ml. Lidocaine clearance was lower than reported in young healthy subjects. The body mass index positively correlated with lidocaine terminal phase half-life, and clearance negatively correlated with age. CONCLUSIONS: The study provides the first data describing lidocaine pharmacokinetics after rectus sheath injection. Peak serum concentrations transiently achieved systemic levels associated with pain relief after a single bolus injection. The data from this study could be used to develop a regime using single shot rectus sheath blockade with a bolus of lidocaine followed by infusion using bilateral rectus sheath catheters.

Single injection ultrasound-guided rectus sheath blocks for children: Distribution of injected anesthetic.

BACKGROUND: Single injection ultrasound-guided rectus sheath blocks are used for postoperative analgesia after midline abdominal incisions, but the ultrasonographic spread of medication posterior to the rectus muscle has not been investigated. AIMS: The primary goal of this study was to determine the ultrasound-measured medication spread superiorly and inferiorly after single injection ultrasound-guided rectus sheath blocks and to calculate the incidence of cases with spread up to the subcostal margin and below of umbilicus. The secondary goals were to correlate the spread with the volume of medication administered and with the patient's age, weight, height, sex, and body mass index. METHODS: Pediatric patients who underwent single injection ultrasound-guided rectus sheath blocks and underwent data collection of ultrasonographic information on medication spread along the plane of the posterior rectus sheath were identified retrospectively from an acute pain service database at UPMC Children's Hospital of Pittsburgh. RESULTS: Sixty-eight children, 10.2 ± 4.2 (mean ± SD) years old, 41.7 ± 17.9 kg, 140 ± 24.6 cm, had complete data collection. Mean injected volume of ropivacaine was 8.3 ± 2.8 mL (right) and 8.2 ± 2.8 mL (left). The average spread was measured as 3.9 ± 1.4 cm (right) and 3.4 ± 1.3 cm (left) cranial to the umbilicus, and 1.5 ± 1.6 cm (right) and 1.6 ± 1.4 cm (left) caudal to the umbilicus. Complete spread up to the level of the subcostal margin was observed in 52.9% (n = 36; right) and 36.8% (n = 25; left) of cases. The spread correlated closely with the volume of injected ropivacaine (right: 0.556, P < 0.001; left: 0.541, P < 0.001). The spread below umbilicus was 70.6% (n = 48, right) and 80.9% (n = 55, left). There was a positive strong correlation (P < 0.001) between total medication spread and age (right: 0.608; left: 0.538), weight (right: 0.600; left: 0.540), and height (right: 0.593; left: 0.526). CONCLUSION: After single injection ultrasound-guided rectus sheath blocks, incomplete cephalocaudal medication spread can be expected within the posterior rectus sheath.

Preoperative versus postoperative ultrasound-guided rectus sheath block for improving pain, sleep quality and cytokine levels in patients with open midline incisions undergoing transabdominal gynecological surgery: a randomized-controlled trial.

BACKGROUND: Nerve block is usually performed before surgery because it inhibits reflection of the skin incision and reduces the amount of intraoperative anesthetic used. We hypothesized that performing rectus sheath block (RSB) after surgery would result in a longer duration of the analgesic effects and have a subtle influence on sleep time after surgery but that it would not decrease the perioperative cytokine levels of patients undergoing gynecological surgery. METHODS: A randomized, double-blinded, controlled trial was conducted from October 2015 to June 2016. Seventy-seven patients undergoing elective transabdominal gynecological surgery were randomly assigned to the following two groups: a general anesthesia group who received 0.5% ropivacaine hydrochloride RSB preoperatively and saline RSB postoperatively, and another group who received the opposite sequence. The objective of the trial was to evaluate the postoperative pain, sleep and changes in cytokine levels of patients during the postoperative 48 h. RESULTS: A total of 61 female patients (mean age: 50 years; range: 24-65 years) were included in the final study sample. There was no significant difference in the pain, consumption of oxycodone, or time to first administration of patient-controlled intravenous analgesia between the two groups. The postoperative sleep stages N2 and N3 were increased by 52.9 and 29.1 min per patient, respectively, in the preoperative RSB group compared with those in the postoperative group. The preoperative IL-6 concentration in the preoperative RSB group was lower than that in the same group at the end of surgery and 24 h postoperatively. CONCLUSIONS: We concluded that preoperative RSB might preserve postoperative sleep by inhibiting the increase of IL-6 without shortening the analgesia time compared with postoperative RSB in female patients undergoing elective midline incision transabdominal gynecological surgery. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02477098 , registered on 15 June 2015.

Anti-inflammatory coatings of hernia repair meshes: A pilot study.

The current prevalence of postoperative chronic pain from hernioplasty procedures employing polymer mesh is close to 30%. Most of the researchers agree that oxidative stress, resulting from the release of oxidants and enzymes during acute inflammatory response, is a key factor in the development of posthernioplasty complications. This results in both the decrease of the biomechanical properties and stiffening of the polymer fibers of the mesh, leading to chronic pain. Moreover, enhanced activity of inflammatory cells can lead to an excessive deposition of connective tissue around the implant. In this study polypropylene hernia repair meshes coated with vitamin E (α-tocopherol), a known antioxidant, were prepared and characterized. The absorption isotherm of vitamin E on the mesh was characterized and a release profile study yielded a promising results, showing sustained release of the drug over a 10-day period. An animal study was conducted, and histological analysis five weeks after implantation exhibited a reduced host tissue response for a modified mesh as compared to a plain mesh, as evidenced by a higher mature collagen to immature collagen ratio, as well as lower level of fatty infiltrates, neovascularization and fibrosis in the case of modified mesh. These results support the use of α-tocopherol as a potential coating in attempt to reduce the extent of postoperative inflammation, and thereby improve long-term outcomes of hernioplasty. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 589-597, 2018.

Does Rectus Sheath Block Analgesia Alter Levels of the Oxidative Stress Biomarker Glutathione Peroxidase: A Randomised Trial of Patients with Cancer and Benign Disease.

AIM: To evaluate whether the overall satisfaction, as measured by numeric rating scale (NRS), regarding rectus sheath block (RSB) analgesia is associated with the plasma glutathione peroxidase (GPX1) level. The second end-point of the study was to evaluate the differences in GPX1 levels in patients with and without RSB analgesia, with special emphasis on benign or malign disease status. PATIENTS AND METHODS: Initially, 56 patients were randomized to the placebo group (n=12) and to one of three active RSB analgesia groups: single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) groups. The plasma level of GPX1 was measured at three time points: just before, immediately after and 24 h after surgery. The overall satisfaction and an opinion on the success of the analgesic procedure were surveyed using an 11-point numeric rating scale 24 h postoperatively (NRS from 0, completely dissatisfied, to 10, fully satisfied). RESULTS: The placebo group and the three active groups were similar in terms of their perioperative data. The plasma level of GPX1 decreased postoperatively in all four groups. No differences were detected in the GPX1 values between the placebo and the three active groups combined preoperatively and immediately after operation. However, the patients in the single-dose group had a significantly lower median GPX1 values 24 h after surgery compared to the three other groups separately (p=0.032). The median (interquartile range) plasma level of GPX1 differed significantly between patients with benign disease and those with cancer preoperatively (18.0, 12.5-22.0 versus 10.0, 6.3-18.8 pg/ml, p=0.006) and cancer diagnosis was correlated with lower individual plasma GPX1 values (r=-0.42, p=0.004). CONCLUSION: The placement of RSB analgesia does not significantly affect the level of oxidative stress biomarker GPX1 in patients with benign disease or cancer. A new finding with possible clinical relevance is that patients with cancer appeared to have a trend for lower plasma GPX1 values.

Pain related to robotic cholecystectomy with lower abdominal ports: effect of the bilateral ultrasound-guided split injection technique of rectus sheath block in female patients: A prospective randomised trial.

BACKGROUND: Robotic cholecystectomy (RC) using port sites in the lower abdominal area (T12-L1) rather than the upper abdomen has recently been introduced as an alternative procedure for laparoscopic cholecystectomy. Therefore, we investigated the time course of different components of pain and the analgesic effect of the bilateral ultrasound-guided split injection technique for rectus sheath block (sRSB) after RC in female patients. METHODS: We randomly assigned 40 patients to undergo ultrasound-guided sRSB (RSB group, n = 20) or to not undergo any block (control group, n = 20). Pain was subdivided into 3 components: superficial wound pain, deep abdominal pain, and referred shoulder pain, which were evaluated with a numeric rating scale (from 0 to 10) at baseline (time of awakening) and at 1, 6, 9, and 24 hours postoperatively. Consumption of fentanyl and general satisfaction were also evaluated 1 hour (before discharge from the postanesthesia care unit) and 24 hours postoperatively (end of study). RESULTS: Superficial wound pain was predominant only at awakening, and after postoperative 1 hour in the control group. Bilateral ultrasound-guided sRSB significantly decreased superficial pain after RC (P < 0.01) and resulted in a better satisfaction score (P < 0.05) 1 hour after RC in the RSB group compared with the control group. The cumulative postoperative consumption of fentanyl at 6, 9, and 24 hours was not significantly different between groups. CONCLUSIONS: After RC with lower abdominal ports, superficial wound pain predominates over deep intra-abdominal pain and shoulder pain only at the time of awakening. Afterwards, superficial and deep pain decreased to insignificant levels in 6 hours. Bilateral ultrasound-guided sRSB was effective only during the first hour. This limited benefit should be balanced against the time and risks entailed in performing RSB.

Presurgical Botulinum Toxin A Treatment Increases Angiogenesis by Hypoxia-Inducible Factor-1α/Vascular Endothelial Growth Factor and Subsequent Superiorly Based Transverse Rectus Abdominis Myocutaneous Flap Survival in a Rat Model.

To date, there have been several experimental studies to assess tissue viability of transverse rectus abdominis myocutaneous (TRAM) flaps. Botulinum toxin A (BoTA) has gained popularity in many clinical fields, for a variety of therapeutic and aesthetic purposes. In addition, there have been reports regarding the positive effect of BoTA on flap survival by various mechanisms. In this study, we hypothesized that pretreatment with BoTA could augment the survival of TRAM flaps via increased hypoxia-inducible factor (HIF)1α/vascular endothelial growth factor (VEGF)-dependent angiogenesis.Twenty-four Sprague-Dawley rats were randomly divided into 2 groups: a control group and a BoTA group. Five days before superiorly based TRAM flap elevation, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Gross flap survival rates were assessed, and quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and Western blotting were performed for the evaluation of angiogenesis-related factors (CD34, HIF-1α, and VEGF).In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral (92.78.3 ± 5.05% vs 86.8 ± 3.88%, P = 0.009) and contralateral (91.57 ± 5.79% vs 74.28 ± 11.83%, P < 0.001) sides.The relative mRNA expression of CD34 and VEGF was significantly higher in the BoTA group than that in the control group in every zone, whereas the relative mRNA expression of HIF-1α was significantly higher in the BoTA group than that in the control group on contralateral sides. The relative protein expression of CD34, VEGF, and HIF-1α was significantly higher in the BoTA group than that in the control group in every zone.In conclusion, we demonstrate that presurgical BoTA treatment might increase angiogenesis by HIF-1α/VEGF, subsequently increase superiorly based TRAM flap survival in a rat model.

The Effect of Selenium on Ischemia-Reperfusion Injury: An Experimental Study on a Transverse Rectus Abdominis Musculocutaneous Flap Model.

BACKGROUND: The aim of this study is to investigate effects of selenium and enlighten the possible mechanism of action in a rat transverse musculocutaneous flap model following ischemia-reperfusion injury. MATERIALS AND METHODS: In this study, an experimental model, which mimicked free tissue transfer, was applied. Twenty-four male Wistar Albino rats were divided into a control group (N = 12), and a selenium treated group (N = 12). A superiorly based transverse rectus abdominis musculocutaneous (TRAM) flap was elevated and an ischemic insult for 4 hours was given. In selenium treated group (Group 2), sodium selenite (0.625 mg/kg) was injected intraperitoneally (i.p), 2 hours before the induction of ischemia. Six rats from each group were sacrificed at 24 hours after the operation and malonyldialdehyde (MDA), nitric oxide (NO), and glutathione (GSH) levels were measured biochemically, whereas the intensity of neutrophil infiltration was evaluated. For the rest of the rats in Group 2, sodium selenite was injected at the same dose everyday to the postoperative 10th day, in which the remaining 6 rats from each group were sacrificed. On postoperative 10th day, flap viability was assessed along with the evaluation of intensity of neovascularization. RESULTS: In Group 1, MDA levels were higher significantly (P < 0.05) when compared with Group 2. No statistical difference, however, was found for NO (P > 0.05), and GSH (P > 0.05) levels among Group 1 and 2. Neutrophil infiltration was more intense in Group 1, when compared with Group 2 whereas neovascularization was more abundant in samples of Group 2. Group 2 shows higher average flap surface areas when compared with Group 1 (P < 0.05). DISCUSSION: The results of this study demonstrated the preventive effect of selenium against ischemia-reperfusion injury by reducing tissue necrosis in muscle flaps possibly by decreasing MDA, increasing neovascularization, and decreasing neutrophil infiltration, thus suppressing inflammation.

Analysis of effect isoxsuprine hydrochloride and nicotine in the Transverse Rectus Abdominis Myocutaneous flap (TRAM) in rats.

PURPOSE: To evaluate the effects of isoxsuprine and nicotine on TRAM. METHODS: Forty eight 48 Wistar rats distributed into four Groups (n=12). All rats received medication managed daily for 20 days: saline solution (SA), nicotine solution (NI), isoxsuprine solution (IS) and nicotine solution (NI) + isoxsuprine solution (IS). On day 21st the rats were submitted to the caudally based, right unipedicled TRAM flap and after 48 hours, made the macroscopic evaluation of the surface of the flap, photographic documentation and collection of material for histology. Data from macroscopic evaluation were analyzed by ANOVA and microscopic evaluation by Kruskal-Wallis test, with significance level of 5%. RESULTS: In the macroscopic evaluation of isoxsuprine Group retail presented absolute numbers: final area (p=0.001*) and viable area (p=0.006*) with the highest values; necrosis (p=0.001*) had the lowest value. Microscopic examination revealed no significant findings in the study of TRAM under the action of isoxsuprine and nicotine to the percentage of necrosis in the left and right cranial and caudal regions. CONCLUSIONS: There was significant improvement in viability of TRAM using the isoxsuprine solution alone. No influence using nicotine alone and in association with isoxsuprine.

Chronological Changes in Ropivacaine Concentration and Analgesic Effects Between Transversus Abdominis Plane Block and Rectus Sheath Block.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane block (TAPB) and rectus sheath block (RSB) are popular methods of controlling postoperative pain. Chronological changes in blood concentrations of local anesthetics have not been described, although a large amount of local anesthetic is required to block these compartments. We postulated that blood concentrations of anesthetics would peak earlier during TAPB than RSB (primary end point). Secondary end points were elapsed time from block until first postoperative rescue analgesia and affected dermatomes. METHODS: This prospective, randomized study included 22 patients scheduled for laparoscopic ovarian surgery under general anesthesia. The patients were randomized to receive either a bilateral single-shot TAPB or a bilateral RSB (15 mL of 0.5% ropivacaine per side). Arterial blood was sampled 10, 20, 30, 45, 60, 90, and 120 minutes after ropivacaine administration. This trial was registered at the UMIN-Clinical Trials Registry (UMIN000012133) before patient recruitment. RESULTS: Arterial ropivacaine levels after block peaked earlier in the TAPB than in RSB [Tmax: 35 (12) vs 53 (16) minutes; P = 0.02], whereas peak ropivacaine concentrations did not significantly differ between the groups [Cmax: 1.83 (0.41) vs 1.79 (0.33) µg/mL; P = 0.54]. Peak ropivacaine concentrations exceeded 2.2 µg/mL in 1 and 2 patients in the RSB and TAPB groups, respectively, although symptoms of local anesthetic systemic toxicity were not evident in any of them. The median [interquartile range] duration of analgesia was significantly longer for TAPB than RSB (421 [335-536] vs 196 [168-277] minutes; P = 0.01). CONCLUSIONS: Peak ropivacaine concentrations were comparable during TAPB and RSB, but peaked earlier during TAPB. Although 150 mg of ropivacaine remained effective significantly longer during TAPB than RSB during laparoscopic surgery, this dose could cause local anesthetic systemic toxicity. The analgesic effects of blocks with less ropivacaine should be assessed.

Analysis of effect isoxsuprine hydrochloride and nicotine in the Transverse Rectus Abdominis Myocutaneous flap (TRAM) in rats

PURPOSE: To evaluate the effects of isoxsuprine and nicotine on TRAM. METHODS: Forty eight 48 Wistar rats distributed into four Groups (n=12). All rats received medication managed daily for 20 days: saline solution (SA), nicotine solution (NI), isoxsuprine solution (IS) and nicotine solution (NI) + isoxsuprine solution (IS). On day 21st the rats were submitted to the caudally based, right unipedicled TRAM flap and after 48 hours, made the macroscopic evaluation of the surface of the flap, photographic documentation and collection of material for histology. Data from macroscopic evaluation were analyzed by ANOVA and microscopic evaluation by Kruskal-Wallis test, with significance level of 5%. RESULTS: In the macroscopic evaluation of isoxsuprine Group retail presented absolute numbers: final area (p=0.001*) and viable area (p=0.006*) with the highest values; necrosis (p=0.001*) had the lowest value. Microscopic examination revealed no significant findings in the study of TRAM under the action of isoxsuprine and nicotine to the percentage of necrosis in the left and right cranial and caudal regions. CONCLUSIONS: There was significant improvement in viability of TRAM using the isoxsuprine solution alone. No influence using nicotine alone and in association with isoxsuprine. .

Histological modification in TRAM flap in rats treated with pentoxifylline.

PURPOSE: To investigate the blood vessels' concentration in TRAM flap's rat model, in the presence of pentoxifylline. METHODS: 32 male, Wistar-EPM rats were divided into two groups. Control group (C): 0.5 ml of saline, intraperitoneally, once a day, for seven days before flap elevation; PTX group (P): pentoxifylline (20mg/kg/day), intraperitoneally, for seven days before flap elevation. After that, they were submitted to a caudal unipedicle TRAM flap. On the fifth postoperative day, percentages of flap necrosis were determined via the "paper template" method and Tram flap's zone IV skin biopsies were taken for histological analysis. RESULTS: the mean percentage of flap necrosis in group C was 58.7 % and in group P, 31.1 (Wilcoxon test; p = 0.003). Mean capillary vessels number in zone IV's skin in C group was 33.4 and in P group was 71.9 (p=0.008). CONCLUSIONS: Pentoxifylline was effective reducing the necrosis in the caudal unipedicle TRAM flap in the rat as well as increasing the number of capillaries in an ischemic zone (zone IV).

Effects of tamoxifen on survival of cutaneous and myocutaneous flap (experimental study).

OBJECTIVES: Breast cancer is the most common non-skin malignancy in women. In breast cancer, the basic principle of endocrine therapy is to deprive tumor cell from the growth-stimulating effect of estrogens. The oldest, best-known and most widely used endocrine therapy medicine is tamoxifen, which is a selective estrogen receptor blocker. All factors that are known to have adverse effects on flap and pre-reconstruction flap survive should be eliminated 3 weeks before the surgery and started at the end of the 3rd week after the surgery. When the literature is reviewed, there are limited studies about that tamoxifen increases the risk of deep vein thrombosis and pulmonary embolism. The aim of this study was to research whether tamoxifen had adverse effects on the skin flap and muscle-skin flap survive. MATERIALS AND METHODS: In this study, 32 female Sprague-Davley rats were used. Their weights ranged from 220 to 250 g. 4 groups, each consisting of 8 rats, were formed. In this experimental study, in which rat models were used caudal based rat dorsal skin flap and superior pedicle rectus abdominis musculocutaneous flaps were applied. Control groups were formed for both flap models. Study groups were treated with tamoxifen citrat and control groups were treated with placebo. RESULTS: As a result of the statistical evaluation done by measuring the surviving flap areas, it was found out that tamoxifen had no negative effect on flap survive. CONCLUTIONS: Based on these findings, it was concluded that there was no need to stop tamoxifen as long as 6-7 weeks in patients undergoing breast reconstruction with pedicle flap techniques.

Histological modification in TRAM flap in rats treated with pentoxifylline

PURPOSE: To investigate the blood vessels' concentration in TRAM flap's rat model, in the presence of pentoxifylline. METHODS: 32 male, Wistar-EPM rats were divided into two groups. Control group (C): 0.5 ml of saline, intraperitoneally, once a day, for seven days before flap elevation; PTX group (P): pentoxifylline (20mg/kg/day), intraperitoneally, for seven days before flap elevation. After that, they were submitted to a caudal unipedicle TRAM flap. On the fifth postoperative day, percentages of flap necrosis were determined via the "paper template" method and Tram flap's zone IV skin biopsies were taken for histological analysis. RESULTS: the mean percentage of flap necrosis in group C was 58.7 % and in group P, 31.1 (Wilcoxon test; p = 0.003). Mean capillary vessels number in zone IV's skin in C group was 33.4 and in P group was 71.9 (p=0.008). CONCLUSIONS: Pentoxifylline was effective reducing the necrosis in the caudal unipedicle TRAM flap in the rat as well as increasing the number of capillaries in an ischemic zone (zone IV). .

Induction of bone formation by transforming growth factor-beta2 in the non-human primate Papio ursinus and its modulation by skeletal muscle responding stem cells.

OBJECTIVES: Four adult non-human primates Papio ursinus were used to study induction of bone formation by recombinant human transforming growth factor-beta(2) (hTGF-beta(2)) together with muscle-derived stem cells. MATERIALS AND METHODS: The hTGF-beta(2) was implanted in rectus abdominis muscles and in calvarial defects with and without addition of morcellized fragments of striated muscle, harvested from the rectus abdominis or temporalis muscles. Expression of osteogenic markers including osteogenic protein-1, bone morphogenetic protein-3 and type IV collagen mRNAs from generated specimens was examined by Northern blot analysis. RESULTS: Heterotopic intramuscular implantation of 5 and 25 microg hTGF-beta(2) combined with 100 mg of insoluble collagenous bone matrix yielded large corticalized mineralized ossicles by day 30 with remodelling and induction of haematopoietic marrow by day 90. Addition of morcellized rectus abdominis muscle to calvarial implants enhanced induction of bone formation significantly by day 90. CONCLUSIONS: In Papio ursinus, in marked contrast to rodents and lagomorphs, hTGF-beta(2) induced large corticalized and vascularized ossicles by day 30 after implantation into the rectus abdominis muscle. This striated muscle contains responding stem cells that enhance the bone induction cascade of hTGF-beta(2). Induction of bone formation by hTGF-beta(2) in the non-human primate Papio ursinus may occur as a result of expression of bone morphogenetic proteins on heterotopic implantation of hTGF-beta(2); the bone induction cascade initiated by mammalian TGF-beta proteins in Papio ursinus needs to be re-evaluated for novel molecular therapeutics for induction of bone formation in clinical contexts.

[Rectus sheath hematomas caused by acenocumarol overdose]. / Acenocumarol-túladagolás okozta rectus abdominis bevérzések.

Acenocumarol is widely used in long-term anticoagulant treatment. Overdose of this drug may result in suffusions in various parts of the body. In three cases, we observed suffusion in the rectus sheath, which is an unusual site of hematomas. At early stage, the lack of discoloration of the abdominal wall may lead to problems in differential diagnosis. Chronic anticoagulant treatment in a patient's history in combination with a palpable abdominal mass facilitate the correct diagnosis. In addition, high INR also makes hemorrhagic complications more likely. In simple cases, suggestive past medical history, abdominal palpation, INR and ultrasound examination can be sufficient to make a diagnosis. However, in more complicated cases, further assessment by CT is required to set up the diagnosis; while, in a further case discussed in this article, we could only establish an accurate diagnosis with laparoscopy. Decreased plasma prothrombin levels were always normalized with vitamin K.

Cementogenesis and the induction of periodontal tissue regeneration by the osteogenic proteins of the transforming growth factor-beta superfamily.

The antiquity and severity of periodontal diseases are demonstrated by the hard evidence of alveolar bone loss in gnathic remains of the Pliocene/Pleistocene deposits of the Bloubank Valley at Sterkfontein, Swartkrans and Kromdrai in South Africa. Extant Homo has characterized and cloned a superfamily of proteins which include the bone morphogenetic proteins that regulate tooth morphogenesis at different stages of development as temporally and spatially connected events. The induction of cementogenesis, periodontal ligament and alveolar bone regeneration are regulated by the co-ordinated expression of bone morphogenetic proteins. Naturally derived and recombinant human bone morphogenetic proteins induce periodontal tissue regeneration in mammals. Morphological analyses on undecalcified sections cut at 3-6 mum on a series of mandibular molar Class II and III furcation defects induced in the non-human primate Papio ursinus show the induction of cementogenesis. Sharpey's fibers nucleate as a series of composite collagen bundles within the cementoid matrix in close relation to embedded cementocytes. Osteogenic protein-1 and bone morphogenetic protein-2 possess a structure-activity profile, as shown by the morphology of tissue regeneration, preferentially cementogenic and osteogenic, respectively. In Papio ursinus, transforming growth factor-beta(3) also induces cementogenesis, with Sharpey's fibers inserting into newly formed alveolar bone. Capillary sprouting and invasion determine the sequential insertion and alignment of individual collagenic bundles. The addition of responding stem cells prepared by finely mincing fragments of autogenous rectus abdominis muscle significantly enhances the induction of periodontal tissue regeneration when combined with transforming growth factor-beta(3) implanted in Class II and III furcation defects of Papio ursinus.