Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

With high success rates of autologous breast reconstruction, the focus has shifted from flap survival to improved patient outcomes. Historically, a criticism of autologous breast reconstruction has been the length of hospital stay. Our institution has progressively shortened the length of stay after deep inferior epigastric artery perforator (DIEP) flap reconstruction and began discharging select patients on postoperative day 1 (POD1). The purpose of this study was to document our experience with POD1 discharges and to identify preoperative and intraoperative factors that may identify patients as candidates for earlier discharge. Methods: An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected. Results: Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1. Conclusions: POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.

Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience.

OBJECTIVE: Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort. STUDY DESIGN: Retrospective review. SETTING: Academic medical center. METHODS: Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence. RESULTS: In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm2. Average skin graft take was 94.5% in full-thickness wounds. Seven patients failed this method. Preoperative scalp irradiation was associated with major complication and delayed graft healing. Comorbidities, wound size, and burring were not associated with complication. Patients were more likely to heal with NPWT compared to bolster (hazard ratio, 1.67; 95% CI 1.01-2.77; P = .046). Time between stages was 6.6 days shorter when NPWT was applied (P < .001). CONCLUSION: Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

A Retrospective Analysis of Intervention for Testicular Torsion: Searching for a Hallmark of High Reliability.

Consistent delivery of high-quality care is a marker of health-care system reliability. Although clinically abstracted outcome databases have revolutionized surgical quality improvement efforts for many high-volume procedures, their utility in aiding the improvement of time-sensitive processes is less clear. The purpose of this study was to determine whether process measures surrounding the delivery of timely surgical care could delineate the variability in the outcome of patients with testicular torsion. Our secondary aim was to use the data to drive quality improvement efforts locally. METHODS: We performed a retrospective review of encounters for testicular torsion in patients less than 18 years. Characteristics of patients undergoing detorsion/orchiopexy and orchiectomy were compared. We evaluated orchiectomy as a function of age, insurance status, time of presentation, duration of symptoms, time to ultrasound, and time to surgery. RESULTS: Over 10 years, we identified 46 patients, of whom 21 met inclusion criteria. Twelve patients (57.1%) underwent detorsion/orchiopexy, whereas 9 patients underwent orchiectomy. After-hours presentation and age were not predictive of orchiectomy, whereas the duration of symptoms was predictive of orchiectomy. Differences in time to surgery for orchiopexy and orchiectomy groups approached but did not reach significance (P = 0.07). CONCLUSIONS: Significant variability persists in the timely delivery of comprehensive and coordinated care for children suffering from time-sensitive surgical conditions. Pediatric surgical programs would realize significant benefit from a surgical quality improvement program that incorporates validated process metrics, along with outcome measures, to help drive efficiencies and integrate care more effectively.

Mechanism of action of the anti-inflammatory connexin43 mimetic peptide JM2.

Connexin-based therapeutics have shown the potential for therapeutic efficacy in improving wound healing. Our previous work demonstrated that the connexin43 (Cx43) mimetic peptide juxtamembrane 2 (JM2) reduced the acute inflammatory response to a submuscular implant model by inhibiting purinergic signaling. Given the prospective application in improving tissue-engineered construct tolerance that these results indicated, we sought to determine the mechanism of action for JM2 in the present study. Using confocal microscopy, a gap-FRAP cell communication assay, and an ethidium bromide uptake assay of hemichannel function we found that the peptide reduced cell surface Cx43 levels, Cx43 gap junction (GJ) size, GJ communication, and hemichannel activity. JM2 is based on the sequence of the Cx43 microtubule binding domain, and microtubules have a confirmed role in intracellular trafficking of Cx43 vesicles. Therefore, we tested the effect of JM2 on Cx43-microtubule interaction and microtubule polymerization. We found that JM2 enhanced Cx43-microtubule interaction and that microtubule polymerization was significantly enhanced. Taken together, these data suggest that JM2 inhibits trafficking of Cx43 to the cell surface by promoting irrelevant microtubule polymerization and thereby reduces the number of hemichannels in the plasma membrane available to participate in proinflammatory purinergic signaling. Importantly, this work indicates that JM2 may have therapeutic value in the treatment of proliferative diseases such as cancer. We conclude that the targeted action of JM2 on Cx43 channels may improve the tolerance of implanted tissue-engineered constructs against the innate inflammatory response.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis.

INTRODUCTION: The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. RESULTS: Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = -0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. CONCLUSION: As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

What Happened to the Complication? The Importance of ACS NSQIP Pediatric in Optimizing Quality Improvement Initiatives for Resident Education.

OBJECTIVE: Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. Most training programs lack standardized methods to evaluate self-reported outcomes and contributions to resident education. The purpose of this study was to determine whether residents underreport pediatric postoperative complications thereby limiting a comprehensive educational opportunity and the ability to adequately perform quality improvement during M&M conference. DESIGN: A retrospective analysis of resident reports submitted to the M&M committee at an academic medical center was conducted over 1 year. All complications were compared to the American College of Surgeons (ACS) Pediatric National Surgical Quality Improvement Program (NSQIP) data abstracted over the same period. A descriptive analysis of perioperative events was performed. SETTING: This study was conducted at the Medical University of South Carolina Medical Center and MUSC Children's Hospital, an academic tertiary care center located in Charleston, South Carolina. RESULTS: Overall, 81 complications were captured. Resident and NSQIP databases captured 27 (33%) and 68 (84%) complications, respectively. Residents were more likely to report major complications. More common sources of postoperative morbidity, including surgical site infection and transfusion, were underreported at 20% and 5%, respectively. CONCLUSIONS: Resident reporting inadequately captures the full complement of pediatric perioperative complications. NSQIP-abstracted data serve as a useful adjunct to traditional M&M reporting in capturing complications underreported by trainees.

Minimally invasive repair of pectus excavatum.

Pectus excavatum, an acquired or congenital depression of the anterior chest wall, is the most commonly occurring chest wall deformity. Patients with pectus excavatum experience psychosocial and physiologic consequences such as impaired social development and pulmonary and/or cardiac dysfunction as a result of the deformity. Traditionally, repair of the defect was performed with a major open operation, the most common being based on modifications of the Ravitch procedure. In the late 1990's, the operative approach was challenged with a new minimally invasive technique described by Dr. Donald Nuss. This approach utilizes thoracoscopic visualization with small incisions and placement of a temporary metal bar positioned behind the sternum for support it while the costal cartilages remodel. Since introduction, the minimally invasive repair of pectus excavatum (MIRPE) has become accepted in many centers as the procedure of choice for repair of pectus excavatum. In experienced hands, the procedure has excellent outcomes, shorter procedural length, and outstanding cosmetic results. However, proper patient selection and attention to technical details are essential to achieve optimal outcomes and prevent significant complications. In the following, we describe our perspective on pectus excavatum deformities, operative planning, and technical details of the MIRPE procedure.

Inhibition of connexin 43 hemichannel-mediated ATP release attenuates early inflammation during the foreign body response.

BACKGROUND: In the last 50 years, the use of medical implants has increased dramatically. Failure of implanted devices and biomaterials is a significant source of morbidity and increasing healthcare expenditures. An important cause of implant failure is the host inflammatory response. Recent evidence implicates extracellular ATP as an important inflammatory signaling molecule. A major pathway for release of cytoplasmic ATP into the extracellular space is through connexin hemichannels, which are the unpaired constituents of gap junction intercellular channels. Blockade of hemichannels of the connexin 43 (Cx43) isoform has been shown to reduce inflammation and improve healing. We have developed a Cx43 mimetic peptide (JM2) that targets the microtubule-binding domain of Cx43. The following report investigates the role of the Cx43 microtubule-binding domain in extracellular ATP release by Cx43 hemichannels and how this impacts early inflammatory events of the foreign body reaction. METHODS: In vitro Cx43 hemichannel-mediated ATP release by cultured human microvascular endothelial cells subjected to hypocalcemic and normocalcemic conditions was measured after application of JM2 and the known hemichannel blocker, flufenamic acid. A submuscular silicone implant model was used to investigate in vivo ATP signaling during the early foreign body response. Implants were coated with control pluronic vehicle or pluronic carrying JM2, ATP, JM2+ATP, or known hemichannel blockers and harvested at 24 h for analysis. RESULTS: JM2 significantly inhibited connexin hemichannel-mediated ATP release from cultured endothelial cells. Importantly, the early inflammatory response to submuscular silicone implants was inhibited by JM2. The reduction in inflammation by JM2 was reversed by the addition of exogenous ATP to the pluronic vehicle. CONCLUSIONS: These data indicate that ATP released through Cx43 hemichannels into the vasculature is an important signal driving the early inflammatory response to implanted devices. A vital aspect of this work is that it demonstrates that targeted molecular therapeutics, such as JM2, provide the capacity to regulate inflammation in a clinically relevant system.

Genetic evidence for the coordinated regulation of collagen fibrillogenesis in the cornea by decorin and biglycan.

Decorin and biglycan are class I small leucine-rich proteoglycans (SLRPs) involved in regulation of collagen fibril and matrix assembly. We hypothesize that tissue-specific matrix assembly, such as in the cornea, requires a coordinate regulation involving multiple SLRPs. To this end, we investigated the expression of decorin and biglycan in the cornea of mice deficient in either SLRP gene and in double-mutant mice. Decorin and biglycan exhibited overlapping spatial expression patterns throughout the corneal stroma with differential temporal expression. Whereas decorin was expressed at relatively high levels in all developmental stages, biglycan expression was high early, decreased during development, and was present at very low levels in the mature cornea. Ultrastructural analyses demonstrated comparable fibril structure in the decorin- and biglycan-null corneas compared with wild-type controls. We found a compensatory up-regulation of biglycan gene expression in the decorin-deficient mice, but not the reverse. Notably, the corneas of compound decorin/biglycan-null mice showed severe disruption in fibril structure and organization, especially affecting the posterior corneal regions, corroborating the idea that biglycan compensates for the loss of decorin. Fibrillogenesis assays using recombinant decorin and biglycan confirmed a functional compensation, with both having similar effects at high SLRP/collagen ratios. However, at low ratios decorin was a more efficient regulator. The use of proteoglycan or protein core yielded comparable results. These findings provide firm genetic evidence for an interaction of decorin and biglycan during corneal development and further suggest that decorin has a primary role in regulating fibril assembly, a function that can be fine-tuned by biglycan during early development.