Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study.

PURPOSE: Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP. METHODS: We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital. RESULTS: For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively. CONCLUSIONS: Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.

Polymorphism rs2066865 in the Fibrinogen Gamma Chain (FGG) Gene Increases Plasma Fibrinogen Concentration and Is Associated with an Increased Microvascular Thrombosis Rate.

Background and Objective: Thrombosis due to inherited hypercoagulability is an issue that has been raised in microvascular flap surgery previously. We analyzed the association of a single nucleotide polymorphism (SNP) in rs2066865 in the fibrinogen gamma chain (FGG) gene, alteration in plasma fibrinogen concentration, and presence of microvascular flap thrombosis. Materials and Methods: A total of 104 adult patients with microvascular flap surgery were subjected to an analysis of the presence of SNP rs2066865 in the FGG gene. Alterations in plasma fibrinogen concentration according to genotype were determined as a primary outcome, and flap thrombosis was defined as a secondary outcome. Results: Flap thrombosis was detected in 11.5% of patients (n = 12). Successful revision of anastomosis was performed in four patients, resulting in a microvascular flap survival rate of 92.3%. We observed an increase in plasma fibrinogen concentration in genotype G/A and A/A carriers (G/G, 3.9 (IQR 4.76-3.04); G/A, 4.28 (IQR 5.38-3.18); A/A, 6.87 (IQR 8.25-5.49) (A/A vs. G/A, p = 0.003 and A/A vs. G/G, p = 0.001). Within group differences in microvascular flap thrombosis incidence rates were observed-G/G 6/79 (7.59%); G/A 5/22 (22.7%); A/A 1/3 (33.3%) (OR 0.30 95%; CI 0.044 to 0.57), p = 0.016; RR 3.2-when G/G versus G/A and A/A were analyzed respectively. Conclusions: A/A and G/A genotype carriers of a single nucleotide polymorphism in rs2066865 in the fibrinogen gamma chain gene had a higher plasma fibrinogen concentration, and this might be associated with an increased microvascular flap thrombosis incidence rate. Determined polymorphism could be considered as a genetic marker associated with microvascular flap thrombosis development. To confirm the results of this study, the data should be replicated in a greater sample size.

Immunohistochemical evaluation after Sr-enriched biphasic ceramic implantation in rabbits femoral neck: comparison of seven different bone conditions.

Strontium (Sr) has shown effectiveness for stimulating bone remodeling. Nevertheless, the exact therapeutic values are not established yet. Authors hypothesized that local application of Sr-enriched ceramics would enhance bone remodeling in constant osteoporosis of rabbits' femoral neck bone. Seven different bone conditions were analyzed: ten healthy rabbits composed a control group, while other twenty underwent ovariectomy and were divided into three groups. Bone defect was filled with hydroxyapatite 30% (HAP) and tricalcium phosphate 70% (TCP) granules in 7 rabbits, 5% of Sr-enriched HAP/TCP granules in 7, but sham defect was left unfilled in 6 rabbits. Bone samples were obtained from operated and non-operated legs 12 weeks after surgery and analyzed by histomorphometry and immunohistochemistry (IMH). Mean trabecular bone area in control group was 0.393 mm2, in HAP/TCP - 0.226 mm2, in HAP/TCP/Sr - 0.234 mm2 and after sham surgery - 0.242 mm2. IMH revealed that HAP/TCP/Sr induced most noticeable increase of nuclear factor kappa beta 105 (NFkB 105), osteoprotegerin (OPG), osteocalcin (OC), bone morphogenetic protein 2/4 (BMP 2/4), collagen type 1α (COL-1α), interleukin 1 (IL-1) with comparison to intact leg; NFkB 105 and OPG rather than pure HAP/TCP or sham bone. We concluded that Sr-enriched biomaterials induce higher potential to improve bone regeneration than pure bioceramics in constant osteoporosis of femoral neck bone. Further studies on bigger osteoporotic animals using Sr-substituted orthopedic implants for femoral neck fixation should be performed to confirm valuable role in local treatment of osteoporotic femoral neck fractures in humans.

Rare malignant peripheral nerve sheath tumor of vagus nerve: A case report.

INTRODUCTION: MPNST is a rare type of malignancy classified as malignant soft tissue sarcoma. One-fourth to one-half of MPNST arise in patients with neurofibromatosis type 1 (NF1) and generally involves major nerve trunks of proximal extremities and body, rarely head and neck region. Aggressive nature of the disease shows poor overall prognosis, where treatment modalities are also limited. PRESENTATION OF CASE: 62-year-old otherwise healthy female underwent radical surgical treatment due to the mass of the right side of the neck. Preoperative MRI studies showed well defined partly cystic and visually malignant neoplasm of the carotid sheath in upper third of the neck. Well-defined tumor of the right vagus nerve was detected during the surgery and was excised with safe and radical margins. Further histological study confirmed MPNST diagnosis. Defect of the vagus nerve was reconstructed with a nerve grafts to maintain and improve patients quality of the life. Adjuvant radiotherapy was appointed. At one year follow-up period no evidence of disease recurrence was found. Nevertheless, patient reported significant improvement of functionality and less vagus nerve impairment symptoms. DISCUSSION: In this article we discuss main epidemiological data of MPNST as well as distinction of our clinical case peculiarities from data mentioned in literature. CONCLUSION: MPNST are described as aggressive neoplasms with unfavorable short and long-term prognosis. Early diagnosis and radical surgical intervention not only improve patient prognosis but also allow to use additional treatment options to improve patients survival and quality of the life even in case of MPNST.

The Controlling Nutritional Status (CONUT) Score for Prediction of Microvascular Flap Complications in Reconstructive Surgery.

Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659-0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99-16.11 vs. 25.38, 14.82-35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery.

Microvascular flap reconstruction of pharynx in patient with actinomycosis.

Surgical treatment for patients with actinomycosis with head and neck reconstruction should be considered as a reliable treatment option with a good long-term effect.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Microsurgical reconstruction of oral defects with free flaps for patients with oral cancer: an 8 year experience with 153 consecutive cases.

OBJECTIVE: Oral squamous cell carcinoma (OSCC) is a common type of cancer affecting people worldwide, with still large proportion of patients diagnosed with the disease in the advanced stage. Due to free vascularised tissue transfers, radical cancer treatment and immediate reconstruction are feasible as a one-stage procedure. The aim of this paper is to evaluate retrospectively our experience with free flap reconstruction of oral defects for patients with oral malignancies in advanced stages. MATERIAL AND METHODS: During the 8-year period, 153 patients with oral cancer had undergone simultaneous extirpation of tumor with or without suspicious lymph node removal and reconstruction of the defect with free flap. A total of 157 free-flap reconstructions had been performed for 153 patients. Accordingly, 116 patients had reconstruction of oral soft tissue defect, but 37 patients had complex soft tissue and bone defect reconstruction. RESULTS: 132 patients had successful free flap surgery with uneventful post surgery period. Flap success rate was 96.8%. Donors site was closed primarily in 58 cases, skin graft was used in 102 cases. Five patients (3.2%) died during post surgery period. Average hospital stay was 20,5 days (from 8 till 44 days). There was no statistically significant correlation found between the patient's age and hospital stay, but hospital stay increased with tumor size (p>0.05). CONCLUSION: The application of the best possible reconstruction method that contributes to the fulfillment of expectations and provision of a good functional and esthetical result is enabled by setting proper, realistic reconstruction goals. Microvascular reconstruction with free flaps for oral defects is a safe method with a very high success rate (96.8%).