The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity.

BACKGROUND: Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. METHODS: Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. RESULTS: Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. CONCLUSION: Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.

Is alpha-B crystallin an independent marker for prognosis in lung cancer?

BACKGROUND: Alpha B-crystallin (CRYAB) is an oncogene that increases tumour survival by promoting angiogenesis and preventing apoptosis. CRYAB is an independent prognostic marker in epithelial tumours including head and neck squamous cell carcinoma and breast cancer where it is predictive of nodal status and associated with poor outcome. We explored the role of CRYAB in non-small-cell lung cancer (NSCLC). METHODS: Immunohistochemical analysis was performed on 50 samples. Following staining with anti-alpha-B crystallin antibody, a blinded pathologist scored samples for nuclear (N) and cytoplasmic (C) staining intensity. Analysis was performed using Cox's proportional hazards model. RESULTS: There were 32 adenocarcinomas and 18 squamous cell carcinomas. The median tumour size was T2, grade 2 moderately differentiated, and 10 patients had nodal spread. Recurrence was seen in 22 patients (46%). Mortality was 48%, with median time to mortality 871 days. N staining was detected in eight samples (16%), and C staining in 20 (40%), with both N and C staining positive in five (10%). Staining for CRYAB predicted neither recurrence (N stain p=0.78, C stain p=0.38) nor mortality (N stain p=0.86, C stain p=0.66). CONCLUSION: CRYAB did not predict outcomes in patients treated for NSCLC. Larger studies are required to validate this finding.

Diabetic control and coronary artery bypass: effect on short-term outcomes.

AIM: To evaluate the effect of preoperative glycemic control on hospital morbidity and mortality in diabetic patients undergoing primary coronary artery bypass grafting. METHODS: Data of 3857 patients undergoing primary coronary artery bypass grafting was prospectively collected and retrospectively analyzed. There were 1109 (29%) diabetic patients, of whom 712 (64%) had hemoglobin A1c levels recorded. They were categorized by diabetic treatment: diet (179), oral hypoglycemic agent, (718) or insulin (212); and by diabetic control: hemoglobin A1c < 7 (265) or ≥7 (447). Nondiabetic patients (2,748) were used as controls. RESULTS: The preoperative risk factors of hypertension (p < 0.001), hyperlipidemia (p < 0.001), renal failure (p < 0.04), peripheral vascular disease (p < 0.001), and chronic obstructive pulmonary disease (p < 0.04) were significantly more prevalent in diabetic patients. Major complications were not significantly different between the diabetic and control groups (p = 0.33), but minor complications were less frequent in diabetic patients (p = 0.03). Major and minor complications were not significantly different among the treatment subgroups of diabetic patients (p = 0.74 and p = 0.48) or in those with hemoglobin A1c < 7 and ≥7 (p = 0.23, p = 0.41). CONCLUSIONS: Short-term outcomes were not affected by the degree of preoperative glycemic control or type of treatment used in diabetic patients undergoing primary coronary artery bypass grafting. A plausible explanation is strict protocol-driven glycemic control in the perioperative period.

Contemporary results following surgical repair of acute type a aortic dissection (AAAD): a single centre experience.

OBJECTIVES: The study aims to define predictors of neurological dysfunction, 30-day mortality, long-term survival and quality of life following repair of acute type A aortic dissection (AAAD). METHODS: Between 2000 and 2008, 65 patients underwent repair of AAAD. Sixty-four pre-, intra- and post-operative variables were studied. Mean follow-up was 26.6 months. RESULTS: The mean age was 61years; 60% were male and five had Marfan's syndrome. At presentation, ischaemic ECG changes were seen in 45%, malperfusion syndrome in 59%, moderate-severe aortic regurgitation in 48% and tamponade in 16%. EF was <40% in 17%. There was a delay of >12hours between diagnosis and operation in 64%. Axillary cannulation was performed in 37%. Cerebral protection was by hypothermic arrest (HCA) alone (19%), HCA with retrograde cerebral perfusion (RCP) (11%), or HCA with antegrade cerebral perfusion (ACP) (46%). The procedure was performed on cross-clamp in 24%. Full arch replacement was performed in 14% and concomitant coronary artery grafting was performed in 11%. Post-operative neurological dysfunction was present in 33.8%. The only significant predictor of poor neurological outcome was full arch replacement (p=0.04) on univariate analysis. In-hospital OR 30 mortality was 23.53%. Significant predictors of mortality were low ejection fraction (p=0.017) and post-operative renal failure (p=0.012). Long-term survival was 70% at two years, 50% at five years and 25% at nine years. Functional outcomes and long-term quality of life were assessed in 69% of patients who were alive at last follow-up. Ninety percent of patients reported minimal limitation on functional scores. Quality of life was assessed using the EQ-5D questionnaire. Forty-eight percent of patients recorded full health with an overall mean index of 0.854 (where the best possible score is 1) using the US preference weighted index score. CONCLUSIONS: Discharged patients have reasonable long-term survival and good quality of life.

Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients.

BACKGROUND: The treatment of common bile duct stones discovered at routine intraoperative cholangiography includes postoperative endoscopic retrograde cholangiography or intraoperative laparoscopic common bile duct exploration. Given the equivalence of short-term outcome data for these two techniques, the choice of one over the other may be influenced by long-term follow-up data. We aimed to establish the long-term outcomes following laparoscopic common bile duct exploration and compare this with endoscopic retrograde cholangiography. METHODS: One hundred and fifty consecutive patients underwent laparoscopic common bile duct exploration between March 1998 and March 2006 carried out by a single surgeon. All were prospectively studied for 1 month followed by a late-term phone questionnaire ascertaining the prevalence of adverse symptoms. Patients presented with a standardized series of questions, with reports of symptoms corroborated by review of medical records. RESULTS: In 150 patients, operations included laparoscopic transcystic exploration (135), choledochotomy (10) and choledochoduodenostomy (2). At long-term follow up (mean 63 months), 116 (77.3%) patients were traceable, with 24 (20.7%) reporting an episode of pain and 18 (15.5%) had more than a single episode of pain. There was no long-term evidence of cholangitis, stricture or pancreatitis identified in any patient. CONCLUSION: Laparoscopic bile duct exploration appears not to increase the incidence of long-term adverse sequelae beyond the reported prevalence of postcholecystectomy symptoms. There was no incidence of bile duct stricture, cholangitis or pancreatitis. It is a safe procedure, which obviates the need and expense of preoperative or postoperative endoscopic retrograde cholangiography in most instances.