The Influence of Body Contouring Surgery on Weight Control and Comorbidities in Patients After Bariatric Surgery.

INTRODUCTION: A considerable number of patients experience some long-term weight regain after bariatric surgery. Body contouring surgery (BCS) is thought to strengthen post-bariatric surgery patients in their weight control and maintenance of achieved improvements in comorbidities. OBJECTIVES: To examine the impact of BCS on long-term weight control and comorbidities after bariatric surgery. METHODS: We performed a retrospective study in a prospective database. All patients who underwent primary Roux-en-Y gastric bypass (RYGB) and presented for preoperative consultation of BCS in the same hospital were included in the study. Linear and logistic mixed-effect model analyses were used to evaluate the longitudinal relationships between patients who were accepted or rejected for BCS and their weight loss outcomes or changes in comorbidities. RESULTS: Of the 1150 patients who underwent primary RYGB between January 2010 and December 2014, 258 patients (22.4%) presented for preoperative consultation of BCS. Of these patients, 126 patients eventually underwent BCS (48.8%). Patients who were accepted for BCS demonstrated significant better ∆body mass index (BMI) on average over time (- 1.31 kg/m2/year, 95% confidence interval (CI) -2.52 - -0.10, p = 0.034) and percent total weight loss (%TWL) was significantly different at 36 months (5.79, 95%CI 1.22 - 10.37, p = 0.013) and 48 months (6.78, 95%CI 0.93 - 12.63, p = 0.023) after body contouring consultation. Patients who were accepted or rejected did not differ significantly in the maintenance of achieved improvements in comorbidities. CONCLUSION: BCS could not be associated with the maintenance of achieved improvements in comorbidities after bariatric surgery, whereas it could be associated with improved weight loss maintenance at 36 and 48 months after body contouring consultation. This association should be further explored in a large longitudinal study.

Long-Term Results of Universal 2 Total Wrist Arthroplasty.

Background The Universal 2 is a widely used total wrist implant that aims to maintain function of the wrist. Purpose Promising mid-term results of the Universal 2 total wrist implant are described in the literature. This study evaluates the long-term results in terms of implant survival and patient satisfaction. Patients and Methods Patients who received a Universal 2 implant between 2004 and 2009 were retrospectively identified through a database search. Clinical outcome and complications of the implant were assessed by examination of the patient's medical records, X-rays, and a questionnaire, consisting of the Patient-Rated Wrist and Hand Evaluation questionnaire (PRWHE) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires and additional questions. Results Twenty-five patients (26 wrists) were included in this study. Twenty-one (81%) Universal 2 implants remained in situ after a mean follow-up of 11 years. Moderate PRWHE (44) and QuickDASH (41) scores were found in these cases. Five Universal 2 implants failed and were converted to a total wrist arthrodesis after a mean period of 9.2 years due to distal component loosening ( n = 3), recurrent luxation ( n = 1), or recurrent synovitis ( n = 1). Twenty-three (92%) patients were (very) satisfied with the Universal 2 implant. Conclusion The Universal 2 demonstrates a high (81%) implant survival with a high patient satisfaction after a mean follow-up of 11 years. Prospective studies of the Universal 2 implant are necessary to objectify improvement in wrist function and to provide a better comparison to other fourth generation wrist implants.

Toll-Like Receptors (TLRs) Expression in Contracted Capsules Compared to Uncontracted Capsules.

INTRODUCTION: The etiology of capsular contracture after surgical implantation of breast implants remains unclear, but an important role is seen for the immune system. Toll-like receptors are immune receptors recognizing both pathogen-associated molecular patterns and damage-associated molecular patterns. The former are present on bacteria such as Staphylococcus epidermidis (bacteria earlier associated with capsular contracture), and the latter are released after (mechanical) stress. The aim of this study was to investigate the expression of TLRs 1-10 in relation to capsular contracture. MATERIALS AND METHODS: Fifty consecutive breast capsules were collected during implant removal or replacement. The extent of capsular contracture was scored according to the Baker score. A sample specimen (0.5 cm3) was obtained from all tissues. cDNA was synthesized from isolated mRNA from the collected specimens. PCR analyses were conducted to test for cDNA presence and to quantify concentration. TLR1-10 expression was measured for each of the Baker scores separately and compared to all Baker scores. RESULTS: Expression of all TLRs in all Baker scores was seen. TLR2 and TLR6 were more often present in contracted samples (Baker 3 or 4) compared to uncontracted samples (Baker 1 or 2) [Baker 2 vs. 3 (p = 0.034) and Baker 2 vs. 3 (p = 0.003), respectively]. None of the TLRs displayed a significantly higher expression in contracted capsules compared to uncontracted capsules. CONCLUSION: This study shows that TLR2 and TLR6 are more often expressed in contracted capsules compared to non-contracted capsules however not in higher concentrations. LEVEL OF EVIDENCE III: 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 .

Short-term cost-effectiveness of one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage expander-implant reconstruction from a multicentre randomized clinical trial.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure and its economic impact is significant. This study aimed to analyse whether a direct one-stage IBBR with use of an acellular dermal matrix (ADM) is more cost-effective than two-stage (expander-implant) breast reconstruction. METHODS: The BRIOS (Breast Reconstruction In One Stage) study was an open-label multicentre RCT in which women scheduled for skin-sparing mastectomy and immediate IBBR were randomized between one-stage IBBR with ADM or two-stage IBBR. Duration of surgery and hospital stay, and visits for the primary surgery, unplanned and cosmetic procedures were recorded. Costs were estimated at an institutional level. Health status was assessed by means of the EuroQol Five Dimensions 5L questionnaire. RESULTS: Fifty-nine patients (91 breasts) underwent one-stage IBBR with ADM and 62 patients (92 breasts) two-stage IBBR. The mean(s.d.) duration of surgery in the one-stage group was significantly longer than that for two-stage IBBR for unilateral (2·52(0·55) versus 2·02(0·35) h; P < 0·001) and bilateral (4·03(1·00) versus 3·25(0·58) h; P = 0·017) reconstructions. Costs were higher for one-stage compared with two-stage IBBR for both unilateral (€12 448 (95 per cent c.i. 10 722 to 14 387) versus €9871 (9373 to 10 445) respectively; P = 0·025) and bilateral (€16 939 (14 887 to 19 360) versus €13 383 (12 414 to 14 669); P = 0·002) reconstructions. This was partly related to the use of relatively expensive ADM. There was no difference in postoperative health status between the groups. CONCLUSION: One-stage IBBR with ADM was associated with higher costs, but similar health status, compared with conventional two-stage IBBR. Registration number: NTR5446 ( http://www.trialregister.nl).

Poly Implant Prothèse silicone breast implants: implant dynamics and capsular contracture.

BACKGROUND: The Poly Implant Prothèse (PIP) implants were withdrawn from the market in 2010 due to the use of low-grade silicone, causing a high risk for implant rupture. The aim of this study was to investigate the implant dynamics of PIP breast implants, as well as to determine the rate and predictors of implant gel bleeding, rupture, and capsular contracture in PIP implants. METHODS: Eighty women with a total of 152 PIP implants who underwent a reoperation in 2012 were enrolled in this study. Physical investigation included assessing the Baker score and demographics were retrospectively traced in medical records. The pre- and post-operative volumes of the implants were calculated and their state was determined intraoperatively by the surgeon. RESULTS: The implants were removed after a mean implant duration of 11 ± 2.1 years. Gel bleed and implant rupture occurred in respectively 42 and 25% of the implants. Intact implants had post-operative volume increase as well as decrease. There was a correlation between gel bleeding and more post-operative implant volume increase (P ≤ 0.05). Capsular contracture had a protective effect against post-operative implant volume increase (P ≤ 0.05), while a post-operative implant volume increase provided a protective influence in developing capsular contracture (P ≤ 0.05). Additionally, implant rupture led to a higher risk of capsular contracture (P ≤ 0.05). CONCLUSIONS: We managed to illustrate that PIP implant shells were too permeable and that there is a correlation between gel bleeding and the increase of the post-operative implant volume. Implant rupture led to a higher risk for developing capsular contracture.Level of evidence: Level III, risk / prognostic study.

The Histological Composition of Capsular Contracture Focussed on the Inner Layer of the Capsule: An Intra-Donor Baker-I Versus Baker-IV Comparison.

BACKGROUND: Capsular contracture remains one of the major complications after breast implantation surgery. The extent of capsular contraction is scored using the Baker scale. The aim of this study was to compare intra-individual Baker-I with Baker-IV capsules, and in particular the prevalence and histological properties of the inner capsule layer. METHODS: Twenty capsules from ten patients were included after bilateral explantation surgery due to unilateral capsular contracture (Baker-IV) after cosmetic augmentation with textured implants. All capsules underwent (immune-)histochemical analysis: haematoxylin-eosin (morphology), CD68 (macrophages), cytokeratin (epithelial cells) and vimentin (fibroblasts), and were visually scored for cell density and the presence of an inner layer and measured for thickness. RESULTS: Baker-IV (n = 10) capsules were significantly thicker compared to Baker-I (n = 10) capsules (P = 0.004). An inner layer was present in 8 Baker-I capsules. All Baker-I capsules were vimentin and CD68-positive and cytokeratin-negative. Positive vimentin was seen throughout the inner layer, and CD-68 staining was observed adjacent to the intermediate capsule layer. In contrast, only 2 Baker-IV capsules had an inner layer, of which only 1 showed the same profile as Baker-I capsules (P = 0.016). No cytokeratin positivity was seen in any capsule. In Baker-IV capsules, outer layers showed more positivity for both vimentin and CD68. CONCLUSION: The inner layer is morphologically consistent with synovial metaplasia and is more prevalent in healthy, uncontracted Baker-I capsules. This inverse relation between the presence of the inner layer and higher Baker classification or pathological contracture could indicate a protective role of the inner layer against capsular contracture formation. LEVEL OF EVIDENCE III: 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 .

Predictors of complications after direct-to-implant breast reconstruction with an acellular dermal matrix from a multicentre randomized clinical trial.

BACKGROUND: In the multicentre randomized trial BRIOS (Breast Reconstruction In One Stage), direct-to-implant (DTI) breast reconstruction with an acellular dermal matrix (ADM) was associated with a markedly higher postoperative complication rate compared with two-stage tissue expander/implant breast reconstruction. This study aimed to identify factors that contribute to the occurrence of complications after DTI ADM-assisted breast reconstruction. METHODS: Data were obtained from the BRIOS study, including all patients treated with DTI ADM-assisted breast reconstruction. Logistic regression analyses were performed to identify factors predictive of postoperative complications. RESULTS: Fifty-nine patients (91 breasts) were included, of whom 27 (35 breasts) developed a surgical complication. Reoperations were performed in 29 breasts (32 per cent), with prosthesis removal in 22 (24 per cent). In multivariable analyses, mastectomy weight was associated with complications (odds ratio (OR) 1·94, 95 per cent c.i. 1·33 to 2·83), reoperations (OR 1·70, 1·12 to 2·59) and removal of the implant (OR 1·55, 1·11 to 2·17). Younger patients (OR 1·07, 1·01 to 1·13) and those who received adjuvant chemotherapy (OR 4·83, 1·15 to 20·24) more frequently required reoperation. In univariable analyses, adjuvant radiotherapy showed a trend towards more complications (OR 7·23, 0·75 to 69·95) and removal of the implant (OR 5·12, 0·76 to 34·44), without reaching statistical significance. CONCLUSION: Breast size appeared to be the most significant predictor of complications in DTI ADM-assisted breast reconstruction. The technique should preferably be performed in patients with small to moderate sized breasts. Registration number: NTR5446 ( http://www.trialregister.nl).

Management of lunotriquetral instability: a review of the literature.

UNLABELLED: Lunotriquetral ligament injury is a relatively common cause of ulnar-sided wrist pain. Injury ranges from partial stable ligament tears to extensive perilunate instability. Clinical decision-making largely depends on the chronicity, instability and cause of the ligament injury. Conservative treatment is generally regarded as first choice of treatment of mild lunotriquetral instability; however, outcome studies on conservative treatment are lacking. Temporary arthroscopic pinning and/or debridement are minimally invasive procedures of preference. In the case of more dissociative injury, surgical interventions may be performed. The literature suggests that soft tissue reconstruction is an effective procedure in this group. Arthrodesis of the lunotriquetral joint is associated with high rates of non-union (up to 57%) and the indications for surgery should therefore be very clear. Methodological issues make it hard to draw firm conclusions from the data. Studies on the effectiveness of conservative management and prospective comparative studies will further improve clinical decision-making in lunotriquetral instability. LEVEL OF EVIDENCE: N/A.

Revealing the impact of local access-site complications and upper extremity dysfunction post transradial percutaneous coronary procedures.

OBJECTIVES: Little is known about local access-site complications and upper extremity dysfunction after transradial percutaneous coronary procedures (TR-PCP). This systematic review study aimed to summarise the current knowledge on the incidences of access-site complications and upper extremity dysfunction after TR-PCP. METHODS: Two independent, trained investigators searched MEDLINE, EMBASE and CENTRAL for eligible studies published before 1 January 2015. Also, they hand-searched the conference proceedings of the annual scientific sessions of the American College of Cardiology, the American Heart Association, European Society of Cardiology, and the Trans-catheter Cardiovascular Therapeutics. Inclusion criteria were cohort studies and clinical trials discussing the incidence of access-site complications and upper extremity function after transradial percutaneous coronary intervention (TR-PCI) and/or transradial coronary angiography (TR-CAG) as endpoints. RESULTS: 176 articles described access-site complications. The incidence is up to 9.6 %. Fourteen articles described upper extremity dysfunction, with an incidence of up to 1.7 %. Upper extremity dysfunction was rarely investigated, hardly ever as primary endpoint, and if investigated not thoroughly enough. CONCLUSION: Upper extremity dysfunction in TR-PCP has never been properly investigated and is therefore underestimated. Further studies are needed to investigate the magnitude, prevention and best treatment of upper extremity dysfunction. Optimising TR-PCP might be achieved by using slender techniques, detection of upper extremity dysfunction and early referral to a hand rehabilitation centre.

MRI screening for silicone breast implant rupture: accuracy, inter- and intraobserver variability using explantation results as reference standard.

OBJECTIVES: The recall of Poly Implant Prothèse (PIP) silicone breast implants in 2010 resulted in large numbers of asymptomatic women with implants who underwent magnetic resonance imaging (MRI) screening. This study's aim was to assess the accuracy and interobserver variability of MRI screening in the detection of rupture and extracapsular silicone leakage. METHODS: A prospective study included 107 women with 214 PIP implants who underwent explantation preceded by MRI. In 2013, two radiologists blinded for previous MRI findings or outcome at surgery, independently re-evaluated all MRI examinations. A structured protocol described the MRI findings. The ex vivo findings served as reference standard. RESULTS: In 208 of the 214 explanted prostheses, radiologists agreed independently about the condition of the implants. In five of the six cases they disagreed (2.6 %), but subsequently reached consensus. A sensitivity of 93 %, specificity of 93 %, positive predictive value of 77 % and negative predictive value of 98 % was found. The interobserver agreement was excellent (kappa value of 0.92). CONCLUSIONS: MRI has a high accuracy in diagnosing rupture in silicone breast implants. Considering the high kappa value of interobserver agreement, MRI appears to be a consistent diagnostic test. A simple, uniform classification, may improve communication between radiologist and plastic surgeon. KEY POINTS: MRI has a high accuracy in diagnosing rupture in silicone breast implants. MRI appears to be a consistent diagnostic test with excellent interobserver agreement. A simple, uniform classification system, improves communication between radiologist and plastic surgeon. The interobserver agreement on implant rupture is higher than on extracapsular leakage.

Restoring wrist extension in obstetric palsy of the brachial plexus by transferring wrist flexors to wrist extensors.

Wrist extension is essential in the development of motor skills in young children. Adequate wrist extension is important for good grip function of the hand, as a slightly extended wrist results in a better and stronger grip. This retrospective study reviews the transfer of the flexor carpi ulnaris (FCU) or flexor carpi radialis (FCR) to the extensor carpi radialis brevis (ECRB) and/or longus (ERCL) to reconstruct wrist extension in 19 patients with obstetric brachial plexus palsy (OBPP). The average age at surgery was 7.2 (range 4-18) years. The mean follow-up was 3 years. Preoperatively, none of the patients had active wrist extension, with an average wrist extension-lag of 37.4 (SD 15.1) degrees. Postoperatively, average active wrist extension was 9.2 (SD 25.5) degrees. Average gain in wrist extension was 46.6 (SD 28.2) degrees, however individual gain varied substantially, i.e. between 0 and 100 degrees. Two patients were unable to reach the neutral wrist position postoperatively and in two patients wrist extension did not increase. The results of the tendon transfer to provide improvement of wrist extension in OBPP were satisfactory in most patients.

Women with silicone breast implants and unexplained systemic symptoms: a descriptive cohort study.

BACKGROUND: Since their introduction, the safety of silicone breast implants has been under debate. Although an association with systemic diseases was never established, women continuously blamed implants for their unexplained systemic symptoms. In 2011, a pattern of symptoms caused by systemic reactions to adjuvants (e.g. vaccines, silicone) was identified: 'autoimmune syndrome induced by adjuvants' (ASIA). Our aim was to collect a cohort of women with silicone breast implants and unexplained systemic symptoms to identify a possible pattern and compare this with ASIA. METHODS: Women with silicone breast implants and unexplained systemic symptoms were invited through national media to visit a special outpatient clinic in Amsterdam. All were examined by experienced consultant physicians and interviewed. Chest X-ray and laboratory tests were performed. RESULTS: Between March 2012 and 2013, 80 women were included, of which 75% reported pre-existent allergies. After a symptom-free period of years, a pattern of systemic symptoms developed, which included fatique, neurasthenia, myalgia, arthralgia and morning stiffness in more than 65% of women. All had at least two major ASIA criteria and 79% fulfilled ≥ 3 typical clinical ASIA manifestations. After explantation, 36 out of 52 women experienced a significant reduction of symptoms. CONCLUSIONS: After excluding alternative explanations, a clear pattern of signs and symptoms was recognised. Most women had pre-existent allergies, suggesting that intolerance to silicone or other substances in the implants might cause their symptoms. In 69% of women, explantation of implants reduced symptoms. Therefore, physicians should recognise this pattern and consider referring patients for explantation.

The effect of radioscapholunate fusion on wrist movement and the subsequent effects of distal scaphoidectomy and triquetrectomy.

Radioscapholunate arthrodesis is a salvage procedure indicated for osteoarthritis of the radiocarpal joint involving the lunate facet of the radius. This cadaver study examines changes in wrist motion resulting from radioscapholunate arthrodesis, and the effects of surgical techniques to improve the range of motion. Simulated radioscapholunate arthrodesis, distal scaphoidectomy and triquetrectomy were carried out sequentially on six cadaver forearms and measurements (maximum flexion/extension and radial/ulnar deviation) were taken in the intact situation and after each surgical step using a magnetic tracking device. Radioscapholunate arthrodesis diminishes the amplitudes of movements of the wrist in all directions, but range of motion in the radioscapholunate fused wrist improves after scaphoidectomy and improves further after triquetrectomy (88% of original flexion/extension and 98% of original radial/ulnar deviation). Radioscapholunate arthrodesis causes a significant change in kinematics between the hamate and the triquetrum in flexion/extension.

Hand and wrist malpractice claims in The Netherlands: 1993-2008.

We analysed hand and wrist injury and disorder related liability claims in the Netherlands to identify causes and to contribute to the prevention of such claims. Data was collected from 743 hand and wrist claims filed between 1993 and 2007. Consultants were involved in 417 claims (56.1%). Treatment in the emergency department (ED) accounted for 64.9% of these 287 claims involved residents (59.5%). The majority of accepted claims in the ED included treatment by general surgeons (89.2%). The percentage of accepted claims was highest in the general surgery group (26.4%). Of accepted claims in the ED which involved a resident, 93.2% involved a general surgery resident. Better training and supervision is indicated. This paper supports hand injury treatment by adequately trained surgeons and preferably, where possible, by a trained hand surgeon.

Adipose tissue-derived mesenchymal stem cell yield and growth characteristics are affected by the tissue-harvesting procedure.

BACKGROUND: Adipose tissue contains a stromal vascular fraction that can be easily isolated and provides a rich source of adipose tissue-derived mesenchymal stem cells (ASC). These ASC are a potential source of cells for tissue engineering. We studied whether the yield and growth characteristics of ASC were affected by the type of surgical procedure used for adipose tissue harvesting, i.e. resection, tumescent liposuction and ultrasound-assisted liposuction. METHODS: Frequencies of ASC in the stromal vascular fraction were assessed in limiting dilution assays. The phenotypical marker profile of ASC was determined, using flow cytometry, and growth kinetics were investigated in culture. ASC were cultured under chondrogenic and osteogenic conditions to confirm their differentiation potential. RESULTS: The number of viable cells in the stromal vascular fraction was affected by neither the type of surgical procedure nor the anatomical site of the body from where the adipose tissue was harvested. After all three surgical procedures, cultured ASC did express a CD34+ CD31- CD105+ CD166+ CD45- CD90+ ASC phenotype. However, ultrasound-assisted liposuction resulted in a lower frequency of proliferating ASC, as well as a longer population doubling time of ASC, compared with resection. ASC demonstrated chondrogenic and osteogenic differentiation potential. DISCUSSION: We conclude that yield and growth characteristics of ASC are affected by the type of surgical procedure used for adipose tissue harvesting. Resection and tumescent liposuction seem to be preferable above ultrasound-assisted liposuction for tissue-engineering purposes.

Early proximal row carpectomy after severe carpal trauma.

Complex fracture dislocations of the wrist often result in post-traumatic arthrosis. In these cases, patients can experience severe pain and loss of function of the wrist and as a result many of them end up having a total arthrodesis. In trying to avoid the disadvantages of a total arthrodesis, alternative treatment strategies have been investigated, amongst which proximal row carpectomy (PRC). Basic conditions for a good outcome of PRC are an intact cartilage of the lunate fossa of the distal radius and an intact surface of the head of the capitate for the new radiocapitate joint (, schematic drawing post-PRC). Also, an intact (volar) radioscaphocapitate (RSC) ligament is necessary because it plays an essential role in stabilizing the new joint and preventing volar dislocation and ulnar translocation of the distal carpal row. Acute post-traumatic PRC can be indicated, but is rarely reported in literature. In this article, we present four patients whom we have treated with early PRC after severe trauma of the wrist. Three patients had a good outcome. In the patient with the bad outcome, the before-mentioned prerequisites were not met, which is discussed.

[Concerns relating to care for transsexuals]. / Zorgen rond de zorg aan transseksuelen.

In the last decade, transsexual patients have increasingly sought sex reassignment (cross-sex hormones and sex reassignment surgery), whilst avoiding adequate diagnostic procedures. They ask non-specialized physicians to prescribe hormones or to perform sex reassignment surgery. Sometimes hormones are ordered through the Internet or obtained from other illegitimate sources. If these patients later turn to a specialized team (for instance for sex reassignment surgery), the obligatory standard diagnostic procedure is problematic: the patient does not accept having to go through a long period of assessment and objective decisionmaking, while the attending health professional feels pressured by the patient's impatience. Non-expert health professionals should draw patients' attention to the necessity of a thorough diagnostic procedure, thus avoiding wrong decisions and future regrets.