Risk factors for pressure ulcer recurrence following surgical reconstruction: A cross-sectional retrospective analysis.

Many studies on the recurrence of pressure ulcers after surgical reconstruction have focused on surgical techniques and socioeconomic factors. Herein, we aimed to identify the risk factors of the associated comorbidities for pressure ulcer recurrence. We enrolled 147 patients who underwent pressure ulcer reconstruction and were followed up for more than three years. The recurrence of pressure ulcers was defined as recurrent pressure ulcers with stage 3/4 pressure ulcers. We reviewed and analyzed systematic records of medical histories, including sex, age, associated comorbidities such as spinal cord injury (SCI), diabetes mellitus (DM), coronary artery disease, cerebral vascular accident, end-stage renal disease, scoliosis, dementia, Parkinson's disease, psychosis, autoimmune diseases, hip surgery, and locations of the primary pressure ulcer. Patients with recurrent pressure ulcers were younger than those without. Patients with SCI and scoliosis had higher odds, while those with Parkinson's disease had lower odds of recurrence of pressure ulcers than those without these comorbidities. Moreover, the decision tree algorithm identified that SCI, DM, and age < 34 years could be risk factor classifiers for predicting recurrent pressure ulcers. This study demonstrated that age and SCI are the two most important risk factors associated with recurrent pressure ulcers following surgical reconstruction.

Effect of a Novel Macrophage-Regulating Drug on Wound Healing in Patients With Diabetic Foot Ulcers: A Randomized Clinical Trial.

Importance: Delayed healing of diabetic foot ulcers (DFUs) is known to be caused by dysregulated M1/M2-type macrophages, and restoring the balance between these macrophage types plays a critical role in healing. However, drugs used to regulate M1/M2 macrophages have not yet been studied in large randomized clinical trials. Objective: To compare the topical application of ON101 cream with use of an absorbent dressing (Hydrofiber; ConvaTec Ltd) when treating DFUs. Design, Setting, and Participants: This multicenter, evaluator-blinded, phase 3 randomized clinical trial was performed in 21 clinical and medical centers across the US, China, and Taiwan from November 23, 2012, to May 11, 2020. Eligible patients with debrided DFUs of 1 to 25 cm2 present for at least 4 weeks and with Wagner grade 1 or 2 were randomized 1:1 to receive ON101 or control absorbent dressings. Interventions: Twice-daily applications of ON101 or a absorbent dressing changed once daily or 2 to 3 times a week for 16 weeks, with a 12-week follow-up. Main Outcomes and Measures: The primary outcome was the incidence of complete healing, defined as complete re-epithelialization at 2 consecutive visits during the treatment period assessed on the full-analysis set (FAS) of all participants with postrandomization data collected. Safety outcomes included assessment of the incidences of adverse events, clinical laboratory values, and vital signs. Results: In the FAS, 236 eligible patients (175 men [74.2%]; mean [SD] age, 57.0 [10.9] years; mean [SD] glycated hemoglobin level, 8.1% [1.6%]) with DFUs classified as Wagner grade 1 or 2 (mean [SD] ulcer area, 4.8 [4.4] cm2) were randomized to receive either the ON101 cream (n = 122) or the absorbent dressing (n = 114) for as long as 16 weeks. The incidence of complete healing in the FAS included 74 patients (60.7%) in the ON101 group and 40 (35.1%) in the comparator group during the 16-week treatment period (difference, 25.6 percentage points; odds ratio, 2.84; 95% CI, 1.66-4.84; P < .001). A total of 7 (5.7%) treatment-emergent adverse events occurred in the ON101 group vs 5 (4.4%) in the comparator group. No treatment-related serious adverse events occurred in the ON101 group vs 1 (0.9%) in the comparator group. Conclusions and Relevance: In this multicenter randomized clinical trial, ON101 exhibited better healing efficacy than absorbent dressing alone in the treatment of DFUs and showed consistent efficacy among all patients, including those with DFU-related risk factors (glycated hemoglobin level, ≥9%; ulcer area, >5 cm2; and DFU duration, ≥6 months). Trial Registration: ClinicalTrials.gov Identifier: NCT01898923.

Hyperbaric oxygen facilitates the effect of endothelial progenitor cell therapy on improving outcome of rat critical limb ischemia.

We tested the hypothesis that hyperbaric oxygen (HBO) (100% oxygen/2.4 atmospheres) facilitated the effect of autologous endothelial progenitor cell (EPC) therapy on restoring the blood flow in rat critical-limb ischemia (CLI). Adult-male-SD rats (n = 8/each group) were categorized into group 1 [sham control (SC)], group 2 (CLI-treated with culture medium), group 3 [CLI-intermittent HBO (3 h/day for 5 consecutive days after CLI), group 4 (CLI-EPC/2.0 × 106 cells), and group 5 (CLI-HBO-EPC). By day 5 after CLI, flow cytometry showed that the circulating EPC (Sca-1/CD31+/C-kit/CD31+/CD34+) levels were highest in group 5 and lowest in group 2 (all P < 0.001). By day 14, laser Doppler demonstrated that the ratio of blood flow (i.e., CLI to normal hind-limb) was highest in group 1, lowest in group 2 and significantly higher in group 5 than in groups 3 and 4 (all P < 0.0001). The protein expressions of endothelial-cell biomarkers (CD31/vWF/eNOS), and numbers of endothelial-cell markers (CD31+/vWF+) and small vessels exhibited a similar pattern to blood-flow ratio among five groups, whereas the angiogenesis parameters in protein (CXCR4/SDF-1α/HIF-1α/VEGF) and cellular (HIF-1α/SDF-1α/CXCR4+) levels were progressively increased from groups 1 to 5 (all P < 0.0001). The protein expression of apoptotic (mitochondrial-Bax/cleaved-capspase-3/PARP), fibrotic (p-Smad3/TGF-ß) and mitochondrial-damaged (cytosolic-cytochrome C) exhibited an opposite pattern, whereas the protein expressions of anti-fibrotic (BMP-2/p-Smad1/5) and mitochondrial integrity (mitochondrial-cytochrome C) exhibited an identical pattern of ratio of blood flow among the five groups (all P < 0.0001). Combined HBO-EPC therapy is superior to either one alone in improving ischemia in rodent CLI.

Hyperbaric Oxygen Therapy Enhanced Circulating Levels of Endothelial Progenitor Cells and Angiogenesis Biomarkers, Blood Flow, in Ischemic Areas in Patients with Peripheral Arterial Occlusive Disease.

BACKGROUND: This study tested the hypothesis that hyperbaric oxygen (HBO) therapy enhanced the circulating levels of endothelial progenitor cells (EPCs), soluble angiogenesis factors, and blood flow in ischemic areas in patients with peripheral arterial occlusive disease (PAOD). METHODS: In total, 57 consecutive patients with PAOD undergoing the HBO therapy (3 atmospheres (atm) for 2 h each time) were prospectively enrolled into the present study. Venous blood sampling was performed to assess the circulating levels of EPCs and soluble angiogenesis factors prior to and during five sessions of HBO therapy. Additionally, skin perfusion pressure (SPP), an indicator of blood flow in ischemic areas, was measured by moorVMS-PRES. RESULTS: The results demonstrated that the circulating levels of EPCs (cluster of differentiation (CD)34⁺/CD133⁺/CD45dim, CD31⁺/CD133⁺/CD45dim, CD34⁺) and soluble angiogenesis factors-vascular endothelial growth factor/stromal cell-derived factor 1/hepatocyte growth factor/fibroblast growth factor (VEGF/SDF-1α/HGF/FGF) were significantly increased post-HBO therapy as compared to pre-HBO therapy (all p < 0.01). Additionally, Matrigel assay showed that the angiogenesis was significantly increased in post-HBO therapy as compared to prior to therapy (p < 0.001). Furthermore, SPP was significantly increased in the ischemic area (i.e., plantar foot and mean SPP of the ischemic foot) in post-HBO therapy as compared to pre-HBO therapy (all p < 0.01). Importantly, the HBO therapy did appear to result in complications, and all the patients were uneventfully discharged without amputation. CONCLUSIONS: HBO therapy augmented circulating levels of EPCs and angiogenesis factors, and improved the blood flow in the ischemic area.

Immediate Negative Pressure Wound Therapy After Free Flap Transfer for Head and Neck Cancer Surgery.

OBJECTIVE: This study aimed to assess the outcomes of administering negative-pressure wound therapy (NPWT) in patients immediately following free flap reconstruction after head and neck cancer surgery and radical neck lymph node dissection. The outcomes were compared with those of patients who received conventional wound care (CWC). METHODS: A retrospective analysis was performed for 58 patients with head and neck cancer who underwent free flap reconstruction after tumor ablation and radical neck dissection between February 1, 2016, and October 31, 2016. All reconstructions were performed by the same plastic surgeon. Charts were reviewed for patient demographics, comorbidities, cancer type, operation time, flap type, postoperative drainage volume, complication rates, length of hospital stay, and wound outcomes. RESULTS: No significant difference was observed between patients receiving NPWT and CWC regarding operation time and drainage volume from the vacuum ball. After the application of NPWT, no patients experienced flap failure or developed a wound infection. Significantly fewer patients receiving NPWT developed complications (9.7% vs. 37.0%; P = 0.025) and developed infections (0.0% vs. 14.8%; P = 0.041) compared with those receiving CWC. CONCLUSION: On the basis of fewer associated complications and infections, this study supports the immediate use of NPWT after free flap reconstruction in patients who have undergone head and neck cancer ablation and radical neck lymph node dissection. LEVEL OF EVIDENCE: 4. Laryngoscope, 2478-2482, 2018.

Combined Therapy with Extracorporeal Shock Wave and Adipose-Derived Mesenchymal Stem Cells Remarkably Improved Acute Ischemia-Reperfusion Injury of Quadriceps Muscle.

Extracorporeal shock wave (ECSW) and adipose-derived mesenchymal stem cells (ADMSCs) have been recognized to have capacities of anti-inflammation and angiogenesis. We tested the hypothesis that ECSW and ADMSC therapy could attenuate ischemia-reperfusion- (IR-) induced thigh injury (femoral artery tightened for 6 h then the tightness was relieved) in rats. Adult male SD rats (n = 30) were divided into group 1 (sham-control), group 2 (IR), group 3 (IR + ECSW/120 impulses at 0.12 mJ/mm2 given at 3 h/24 h/72 h after IR), group 4 (allogenic ADMSC/1.2 × 106 cell intramuscular and 1.2 × 106 cell intravenous injections 3 h after IR procedure), and group 5 (ECSW + ADMSC). At day 7 after the IR procedure, the left quadriceps muscle was harvested for studies. At 18 h after the IR procedure, serum myoglobin/creatine phosphokinase (CPK) levels were highest in group 2, lowest in group 1, and with intermediate values significantly progressively reduced in groups 3 to 5 (all p < 0.0001). By day 5 after IR, the mechanical paw-withdrawal threshold displayed an opposite pattern of CPK (all p < 0.0001). The protein expressions of inflammatory, oxidative-stress, apoptotic, fibrotic, DNA-damaged, and mitochondrial-damaged biomarkers and cellular expressions of inflammatory and DNA-damaged biomarkers exhibited an identical pattern of CPK among the five groups (all p < 0.0001). The microscopic findings of endothelial-cell biomarkers and number of arterioles expressed an opposite pattern of CPK, and the angiogenesis marker was significantly progressively increased from groups 1 to 5, whereas the histopathology showed that muscle-damaged/fibrosis/collagen-deposition areas exhibited an identical pattern of CPK among the five groups (all p < 0.0001). In conclusion, ECSW-ADMSC therapy is superior to either one applied individually for protecting against IR-induced thigh injury.

Extracorporeal shock wave treatment attenuated left ventricular dysfunction and remodeling in mini-pig with cardiorenal syndrome.

This study tested the hypothesis that extracorporeal shock wave (ECSW) treatment can improve ischemia-induced left ventricular (LV) dysfunction in mini-pig with co-existing chronic kidney disease (CKD). LV ischemia in mini-pigs was induced by applying an ameroid constrictor over mid-left anterior descending artery (LAD), while model of CKD was established by right nephrectomy with partial ligation of left renal arterioles 2 weeks before LAD constriction. Thirty mini-pigs were randomly divided into group 1 (sham-control), group 2 (LV-ischemia), group 3 (LV-ischemia + CKD), Group 4 [LV-ischemia + ECSW (applied 1200 shots at 0.1 mJ/m2/equally to 4-ischemic regions by day-90 after LAD constriction], and group 5 (LV-ischemia-CKD + ECSW). By day-180 after CKD induction, echocardiography showed that LV ejection fraction (LVEF) was highest in group 1, lowest in group 3, significantly lower in group 2 than that in groups 4 and 5, and significantly lower in group 5 than that in group 4, whereas LV-end systolic and diastolic dimensions displayed an opposite pattern (all p<0.001). Protein expressions of oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptotic (cleaved-caspase-3/cleaved-PARP/mitochondrial-Bax), fibrotic (TGF-ß/Smad3), pressure/volume-overload (BNP/ß-MHC), endothelial (CD31/vWF) and mitochondrial-integrity (PGC-1/mitochondrial-cytochrome-C) biomarkers exhibited a pattern identical to that of LVEF, whereas angiogenesis factors (VEGF/CXCR4/SDF-1α) showed significant progressive increase among all groups (all p<0.0001). Microscopic findings of CD31+cells/vWF+cells/small-vessel density/sarcomere-length showed an identical pattern, whereas collagen-deposition area/fibrotic area/apoptotic nuclei expressed an opposite pattern compared to that of LVEF among all groups (all p<0.0001). In conclusion, CKD aggravated ischemia-induced LV dysfunction and remodeling and molecular-cellular perturbations that were reversed by ECSW treatment.

Therapeutic effect of rosuvastatin and propylthiouracil on ameliorating high-cholesterol diet-induced fatty liver disease, fibrosis and inflammation in rabbit.

This study tested the hypothesis that high-cholesterol diet (HCD)-induced fatty liver disease could be ameliorated by rosuvastatin (Ros) and propylthiouracil (PTU) therapy. Thirty-two Zealand rabbits were equally divided into group 1 (sham-control), group 2 (HCD for 8 weeks), group 3 [HCD-Ros (20 mg/kg/day administration after 4-week HFD for 4 weeks)], group 4 [HCD-PTU (0.1% PTU in drinking water) with treatment course as group 3]. Liver weight, fibrosis, collagen deposition area, and serum levels of AST/ALT were highest in group 2, lowest in group 1, and significantly higher in group 4 than group 3 (all P<0.0001). The levels of inflammatory (TNF-α/NF-κB/IL-1ß/IL-6/MMP-9/VCAM-1/PAI-1/TLR-4, MyD88/IL-12/IFN-γ), oxidative stress (NOX-1/NOX-2/oxidized protein), apoptotic (Bax/cleaved-capase-3/PARP), fibrotic (Smad-3/TGF-ß), and mitochondria-damaged (cytosolic-cytochrome-C) proteins showed an identical pattern, whereas antiapoptotic (Bcl-2), mitochondrial-integrity (mitochondrial-cytochrome-C) and antioxidative (SIRT1/SIRT3) biomarkers exhibited an opposite pattern to fibrosis among the four groups (all P<0.0001). The cellular expressions of inflammatory (Kupffer/CD14/CD44), α-fetoprotein-positively stained biomarkers, apoptotic nuclei and fat cells displayed an identical pattern to fibrosis (all P<0.0001). In conclusion, Ros-PTU therapy attenuated liver fibrosis, inflammatory reaction and generation of oxidative stress and fatty liver after HCD challenge in rabbits.

Impact of impaired cardiac function on the progression of chronic kidney disease---role of pharmacomodulation of valsartan.

Although chronic kidney disease (CKD) is known to aggravate cardiovascular disease in the setting of cardiorenal syndrome (CRS), the impact of impaired cardiac function on the progression of CKD has seldom been reported. This study tested the impact of acute myocardial infarction on a rodent CKD model and the therapeutic effect of valsartan in this setting. Adult male Sprague-Dawley rats (n = 50) equally divided into group 1 (sham control), group 2 (CKD induced by 5/6 nephrectomy), group 3 (AMI by ligation of left coronary artery), group 4 (CKD+AMI), group 5 (CKD+AMI+valsartan, orally 10 mg/kg/day). By day 60, kidney injury score, creatinine levels, and ratio of urine to creatinine were highest in group 4 and lowest in group 1, significantly higher in group 4 than those in groups 2 and 5, and significantly higher in group 5 than those in group 2 (all p < 0.001). Protein expressions of inflammation (IL-1ß/MMP-9), oxidative stress (NOX-1/NOX-2/oxidized protein, angiotensin-II receptor), apoptosis (Bax, cleaved caspase-3/PARP), fibrosis (Smad3/TGF-ß), and kidney injured (KIM-1/FSP-1) markers showed an identical pattern, whereas anti-fibrosis (Smad5/BMP-2) indices exhibited an opposite pattern compared to that of creatinine level among all groups (all p < 0.01). Cellular expressions of inflammation (CD14/CD68), DNA-damage (γ-H2AX, CD90/XRCC1) and proximal-renal tubule (KIM-1) biomarkers displayed an identical pattern, whereas podocyte-integrity markers (podocin/ZO-1/p-cadherin/synaptopodin) showed a pattern opposite to that of creatinine level among all groups (all p < 0.001). In a rodent CKD setting, renal function impairment and parenchymal damage further deteriorated after AMI but were suppressed following valsartan treatment.

The therapeutic effect of rosuvastatin and propylthiouracil on ameliorating high-cholesterol diet-induced rabbit aortic atherosclerosis and stiffness.

BACKGROUND: We tested the hypothesis that arteriosclerosis-augmented aortic pulse wave velocity (PWV) and -impaired vasorelaxation were attenuated by rosuvastatin (Rosu) and propylthiouracil (PTU) therapy. METHODS AND RESULTS: Thirty-two New Zealand rabbits were equally divided into group 1 (sham-control), group 2 [high-cholesterol-diet (HCD) for 8weeks], group 3 [HCD-Rosu (20mg/kg/day administration after 4-week HFD for 4weeks)], and group 4 [HCD-PTU (0.1% PTU in drinking water), the treatment course as group 3]. KCl-induced vasoconstriction of carotid artery (CA) was significantly higher in group 2 than in other groups (all p<0.01), but showed no differences among groups 1, 3 and 4, whereas acetylcholine-induced vasorelaxation exhibited an opposite pattern of KCl-induced vasoconstriction among the four groups (p<0.001). Basic nitric-oxide release from endothelial cells of CA was highest in group 1, lowest in group 2, but showed no difference between groups 3 and 4 (all p<0.001). PWV value was highest in group 2, lowest in group 1, and significantly higher in group 4 than in group 3 (all p<0.001). Serum levels of total-cholesterol, LDL and TG showed an identical pattern to PWV (all p<0.001), whereas the levels of free T4, sugar, and body weight did not differ among the four groups (all p>0.4). Aortic inflammatory biomarkers in cellular (CD68+/IL-1ß+/CD14+) and protein (TNF-α/NF-κB/IL-1ß/MMP-9/MCP-1/ICAM-1/PDGF) levels, and aortic oxidative-stress biomarkers in cellular (8-OHdG) and protein (NOX-1/NOX-2/oxidized protein) levels showed an identical pattern to PWV among the four groups (all p<0.001). CONCLUSION: Rosu-PTU therapy ameliorated aortic stiffness and inflammation/oxidative-stress, and improved endothelial-cell function after HCD challenge in rabbit.

Comparison of the outcomes of free jejunal flap reconstructions of pharyngoesophageal defects in hypopharyngeal cancer and corrosive injury patients.

INTRODUCTION: Free jejunal flap is one of the optimal choices for restoring upper digestive tract. The purpose of this study was to introduce the treatment strategies and to compare the outcomes of free jejunal flap for pharyngoesophageal reconstruction between hypopharyngeal cancer and chemical corrosive injured esophagus. METHODS: From 2001 to 2012, patients who had been received esophageal reconstruction by free jejunal flap for pharyngoesophageal defect were divided into squamous cell carcinoma (SCC) group and corrosive chemical injury (CCI) group. All data on outcomes and complications including relevant radiographic investigations were collected retrospectively. RESULTS: Sixteen patients were in SCC group and 9 patients in CCI group underwent free jejunal flap reconstruction. Two cases of flap failure were noted in SCC group, and no flap failure in CCI group-the total failure rate was 8% (2/25 patients). In SCC group, 5 of 16 patients (31.3%) developed fistula; however, no fistula in CCI group. One patient in SCC group and 3 patients in CCI group developed esophageal strictures. Other than early stricture (stricture <1 year) which reached significant difference, all of other complications were not statistically significant between two groups. The average follow-up time was 42 months. CONCLUSIONS: Postoperative early stricture but lower fistula occurrence is expected in patients with corrosively injured esophagi. This helpful preliminary findings could not only early-check complication, but also better explanation and prepare were taken placed before operation.

The First Hand Allotransplantation in Taiwan: A Report at 9 Months.

PURPOSE: Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. MATERIALS AND METHODS: On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. RESULTS: The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. CONCLUSIONS: Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

The new innovation of the lower medial thigh perforator flap for head and neck reconstruction.

BACKGROUND: The choice of optimal flap is still a challenge for patients with resection of head and neck cancer and reconstruction, especially for recurrent cases. In this article, we report the results of the new innovation of free lower medial thigh perforator (LMTP) flap for head and neck reconstruction in a series of patients. PATIENTS AND METHODS: Fifteen patients received reconstruction with free LMTP flaps. The defect locations included the buccal area (3 cases), tongue (6 cases), lower/upper gum (5 cases), and soft palate (1 case). The perforators of flap design were detected at the distal third of the line, which was drawn from the midpoint of inguinal ligament to medial upper border of patella. The superficial temporal artery (7 cases), superior thyroid artery (6 cases), and facial artery (2 cases) were dissected as recipient vessels. RESULTS: The flap sizes varied from 12 × 5 cm(2) to 20 × 8 cm(2) . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All of flaps were survived after surgery, except one failed due to venous thrombosis. Another one flap suffered from venous thrombosis and was successfully salvaged by performing a venous thrombectomy. All donor sites were primarily closed except one skin grafting. The follow-up time ranged from 3 to 15 months (average: 7 months) and all patients had good recovery with satisfactory results. CONCLUSION: The LMTP flap indicates a pliable with constant vascular anatomy and low donor-site morbidity. It could be an alternative for reconstructing defects in head and neck region. © 2015 Wiley Periodicals, Inc. Microsurgery 36:284-290, 2016.

An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction.

BACKGROUND: The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral thigh (ALT) flap, and the jejunum flap. This study was to objectively compare three different flaps for pharyngeal reconstruction during the past 10 years. Stricture and fistula were assessed using esophagogram and esophagoscopy. METHODS: Forty-five patients with pharyngeal reconstructions had esophagram and esophagoscopy done postoperatively to assess for strictures and fistulas. These patients were divided into three groups based on pharyngeal reconstruction by ALT, RFF, and jejunal flaps. From the results of the esophagogram and esophagoscope, the presence of a fistula or stricture was compared and analyzed. RESULTS: There was only one ALT flap failure. The rate of fistula was 33%, 50%, and 30% in the ALT, RFF, and jejunal flap group respectively. The fistula rate revealed no significant difference between ALT, RFF, jejunal flap groups (P = 0.63). The rate of stricture was 38.1%, 57.1%, and 0% in the ALT, RFA, jejunal flap groups respectively. The stricture rate in jejunal flap group revealed significant decrease (P = 0.0093). CONCLUSION: Jejunal flap has a significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps.

Dermatofibrosarcoma protuberans in children and adolescents: Clinical presentation, histology, treatment, and review of the literature.

PURPOSE: Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade malignant tumor. It is characterized by aggressive local infiltration, leading to a propensity for recurrence. In children, DFSP is even less common and likely misdiagnosed or underdiagnosed. This study is a review of DFSP in the pediatric population and aims to identify factors for successful treatment. MATERIALS AND METHODS: From July of 1986 to 2011, a total of 159 patients were diagnosed with dermatofibrosarcoma protuberans at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Subject to the age classification of our institution, patients under the age of 18 are defined in the pediatric category, of which159 cases were identified as our research subjects. Detailed data, including demographic data, imaging studies, pathology, treatment methods, and outcomes, of these identified patients were collected, reviewed, and analyzed. RESULTS: A total of 13 patients, consisting of six male and seven female patients, were identified based on our criteria. Two had the lesions noticed at birth. Most patients experienced a variable period of quiescence, followed by a rapid growth phase. All 13 patients underwent wide excisions. Post-excision reconstruction included direct closure in three cases, skin grafting in three cases, and local or free flap reconstruction in seven cases. Of 13 patients, four received postoperative radiotherapy. All patients survived without recurrence up to July 2011, with follow-up periods ranging from 20 months to 19 years. CONCLUSION: Clinicians should be aware that DFSP is known to occur among children. Owing to its relatively low incidence, its presence may be confused with commoner lesions such as hemangioma, fibroma, or atrophic plaques without nodule. The confusing situation, as a result, frequently leads to delayed diagnosis. Vigilance in its diagnosis allows for treatment at manageable sizes as well as ensures complete excision. Reconstructive options, such as skin grafting, and modalities, such as adjuvant postoperative radiotherapy, are suggested to best complement each other. The former minimizes disfigurement while the latter minimizes recurrences.

Influence of neck dissection and preoperative irradiation on microvascular head and neck reconstruction-Analysis of 853 cases.

BACKGROUND: Previous neck dissection and irradiation is believed to affect the success of free tissue transfers in head and neck reconstruction, but evidence is scarce and conflicting. This study seeks to evaluate flap success rates in the presence of these two factors. METHODS: Over a ten-year period, a total of 853 free flap cases were evaluated. Success rates were compared between a control group with no prior intervention (non-irradiation and neck dissection, NRTND) against three other groups: irradiation only (RT), previous neck dissection only (ND), and both (RTND). The choices of recipient vessel used were also compared. RESULTS: The flap failure rate was 6.3% (4/63) in the RTND group; 4.8% (1/21) in the ND group; 5.2% (6/115) in the RT group; and 2.1% (14/654) in the NRTND group. There was no statistical significance among the four groups (P = 0.254). Ipsilateral neck vessels (92.7%) were more frequently used in the NRTND group. In contrast, the superficial temporal vessels, contra-lateral neck vessels were more likely to be selected in the groups with irradiation and/or neck dissection. CONCLUSIONS: Free tissue transfer in head and neck patients with previous irradiation and neck dissection is feasible and can be safely done. In addition, superficial temporal vessel could be the first choice in patients with previous radiotherapy and neck dissection.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps.

BACKGROUND: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. METHODS: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. RESULTS: The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. CONCLUSIONS: In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted.

Levels and values of lipoprotein-associated phospholipase A2, galectin-3, RhoA/ROCK, and endothelial progenitor cells in critical limb ischemia: pharmaco-therapeutic role of cilostazol and clopidogrel combination therapy.

OBJECTIVE: We tested the hypothesis that clopidogrel and cilostazol combination therapy could effectively attenuate systemic inflammatory reaction, facilitate proliferation of circulating endothelial progenitor cell (EPC), and improve the clinical outcomes of critical limb ischemia (CLI) in patients unsuitable for surgical revascularization or percutaneous transluminal angioplasty (PTA). METHODS: A total 55 patients (mean age, 72 years; 56% female) were consecutively enrolled. Clopidogrel and cilostazol combination therapy was administered throughout the study period. RESULTS: As compared with the baseline, circulating endothelial progenitor cell level (as shown by flow cytometry) was significantly increased (p<0.003), whereas the CLI-related ulcers and painfulness were significantly improved (all p<0.01) by day 90 after treatment. On the other hand, after clopidogrel and cilostazol combination therapy, galectin-3 level, lipoprotein-associated phospholipase A2 gene expression, and RhoA/ROCK-related protein expression in peripheral blood mononuclear cells were significantly suppressed (all p<0.01). Eventually, by day 90, 5 patients (9.1%) died of other etiologies, 3 (5.5%) withdrew from the study, 6 (10.9%) required amputation, and the remaining 41 had satisfactory clinical improvement with complete wound healing in 9 (16.4%) patients. CONCLUSION: The results of the present study highlight that clopidogrel and cilostazol combination therapy may be considered to be an alternative method for treating patients with CLI unsuitable for surgical revascularization or PTA.