Prolonged preoperative fasting induces postoperative insulin resistance by ER-stress mediated Glut4 down-regulation in skeletal muscles.

Preoperative fasting aims to prevent pulmonary aspiration and improve bowel preparation, but it may induce profound systemic catabolic responses that lead to protein breakdown and insulin-resistant hyperglycemia after operation. However, the molecular mechanisms of catabolic reaction induced by prolonged preoperative fasting and surgical stress are undetermined. In this study, anesthetized rats were randomly assigned to receive a sham operation or laparotomy cecectomy. Fasting groups were restricted from food and water for 12 h before operation, while the feeding group had free access to food throughout the study period. Twenty-four hours after operation, the animals were sacrificed to collect blood samples and soleus muscles for analysis. Postoperative blood glucose level was significantly increased in the fasting group with elevated serum insulin and C-peptide. Continuous feeding reduced serum myoglobin and lactate dehydrogenase concentrations. Preoperative fasting activated inositol-requiring transmembrane kinase/endoribonuclease (IRE)-1α and c-Jun N-terminal kinase (JNK) mediated endoplasmic reticulum (ER)-stress, and reduced glucose transporter type 4 (Glut4) expression in the soleus muscle. Phospholamban phosphorylation was reduced and intracellular calcium levels were increased in the isolated skeletal muscle cells. Similar results were found in ER stress-induced C1C12 myoblasts. The expression of Glut4 was suppressed in the stressed C1C12, but was potentiated following inhibition of ER stress and chelation of intracellular free calcium. This study provides evidence demonstrating that prolonged preoperative fasting induces ER stress and generates insulin resistance in the skeletal muscle through suppression of Glut4 and inactivation of Ca2+-ATPase, leading to intracellular calcium homeostasis disruption and peripheral insulin resistance.

Involvement of Aquaporins in the Intense Pulsed Light-Enhanced Wound Healing in Diabetic Rats.

BACKGROUND AND OBJECTIVES: We previously demonstrated that intense pulsed light (IPL) irradiation prior to wounding improved the wound healing in rats with diabetes mellitus (DM). Also, we found that IPL upregulated the expression of aquaporin 3 (AQP3), a protein that is crucial for wound healing, in normal rats. This present study aimed to examine the involvement of AQPs in the IPL-enhanced wound healing in diabetic rats. STUDY DESIGN/MATERIALS AND METHODS: Streptozotocin was used to induce diabetes in Sprague-Dawley rats. Animals were divided into four groups: normal group, DM only group, DM rats with IPL treatment 2 weeks before wounding (DM + IPL-Pre group), and DM rats with concurrent IPL irradiation and wounding (DM + IPL-Con group). Wounds were created on the dorsal skin of rats. The expressions of AQP1, 3, 4, 7, and 9 in the pre-injured skin, periwound, and wound were determined. RESULTS: Among all the AQPs analyzed, only the expressions of AQP3 and AQP7 were significantly altered. Unirradiated diabetic rats showed much higher expression level of AQP3 in the regenerating skin compared with normal rats. IPL pretreatment, but not concurrent treatment, attenuated the expression toward the level detected in the normal wounds. In contrast, a lower expression level of AQP7 was noted in the regenerating skin of DM only rats and IPL pretreatment upregulated the expression to a level similar to that in the normal rats. CONCLUSION: The beneficial effect of IPL pretreatment on the wound healing in diabetic rats might involve a mechanism by which the expression of AQPs is regulated. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Beneficial Effect of Intense Pulsed Light on the Wound Healing in Diabetic Rats.

BACKGROUND AND OBJECTIVE: Wound healing in diabetes mellitus (DM) patients is one of the major health concerns globally. Intense pulsed light (IPL) has been widely used in cosmetic dermatology via mechanisms involving fibroblast stimulation, collagen synthesis, and dermal remodeling, which are events that also occur during the process of wound healing. This present study was aimed to evaluate the possible beneficial effect of IPL on the wound healing in diabetic rats. MATERIALS AND METHODS: Diabetes was induced in Sprague-Dawley rats using streptozotocin. The rats were randomly divided into four groups: normal group, DM only group, DM rats with IPL treatment 2 weeks before wounding (DM + IPL-Pre group), and DM rats with concurrent IPL exposure and wounding (DM + IPL-Con group). The wounds were created on the dorsal skin of rats. Wound closure rate, collagen deposition, and angiogenesis were assessed. RESULTS: There were no significant differences in the wound closure rate and mean time to wound closure between IPL-treated diabetic rats and normal rats. By contrast, delayed wound closure and prolonged mean time to wound closure were both noticed in DM only group. Enhanced collagen deposition and angiogenesis were observed in IPL-Pre, but not IPL-Con diabetic rats, as compared with untreated DM rats. CONCLUSION: Results of this study may provide novel insight into future preventive strategies using IPL for the management of wounds in diabetic patients. Lasers Surg Med. © 2019 Wiley Periodicals, Inc.

The Antinociceptive Effect of Light-Emitting Diode Irradiation on Incised Wounds Is Correlated with Changes in Cyclooxygenase 2 Activity, Prostaglandin E2, and Proinflammatory Cytokines.

Background. Light-emitting diode (LED) phototherapy has been reported to relieve pain and enhance tissue repair through several mechanisms. However, the analgesic effect of LED on incised wounds has never been examined. Objectives. We examined the analgesic effect of LED therapy on incision pain and the changes in cyclooxygenase 2 (COX-2), prostaglandin E2 (PGE2), and the proinflammatory cytokines interleukin 6 (IL-6), IL-1ß, and tumor necrosis factor α (TNF-α). Methods. Rats received LED therapy on incised skin 6 days before incision (L-I group) or 6 days after incision (I-L group) or from 3 days before incision to 3 days after incision (L-I-L group). Behavioral tests and analysis of skin tissue were performed after LED therapy. Results. LED therapy attenuated the decrease in thermal withdrawal latency in all the irradiated groups and the decrease in the mechanical withdrawal threshold in the L-I group only. The expression levels of COX-2, PGE2, and IL-6 were significantly decreased in the three LED-treated groups, whereas IL-1ß and TNF-α were significantly decreased only in the L-I group compared with their levels in the I groups (p < 0.05). Conclusions. LED therapy provides an analgesic effect and modifies the expression of COX-2, PGE2, and proinflammatory cytokines in incised skin.

Stress alters the expression of aquaporins in cultured rat intestinal epithelial cells.

Aquaporins (AQPs) are widely-expressed small water channel proteins that provide the major route for water transport across plasma membranes in various cell types. Although the quantity of water transported in the intestinal tract is second only to that in the kidney, the precise role of AQPs in this organ remains largely uncertain. The present study reports the effects of hypertonic stress and ischemia/reperfusion injury on the expression of AQPs in intestinal epithelial cells. Cultured rat intestinal epithelial cells were incubated in 300 mM mannitol-containing, hypertonic culture medium or subjected to simulated ischemia/reperfusion treatment. The cell viability was evaluated by MTT assay, and the expression of AQPs was determined by semi-quantitative reverse transcription polymerase chain reaction and western blotting. Despite reduced viability, the cells exposed to hypertonic stress for 16 h demonstrated enhanced expression of AQP1 mRNA and protein. AQP9 and glycosylated AQP11 proteins were also markedly upregulated. Ischemia alone did not affect the cell viability, but subsequent reperfusion significantly reduced viability. The mRNA expression levels of all the tested AQPs were not altered by ischemia alone or by ischemia/reperfusion; however, AQP8 protein was markedly reduced by ischemic injury. In addition, treatment with ischemia alone eradicated the normally-expressed, non-glycosylated AQP11 protein whilst inducing pronounced expression of the glycosylated form. These observations may indicate that AQPs function in the intestinal epithelia in response to stress.

Effect of intense pulsed light on the expression of aquaporin 3 in rat skin.

Intense pulsed light (IPL) technology has been popularly employed in clinical treatments for dermatological and cosmetic purposes in recent years; yet, the underlying mechanisms of its functions are not fully elucidated. On the other hand, aquaporin (AQP) 3, a member of a subgroup of the aquaporin family that transports both water and small solutes, such as glycerol, has been documented to play an important role in the skin homeostasis. We thus examined the possible involvement of AQP3 in the functional mechanisms of IPL irradiation. Rat dorsal skin areas were irradiated one to three times with IPL at doses of 15, 25, and 35 J/cm2. Skin specimens were collected 7 days after the final irradiation and analyzed for changes in histology, skin hydration, mRNA, and protein expressions of AQP3. IPL induced no significant variations in the mRNA expression levels. Twice or thrice irradiation at the dose of 25 or 35 J/cm2 significantly enhanced AQP3 protein expression. Immunofluorescence study revealed that AQP3 was mainly localized to keratinocyte membranes in the basal layer of epidermis, and the localization was unaltered by IPL. In addition, the pattern of IPL-induced changes in skin hydration was generally coincided with the expression profile of AQP3. These results suggest the possibility that one of the functional mechanisms of IPL might be related to the regulation of AQP3 protein expression.

Heterotopic Procedures in Mutilating Hand Injuries: A Synopsis of Essential Reconstructive Tools.

BACKGROUND: In the complex and challenging treatment of a mutilating hand injury, any available resources need to be primarily recruited. Besides direct digital replantation, the tissue of the nonreplantable "spare parts" could often be "recycled," and also some replantable or injured structures could be "redistributed" in a more functional individualized pattern, irrespective of their initial origin. METHODS: Ten patients, six male and four female, were treated for multidigital mutilating injury with various "heterotopic" procedures. Immediate digital heterotopic replantations were performed in seven patients. In one case, the bone and skin of a nonreplantable digital part were used as grafts in the reconstruction of a metacarpal bone and the overlying skin defect. A neurovascular fillet flap from a nonreplantable finger for the reconstruction of the webspace and a pollicization of an injured index were undertaken in two further cases. Another patient underwent pedicled transfer of the proximal interphalangeal joint and metacarpal bone of an impaired index to the middle finger. RESULTS: Sensate prehensile function was restored in 100 percent of the cases, and the ability for tripod pinch and more subtle tasks was restored in 90 percent. The minimum of two long fingers and a thumb was restored in every case, and the patients judged the appearance of their hands as "acceptable." CONCLUSION: In the reconstruction of a mutilating hand injury, besides and beyond the straightforward microsurgery, the various heterotopic procedures are essential reconstructive tools that can enhance the versatility of the hand surgeon when pursuing a better outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A "green" approach to secondary reconstruction: the concept of the recycle flap and a classification.

BACKGROUND: Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option. METHODS: Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years). RESULTS: Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps. CONCLUSIONS: There are a number of ways to safely "recycle" the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An alternative option to overcome difficult venous return in head and neck free flap reconstruction.

BACKGROUND: The frozen neck secondary to prior neck irradiation and surgery is not uncommon in head and neck surgery. Identifying the optimal and alternative recipient vein in patients with difficult necks is one of most important steps in preceding a free flap for head and neck reconstruction. PATIENTS AND METHODS: This is a retrospective study. From January 2006 to October 2011, the authors performed 544 cases of free flap reconstruction for head and neck cancer. The indications for choosing the retrograde limb of the superficial temporal vein as recipient vein were: (1) the flap pedicle contained only one vein 'and' (2) the patient had frozen neck or vessel-depleted neck from surgery. Amongst them, 10 patients with difficult neck where the retrograde limb of the superficial temporal vein was used as the only recipient vein for outflow were collected for the study. RESULTS: The mean age was 51.7 years. The types of flaps included the anterolateral thigh (ALT) flap (n = 6), anteromedial thigh (AMT) flap (n = 1), medial sural perforator flap (n = 1) and trapezius perforator flap (n = 1). One flap needed take-back due to haematoma compression of the pedicle. All nine flaps survived completely. CONCLUSION: The retrograde limb of the superficial temporal vein used as the only recipient vein served as an alternative option for venous return to precede a successful free flap reconstruction in difficult neck cases. The presence of valves in the vein system in the head and neck does not seem to preclude the use of retrograde flow anastomosis in patients with frozen neck.

Clinical application of the internal mammary artery perforator flap in head and neck reconstruction.

BACKGROUND: The skin texture of the internal mammary artery perforator flap closely resembles that in the face and neck, making it the perfect source of tissue for head and neck reconstruction. In this article, the authors describe their experience in recent application of this flap in head and neck reconstruction and evaluate its pros and cons. METHODS: A total of 15 patients (three women and 12 men) with a mean age of 58.6 years received an internal mammary artery perforator flap for head and neck defect repair from April of 2007 to August of 2011. There were 11 internal mammary artery perforator pedicle flaps and four internal mammary artery perforator free flaps. RESULTS: Flap size ranged from 5 × 3 cm to 15 × 8 cm, pedicle length ranged from 3 to 6 cm, and 14 of 15 flaps (93.3 percent) had a sizable perforator identified during dissection. In the female patient who had no sizable perforator, the originally intended free flap was transformed to a platysma myocutaneous flap, which served as a backup procedure, extending from the same surgical incision. All of the transfers were successful. The donor sites were closed primarily in all patients except one, who received a split-thickness skin graft for a 15 × 8-cm donor defect. CONCLUSION: With excellent skin color and tissue texture matching and minimal donor-site morbidity, the internal mammary artery perforator flap is emerging as a potential alternative reconstructive tool for the head and neck region.

Vacuum-assisted closure for complicated wounds in head and neck region after reconstruction.

OBJECTIVE: The aim of this study is to suggest that negative pressure wound therapy (NPWT) is an excellent alternative for managing complicated wounds after head and neck reconstruction. SUMMARY BACKGROUND DATA: Management of complicated wounds such as wound infection or persistent saliva leakage from poor wound healing with dead space is challenging in head and neck reconstruction. The NPWT is a useful device widely used in treating many complicated wounds. In this study, we applied this device on complicated wounds after head and neck reconstruction and share our experience and modifications. METHODS: From January 2004 to December 2009, 13 male patients (mean age: 50.0 years) were included. Eleven patients were reconstructed with free flap transfer and the other two patients received a local flap for repair immediately after tumour ablation. Among them, 12 patients (92%) had complicated wounds with infection and one patient (8%) with partial loss of the free flap. Eight of these 13 patients (62%) had saliva leakage and fistula formation. For those who had a free flap transfer, the vacuum-assisted closure (VAC) system was applied with modifications to the complicated wound 2 weeks later, after better neo-vascularisation around the free flap. Watertight suturing on the mucosal side is needed to ensure air sealing and enhance wound healing acquired by the VAC system. RESULTS: All wounds demonstrated adequate control of wound infection, quick obliteration of dead space and rapid growth of granulation tissue under the NPWT. Eleven patients (85%) had wound healing with secondary intention; one (8%) needed a further skin grafting; and one patient (8%) needed a free flap transfer due to partial flap loss in a severe wound infection even after the NPWT application. The average duration of the NPWT usage was 10.8 days (4-24 days); most of the wounds healed within 1 week after the NPWT application. CONCLUSION: The NPWT is an excellent alternative for managing complicated wounds after head and neck reconstruction. It is safe and comfortable for the patient and provides good results in infection control, dead space obliteration and improvement of wound healing.

Expression of aquaporins in rat liver regeneration.

OBJECTIVE: The remarkable ability of liver to regenerate after insults has been harnessed by surgeons when designing techniques for liver resection or transplantation. However, the underlying mechanisms of liver regeneration are not fully clarified. On the other hand, aquaporins (AQPs) are small transmembrane proteins with unexpected physiological roles in addition to water transport. For example, they play pivotal roles in cell migration, angiogenesis, and cell proliferation, events that are also occurred during liver regeneration. We thus examined the possible involvement of AQPs in this regenerative process. MATERIAL AND METHODS: A two-thirds partial hepatectomy (PH) rat model was employed. The temporal expression of various AQPs in the liver following PH was determined by semiquantitative reverse transcription polymerase chain reaction (RT-PCR) and Western blotting. The localization of AQPs was evaluated by immunohistochemistry. RESULTS: As anticipated, AQP0, 8, 9, and 11 were detected mainly in hepatocytes; unexpectedly, Kupffer cells were observed to express AQP8 during a specific period of time in the regenerative process. AQP9 protein was shown to be expressed in a progressively enhanced pattern at early time points after PH. A transient expression of AQP11 in the nucleus of hepatocytes was observed. CONCLUSION: These findings suggest the possibility that AQP might be involved in the PH-induced liver regeneration.

Effect of docosahexaenoic acid on hypoxia/reoxygenation injury in human coronary arterial smooth muscle cells.

PURPOSE: Hypoxia and reoxygenation (H/R) occur in a wide variety of important clinical conditions such as myocardial infarction. H/R injury is a complex phenomenon involving not only intracellular damage processes but also an injurious inflammatory response. Docosahexaenoic acid (DHA), an n-3 polyunsaturated fatty acid, has long been proved to be protective against several types of cardiovascular disease. However, its beneficial effect during H/R is inconclusive. In this study, we employed an in vitro model to examine whether DHA is protective against H/R-induced cell damage in human coronary artery smooth muscle cells (HCASMCs). METHODS: HCASMCs in the absence or presence of DHA (1, 3, 10, and 30 µM) were subjected to control or H/R treatment using a modular incubator chamber to create hypoxic condition. Cell viability was evaluated by MTT assay. Spectrophotometric and spectrofluorometric assays were used to measure the generation of nitric oxide (NO) and reactive oxygen species (ROS), respectively. Inflammatory cytokines were determined by enzyme-linked immunosorbent assay. Intracellular calcium mobilization was estimated microfluorimetrically using calcium indicator dye, fura 2-acetomethyl ester. RESULTS: Hypoxia/reoxygenation caused significant injury in cultured HCASMCs. DHA at low concentrations (1, 3, and 10 µM) did not afford protection, whereas at 30 µM, it caused deleterious effects, presumably by enhancing the production of NO, ROS, IL-1ß, and IL-6 and altering the intracellular calcium dynamics. CONCLUSIONS: Our results do not support the protective function of DHA in H/R-injured coronary arterial smooth muscle cells.

Early enteral 5% glucose infusion maintains the epidermal growth factor levels in the jejunal flap used for pharyngo-oesophageal reconstruction.

BACKGROUND: Free jejunal flap reconstruction is the main treatment for patients after pharyngo-oesophagectomy. Flaps are unavoidably subjected to ischaemia and reperfusion (I/R) during preparation. Enteral nutrition has been shown to improve the recovery of injured intestine, although the precise underlying mechanism remains unclear. This study was aimed to determine whether early enteral 5% glucose infusion is beneficial for the recovery of flap. Further, the possibility that enteral glucose infusion induces altered mucosal responses was evaluated. PATIENTS AND METHODS: Patients, who underwent free jejunal flap reconstructions after pharyngo-oesophagectomy, were enrolled. An externalised monitor loop was made to observe the viability of flap and to collect intestinal fluid. Control patients (n = 11) received peripheral parenteral nutrition for seven post-operation days. For early enteral-fed patients (n = 12), in addition to fluid infusion, administration of 5% glucose (25 ml h(-1)) via a jejunostomy tube was initiated 6h after surgery. Blood, flap fluid and mucosal specimens were harvested. Plasma and flap luminal levels of interleukin (IL)-6, IL-10, epidermal growth factor (EGF) and secretory immunoglobulin A (sIgA) were measured. Further, mucosal morphology was examined. RESULTS: There were no significant differences in either plasma or luminal concentrations of IL-6, IL-10 and sIgA at different time points between groups. The luminal EGF level in the control group reduced markedly from the 3rd postoperative day, contrasting with a well-maintained level in the early enteral-fed group. No significant difference in mucosal histology between groups was observed. CONCLUSION: Early enteral glucose infusion does not significantly benefit the ischaemia-reperfusion-injured flap; however, it does preserve EGF levels in the flap lumen.

Periodic alterations of jejunal mucosa morphology following free microvascular transfer for pharyngoesophageal reconstruction.

BACKGROUND: Free jejunal flap reconstruction is the treatment of choice for patients after pharyngoesophagectomy. It remains unclear as to how the transplanted jejunal mucosal damage proceeds after the warm ischaemia. The current study aims to assess the relationship between the duration of ischaemia and the damage of jejunal mucosa. PATIENTS AND METHODS: From May 2002 to February 2003, 15 free jejunal flaps in 15 patients were transplanted to the cervical area for the reconstruction after pharyngoesophagectomy. Biopsy specimens were taken from the monitor loop at the time of pedicle ligation, 10 min after reperfusion, every day for 10 days, 14th day, 28th day, and 40th day after operation. Mucosal injury was assessed based on an accepted three-point scale which evaluates oedema, inflammation, mucosal necrosis or exfoliation, shortening of villi, and increase of goblet cells. FINDINGS: All 15 jejunal flaps survived. The mean ischaemia time was 68.7+/-5.2 min (range: 37-116). Serious injury to the mucosa was observed at 10 min after reperfusion, and gradually recovered until the 8th day, when it became normal in all flaps. The degree of damage was not found to be correlated with the length of ischaemia (less than 116 min). Severe ischaemia/reperfusion-induced mucosal damage occurs immediately following reperfusion and gradually recovers with time. The severity of the damage is not related linearly to the ischaemia time within 2h. The mucosa recovers gradually from the 8th day and returns to normal at the 28th day.

Deltopectoral flap revisited: role of the extended flap in reconstruction of the head and neck.

The extended deltopectoral flap is still the best choice in selected cases. During the period 1987-2004, 34 patients required reconstruction of the head and neck using this flap. Twenty-nine had had one or more failed attempts at microsurgical reconstruction after excision of cancer. Five were treated primarily. The flap was divided at least three weeks after the primary operation. All 34 survived, and there were no donor site complications. Twenty-seven patients had an uncomplicated outcome, but the remaining seven required later closure or skin grafting, usually under local anaesthesia, for complications. The extended deltopectoral flap has been used successfully to provide stable coverage of defects in the head and neck and should remain in the armamentarium of reconstructive microsurgeons.

Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing.

BACKGROUND: A thin skin flap is often required for optimal resurfacing of particular areas of the body. An anterolateral thigh perforator flap can be thinned to an extent to which it is vascularized by the subdermal plexus only. This study presents a novel flap thinning technique and its application for resurfacing the dorsum of the foot. METHODS: From July of 2002 to October of 2003, 18 patients underwent resurfacing of the dorsum of the foot with thin anterolateral thigh flaps. The main perforators were strategically located in the flap center to keep the peripheral area within the vascular territory. The flaps were larger than needed, initially elevated subfascially, and then thinned to the suitable thickness while the pedicle was still attached. The dissection of perforators in the adipose layer close to the dermis entry was carried out microscopically. Flap sizes ranged from 3 x 3 to 16 x 8 cm. RESULTS: Seventeen flaps survived completely and one had distal superficial necrosis of 1 x 2 cm. No debulking procedures were necessary. Average follow-up was 12 months. CONCLUSIONS: A thin flap vascularized through subdermal plexus is reliable. Microsurgical dissection of the perforator is a recommended technique. The thin anterolateral thigh perforator flap provides ideal reconstruction in resurfacing the dorsum of the foot.

Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step.

Failure of the transferred toe in toe-to-hand transplantations is a catastrophe and a devastating complication for both the patient and the reconstructive surgeon, as in all microvascular tissue transfers. Management of the toe transfer in the case of reexploration is still a challenging issue, even for experienced microsurgeons. In this report, basic principles for a successful outcome are proposed, based on experience with more than 500 toe-to-hand transfers. Although the requirements for each case may vary, technical details and some basic salvage strategies receive special emphasis. When faced with a problem, the first step should be focused on perceiving the problem differently from under completely normal conditions. The problem may occur at any stage of the procedure. The basic orientations are focused on vasospasm, a thrombus inside the lumen, possible intimal damage that may be caused during the surgery or by a thrombus, or technical failures regarding anastomoses. After all possible revisional procedures have been carried out, if the proper arterial inflow and/or venous outflow are still not provided, or if the general health status of the patient is no longer suitable for additional lengthy procedures, the tubed groin flap can be used to salvage the transferred toe. Between 1996-2004, eight tubed groin flaps were used to salvage transferred toes in the last step of the revisional procedure, with satisfactory results. In conclusion, close follow-up and prompt reexploration when needed are both essential to salvaging transferred toes. Proper surgical strategies and decision-making in reexploration are highly important factors in achieving a successful outcome. In prolonged and recurrent revisional steps, the creation of a tubed flap by means of a reliable flap is an effective procedure as the last step of the salvage procedure.

Tubed deltopectoral flap for creation of a controlled esophagocutaneous fistula in patients with persistent choking following esophageal reconstruction with free diversionary jejunum.

Esophageal reconstruction in patients with abnormal pharyngeal muscles or epiglottis may result in episodes of choking. The jejunal flap has been used to prevent choking by insetting the proximal end into the gingivobuccal sulcus and separating the digestive tract from the airway. A technique has been developed to deal with patients with aspiration due to collection of food near the nonfunctioning epiglottis. Between 1997 and 2004, 25 patients underwent reconstruction with jejunal flaps inset into the gingivobuccal sulcus. Postoperatively, 5 patients presented with episodes of choking. All patients underwent creation of an esophagocutaneous fistula using a deltopectoral flap. All flaps survived. Choking resolved and vocal performance was preserved in all patients. The jejunum, inset proximally into the gingivobuccal sulcus, has been successful in reconstructing patients unable to separate the airway from the digestive tract. The deltopectoral flap provides tissue for creation of a tubed flap and allows for the creation of a long fistula that prevents aspiration and can divert oral fluids away from a tracheostomy or a fresh wound.