Perforator-Guided Drug Injection in the Treatment of Abdominal Wall Pain.

BACKGROUND: Pain from the abdominal wall can be caused by nerve entrapment, a condition called abdominal cutaneous nerve entrapment syndrome (ACNES). As an alternative to surgery, ACNES may be treated with injection of local anesthetics, corticosteroids, or botulinum toxin at the point of maximal pain. METHOD: The point of maximal pain was marked on the abdominal skin. Using color Doppler ultrasound, the corresponding exit point of perforating blood vessels through the anterior fascia of the rectus abdominis muscle was identified. Ultrasound-guided injection of botulinum toxin in close proximity to the perforator's exit point was performed below and above the muscle fascia. RESULTS: The technique was used from 2008 to 2014 on 15 patients in 46 sessions with a total of 128 injections without complications. The injection technique provided safe and accurate administration of the drug in proximity to the affected cutaneous nerves. The effect of botulinum toxin on ACNES is beyond the scope of this article. CONCLUSION: Perforator-guided injection enables precise drug administration at the location of nerve entrapment in ACNES in contrast to blind injections.

Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study.

BACKGROUND: The current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping. METHODS: Twenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed. RESULTS: First appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps. CONCLUSION: This study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov with identifier NCT02806518 .

Free Vascularized Fibula Graft as Primary Salvage Procedure for Acute Cervical Osteomyelitis Caused by Epidural Abscess.

Acute cervical osteomyelitis due to an epidural abscess and pyogenic spondylodiscitis in an immunosuppressed patient with progressive myelopathy is a challenge for the reconstructive surgeon. This report presents our novel approach to treat such a condition in a 56-year-old patient in whom antibiotic treatment and decompression of the medulla by laminectomy of C4-C6 failed. Under general anesthesia, debridement of all infected tissue, including anterior corpectomy of C4-C6, was performed. Simultaneously, a free vascularized fibula graft (FVFG) was harvested, adapted to the bone defect, and anastomosed to the superior thyroid artery and external jugular vein. The graft was stabilized with an anterior plate. A scheduled posterior stabilization was performed 1 week later. Staphylococcus aureus was cultured from bone samples and was treated with antibiotics. The postoperative course was uncomplicated besides a dorsal midline defect 6 weeks postoperatively that was closed with a sensate midline-based perforator flap. Five years on, the patient is infection free, and regular control computed tomography and magnetic resonance imaging scan images show progressive fusion and hypertrophy of the fibula to C3/C7 vertebrae. An FVFG combined with posterior stabilization could be a promising primary salvage procedure in cases with progressive myelopathy caused by acute cervical osteomyelitis due to spinal infection. The FVFG contributes to blood circulation, delivery of antibiotics, and an immunological response to the infected wound bed and can stimulate rapid fusion and hypertrophy over time.

Closure of large, complex defects after oncologic neurosurgery with a free myoperitoneal flap.

Extensive and complex defects after neurosurgical oncologic resections including dura are a challenge, as watertight closure is of paramount importance. This article illustrates the usefulness of a free myoperitoneal flap in closure of such a defect when located at the skull base or cranium. The vascularized peritoneum appears to be an excellent biological replacement for the dura and the well-vascularized muscle promotes wound healing and obliterates dead space.

Botulinum Toxin A in the treatment of frostbite sequelae - results from a blinded, early-phase, comparative trial.

INTRODUCTION: Freezing Cold Injuries (FCI) have been associated with long-term sequelae including vasospasm. The aims of the pilot study are to explore the research methodology and investigate the tolerability and safety of treatment with Botulinum Toxin-A (BTX-A) in FCI Sequelae. METHODOLOGY: This pilot study tests the logistics, the treatment setting and the follow-up procedure in an early-phase, double-blinded, randomized, controlled trial study-design. The variables in the study were subjective symptoms, peripheral micro-vascularization/rewarming, somatosensory responsiveness, and generic measure of health status. RESULTS: No major challenges or difficulties were noticed according to the protocol or the study methodology. The monitoring of tolerability and safety of treatment with BTX-A did not reveal any major unwanted and/or adverse reactions among the patients in the pilot study and no challenges occurred during data collection of endpoints. The study revealed an inaccuracy of the 2nd degree FCI diagnosis and uncover a need for relevant and sufficient clinical information for FCI classification. CONCLUSIONS: This pilot study showed the study methodology with minor adjustments is feasible in a future full-scale clinical trial. The recruitment process needs to be more refined to ensure that the eligible study participants are a homogenous group of FCI patients.

The parachute design as a new extraperitoneal method of closing a recalcitrant high-output enterocutaneous fistula: report of a case.

We introduce a new method for closure of a recalcitrant high-output jejunal enterocutaneous fistula. First, a transposed rectus abdominis muscle is sutured into the fistula opening using a parachuting technique, then the muscle is covered with a skin graft and temporarily immobilized to the fistula wall and abdominal wall with a negative pressure device. This extraperitoneal method provides tension-free closure of the fistula with well-vascularized tissue, without compromising the intestinal lumen. No bowel is resected. This new technique allows for early mobilization and recommencement of enteral nutrition.

Health effects of voluntary exposure to cold water - a continuing subject of debate.

This review is based on a multiple database survey on published literature to determine the effects on health following voluntary exposure to cold-water immersion (CWI) in humans. After a filtering process 104 studies were regarded relevant. Many studies demonstrated significant effects of CWI on various physiological and biochemical parameters. Although some studies were based on established winter swimmers, many were performed on subjects with no previous winter swimming experience or in subjects not involving cold-water swimming, for example, CWI as a post-exercise treatment. Clear conclusions from most studies were hampered by the fact that they were carried out in small groups, often of one gender and with differences in exposure temperature and salt composition of the water. CWI seems to reduce and/or transform body adipose tissue, as well as reduce insulin resistance and improve insulin sensitivity. This may have a protective effect against cardiovascular, obesity and other metabolic diseases and could have prophylactic health effects. Whether winter swimmers as a group are naturally healthier is unclear. Some of the studies indicate that voluntary exposure to cold water has some beneficial health effects. However, without further conclusive studies, the topic will continue to be a subject of debate.

Abstracts from The Cold Weather Operations Conference 2021.

A common effort for both military and civil healthcare is to achieve knowledge-based health care in cold weather injuries and fatal accidents in harsh arctic environment. The Cold Weather Operations Conference in November 2021, having more than 300 participants from 20 countries, was addressing the prevention and treatment of injuries and trauma care in cold weather conditions and the challenges for military prehospital casualty care. The intention of the programme was to stimulate further research and systematic knowledge-based clinical work. The abstracts from the conference present cold weather research and clinical experience relevant for readers of the International Journal of Circumpolar Health.

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study.

BACKGROUND: The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions. METHODS: This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay. RESULTS: Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome. CONCLUSIONS: The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

Impact on Abdominal Skin Perfusion following Abdominoplasty.

Wound healing problems following abdominoplasty may be a result of impaired tissue perfusion. This study evaluated the impact a standard abdominoplasty may have on abdominal skin perfusion. METHODS: A standard abdominoplasty was performed in 16 patients. Dynamic infrared thermography (DIRT) using a mild and a stronger cold challenge was performed pre-, intra-, and postoperatively on day 1, 2, and in week 6. The abdomen was divided into Huger's vascular zones. A two-tailed t test was used to evaluate differences in mean temperature between zones. Statistical significance was defined as P < 0.05. RESULTS: Two patients suffered wound healing problems. Abdominal skin perfusion showed a hyperaemic state on day 1, day 2, and week 6, postoperatively. Hotspots in zones I and II had all disappeared at the end of surgery and on day 1, except in the cranial part of zone I. Hotspots reappeared in zones I and II during day 2. A statistically significant difference between zones I and II was seen on day 1 and 2, with zone II being cooler. This difference had disappeared in week 6 for the mild cold challenge but not for the stronger cold challenge. CONCLUSIONS: A standard abdominoplasty has a significant impact on abdominal skin perfusion. The skin perfusion is a dynamic process with a gradual improvement over time. The strongest effect was seen in zone II near the lower transverse incision line, where skin perfusion was the least. Such may contribute to impaired wound healing at this site.

A New Extraperitoneal Method for Entero-atmospheric Fistula Closure Using a Free Muscle Flap.

Treatment of an entero-atmospheric fistula (EAF) is challenging and associated with significant morbidity and mortality. For an EAF with protrusion of mucosa, chances for spontaneous closure are minimal. Standard surgical procedures may be associated with a high risk for complications in patients with a hostile abdomen. This article describes a new method for extraperitoneal closure of an EAF in a patient with a hostile abdomen. A free segmental latissimus dorsi musculocutaneous flap was harvested on its thoracodorsal pedicle, leaving the remaining muscle innervated. The flap was anastomosed to the internal mammary vessels. The muscle was sutured into the fistula opening using a parachute technique and temporarily immobilized with a negative wound pressure device. The skin of the flap was used for monitoring and later replaced by a skin graft. The postoperative course was uneventful. At 24 months follow-up, there were no signs of recurrences. The patient had no pain and had no defecation problems. Extraperitoneal closure of an EAF with a segmental free latissimus dorsi muscle flap sutured into the fistula opening with a parachute technique may be a new promising technique in patients where standard surgical procedures are associated with too high a risk for complications and where a local pedicled muscle flap is not available. The advantages of this method are that no laparotomy is required, the intestinal lumen is not reduced in diameter, and that no bowel resection is performed, which is a particular advantage in cases with a short bowel syndrome.

In Vivo Perforasome Perfusion in Hemi-DIEP Flaps Evaluated with Indocyanine-green Fluorescence Angiography and Infrared Thermography.

There are no in vivo studies that evaluate the effect of perforator dissection on the perfusion territory of a perforator (perforasome). In this study, indocyanine green fluorescence angiography (ICG-FA) and infrared thermography (IRT) were used intraoperatively to evaluate perforasome perfusion in hemi-DIEP flaps. METHODS: Patients selected for DIEP breast reconstruction were prospectively included in the study. Preoperative perforator mapping was performed with CTA and handheld Doppler ultrasound. In general anesthesia, perforasome perfusion was evaluated with ICG-FA and IRT both before surgery and after flap dissection with preserved dominant perforators. RESULTS: Thirty hemi-DIEP flaps were dissected in 15 patients (average BMI 26.6 kg/m2), of which 40% had been operated on in the lower abdomen. Fluorescence spots from ICG were associated with infrared radiation hotspots on IRT and these corresponded with the locations of the selected perforators. IRT and ICG-FA demonstrated similar patterns in perforasome perfusion before and after perforator dissection. Perforator dissection changed the perforasome perfusion. IRT made it possible to continuously monitor the perforator activity during surgery. ICG-FA easily identified areas with impaired flap perfusion due to previous surgery. CONCLUSIONS: Perforasome perfusion is a dynamic process that changes with perforator dissection. ICG-FA and IRT are reproducible techniques for in vivo evaluation of perforasome perfusion and produce comparable results.

The Value of Dynamic Infrared Thermography in Pedicled Thoracodorsal Artery Perforator Flap Surgery.

Dynamic infrared thermography (DIRT) is a noninvasive imaging technique that can provide indirect and real-time information on skin perfusion by measuring skin temperature. Although used in flap surgery, there are no reports on its value in procedures using a pedicled thoracodorsal artery perforator (TDAP) flap. The aim of this study was to assess the usefulness of DIRT in preoperative perforator mapping and in monitoring intra- and postoperative flap perfusion of pedicled TDAP flaps. METHODS: This prospective study comprised 21 patients (21 flaps) scheduled for reconstructive surgery with a TDAP flap. Perforator mapping was done by DIRT, handheld unidirectional Doppler ultrasound, and computer tomography angiography. Intra- and postoperative flap perfusion was assessed by clinical signs and with the use of DIRT and handheld unidirectional Doppler ultrasound. RESULTS: Perforator mapping with DIRT showed that first-appearing bright hotspots were always associated with arterial Doppler sounds and suitable perforators intraoperatively. Computer tomography angiography presented useful information on the thoracodorsal artery branching pattern but was less beneficial for perforator mapping. Intra- and postoperative flap monitoring with DIRT was more useful than handheld unidirectional Doppler ultrasound and clinical signs to detect early arterial and venous perfusion problems. DIRT demonstrated that TDAP flap perfusion is a dynamic process with an increase in perfusion during the first operative days. Nineteen flaps survived, of which 3 sustained distal necrosis. Two flaps were lost due to inadequate blood perfusion. CONCLUSION: DIRT provides valuable real-time information for perforator mapping and for monitoring TDAP flap perfusion intra- and postoperatively.

Triple Use of Autologous Amnion Graft in the Treatment of Meningomyelocele and Split Cord Malformation.

This article describes the triple use of autologous amnion graft as a new procedure in the treatment of myelomeningocele and in myelomeningocele with split cord malformation. The first amnion graft was used as a physical and mechanical barrier to protect the myelomeningocele (MMC) from desiccation and mechanical stress directly after birth. A second graft was used as a dura substitute to close the cerebrospinal fluid compartment. Autologous amnion seems to be the ideal dural graft for closure of an MMC and for an MMC with split cord malformation. A tension-free and watertight closure was obtained. With the epithelium side placed to the spinal cord and due to its beneficial effect on scar formation, the risk for tethering cord syndrome is reduced when using autologous amnion as a dural graft. The regenerative properties of autologous amnion may contribute to repair neural damage. Finally, a third amnion graft was placed beneath the perforator flap used to close the skin defect to provide a watertight barrier and to stimulate flap survival.

The sensate medial dorsal intercostal artery perforator flap for closure of cervicothoracic midline defects after spinal surgery: an anatomic study and case reports.

Complex cervicothoracic midline defects after spinal surgery are traditionally treated with the use of muscle and myocutaneous flaps. The authors introduce the sensate medial dorsal intercostal artery perforator flap as an alternative treatment for these defects. Following an anatomic study, the use of the flap is illustrated with 3 case reports. This well-vascularized flap is easy to harvest and causes minimal donor site morbidity. It can provide enough volume to obliterate dead space. Inclusion of the cutaneous nerve gives protective sensibility to the reconstructed area.