Rectovaginal Fistula Repair 1 Year Later: Lessons Learned.

INTRODUCTION: Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS: Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS: Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS: We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.

Refining Approaches to Surgical Repair of Rectovaginal Fistulas.

INTRODUCTION: Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. METHODS: A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. RESULTS: Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. CONCLUSIONS: Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.

The K-Wire Fixation Technique for Endoscopic Brow Lift: A Long-Term Follow-Up.

BACKGROUND: Many techniques have been presented for fixation during endoscopic brow lift, but no singular technique has become dominant. OBJECTIVES: The authors described a technique for fixation for endoscopic brow lift that is inexpensive, easy to use, and versatile and has minimal morbidity. METHODS: The charts of 284 patients who underwent the K-wire fixation technique between December 1996 and September 2018 were reviewed. This technique employs a transcutaneous K-wire to hold the brow in position until tissue adhesion creates a lasting elevation of the brow. RESULTS: A total of 284 patients underwent K-wire fixation for endoscopic brow lifting. Two patients had hematomas and 5 patients (1.8%) required a second unilateral brow lift procedure. Long-term elevation of the brow was maintained in all patients. CONCLUSIONS: K-wire fixation for endoscopic brow lift is a simple, safe, and effective technique for fixation during endoscopic brow lifting that provides long-term aesthetic results.

Melatonin suppression of aerobic glycolysis (Warburg effect), survival signalling and metastasis in human leiomyosarcoma.

Leiomyosarcoma (LMS) represents a highly malignant, rare soft tissue sarcoma with high rates of morbidity and mortality. Previously, we demonstrated that tissue-isolated human LMS xenografts perfused in situ are highly sensitive to the direct anticancer effects of physiological nocturnal blood levels of melatonin which inhibited tumour cell proliferative activity, linoleic acid (LA) uptake and metabolism to 13-hydroxyoctadecadienoic acid (13-HODE). Here, we show the effects of low pharmacological blood concentrations of melatonin following oral ingestion of a melatonin supplement by healthy adult human female subjects on tumour proliferative activity, aerobic glycolysis (Warburg effect) and LA metabolic signalling in tissue-isolated LMS xenografts perfused in situ with this blood. Melatonin markedly suppressed aerobic glycolysis and induced a complete inhibition of tumour LA uptake, 13-HODE release, as well as significant reductions in tumour cAMP levels, DNA content and [(3) H]-thymidine incorporation into DNA. Furthermore, melatonin completely suppressed the phospho-activation of ERK 1/2, AKT, GSK3ß and NF-kB (p65). The addition of S20928, a nonselective melatonin antagonist, reversed these melatonin inhibitory effects. Moreover, in in vitro cell culture studies, physiological concentrations of melatonin repressed cell proliferation and cell invasion. These results demonstrate that nocturnal melatonin directly inhibited tumour growth and invasion of human LMS via suppression of the Warburg effect, LA uptake and other related signalling mechanisms. An understanding of these novel signalling pathway(s) and their association with aerobic glycolysis and LA metabolism in human LMS may lead to new circadian-based therapies for the prevention and treatment of LMS and potentially other mesenchymally derived solid tumours.

Factors associated with higher risk of complications after adrenal surgery.

BACKGROUND: Surgeon experience has been demonstrated to result in better outcomes after a variety of advanced operations. Less information is available regarding adrenal surgery. We compared the outcomes after adrenalectomy for a variety of indications and determined the effect of surgeon's case volume. METHODS: Cross-sectional analysis was performed using ICD-9 procedure codes included in the Nationwide Inpatient Sample from 2003 to 2009 to identify all adult patients who underwent unilateral or bilateral adrenalectomy for benign or malignant conditions. Logistic regression was used to test for interaction between surgeon case volume (low = 1, intermediate = 2-5, and high = >5 adrenalectomies per year), diagnosis, type of operation performed, and risk of complications. RESULTS: A total of 7,829 adrenalectomies were included. Risk of complications after bilateral adrenalectomy was 23.4 % compared to 15.0 % for unilateral adrenalectomy (odds ratio 2.165, 95 % confidence interval 1.335, 3.512). Malignancy was associated with higher risk of complication (23.1 %) than benign disease (13.2 %) (odds ratio 1.685, 95 % confidence interval 1.371, 2.072). Complication rates for low- and intermediate-volume surgeons were 18.8 and 14.6 %, respectively, and both were significantly higher than complications by high-volume surgeons (11.6 %, p < 0.05). Length of stay and charges were both significantly less for high-volume surgeons compared to lower-volume groups (p < 0.05). CONCLUSIONS: Low surgeon case volumes and adrenal surgery for malignant or bilateral disease are associated with increased risk of postoperative complications. Length of stay and charges were significantly less when high-volume surgeons perform adrenal surgery.

The effect of race and socioeconomic status on outcomes following adrenal operations.

BACKGROUND: Disparities following different operations exist. We seek to measure the effects of race/ethnicity and socioeconomic status on outcomes following adrenal surgery. METHODS: Cross-sectional analysis of adrenal operations identified in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. RESULTS: A total of 7,537 procedures were included. Operations by high-volume surgeons had shorter length of stay (LOS) (3.4 days vs. 5.2 days, P < 0.001) and fewer complications (11.6% vs. 16.7%, P < 0.001). Hispanics were more likely to be operated on by low-volume surgeons [OR: 2.17, 95%CI: (1.33, 3.55)]. There were significant differences in LOS and cost among races/ethnicities, income categories, and insurance types (P < 0.05). Hispanics had longer LOS compared to Whites (P = 0.002) and their management was associated with a higher cost ($20,754.00 ± 1,478.40). Patients with either Medicaid [OR: 1.70, 95%CI: (1.30, 2.22)] or Medicare [OR: 1.86, 95%CI: (1.36, 2.54)] were more likely to have a LOS >5 days. CONCLUSIONS: Racial and socioeconomic disparities exist; however, they are not solely related to access. A complex interplay between various racial, cultural, and socioeconomic factors likely influence outcomes in adrenal surgery.

Doxorubicin resistance in breast cancer is driven by light at night-induced disruption of the circadian melatonin signal.

Chemotherapeutic resistance, particularly to doxorubicin (Dox), represents a major impediment to successfully treating breast cancer and is linked to elevated tumor metabolism and tumor over-expression and/or activation of various families of receptor- and non-receptor-associated tyrosine kinases. Disruption of circadian time structure and suppression of nocturnal melatonin production by dim light exposure at night (dLEN), as occurs with shift work, and/or disturbed sleep-wake cycles, is associated with a significantly increased risk of an array of diseases, including breast cancer. Melatonin inhibits human breast cancer growth via mechanisms that include the suppression of tumor metabolism and inhibition of expression or phospho-activation of the receptor kinases AKT and ERK1/2 and various other kinases and transcription factors. We demonstrate in tissue-isolated estrogen receptor alpha-positive (ERα+) MCF-7 human breast cancer xenografts, grown in nude rats maintained on a light/dark cycle of LD 12:12 in which dLEN is present during the dark phase (suppressed endogenous nocturnal melatonin), a significant shortening of tumor latency-to-onset, increased tumor metabolism and growth, and complete intrinsic resistance to Dox therapy. Conversely, a LD 12:12 dLEN environment incorporating nocturnal melatonin replacement resulted in significantly lengthened tumor latency-to-onset, tumor regression, suppression of nighttime tumor metabolism, and kinase and transcription factor phosphorylation, while Dox sensitivity was completely restored. Melatonin acts as both a tumor metabolic inhibitor and circadian-regulated kinase inhibitor to reestablish the sensitivity of breast tumors to Dox and drive tumor regression, indicating that dLEN-induced circadian disruption of nocturnal melatonin production contributes to a complete loss of tumor sensitivity to Dox chemotherapy.

Trocar Site Metastasis Following Robotic Oophorectomy for Ovarian Cancer: A Case Report and Review of the Literature.

While robotic surgery has seen much success in the treatment of gynecologic malignancies, the technical aspects of this approach raise concern for spreading tumor cells within the peritoneal cavity and to trocar sites. To date, robotic trocar site metastases have been identified following surgery for both endometrial and cervical cancer.

Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons.

BACKGROUND: There has been an increased use of total thyroidectomy (TT), including in the management of benign thyroid diseases. We sought to compare the risk of complications between TT and unilateral thyroidectomy (UT) and to evaluate the effect of surgeon's experience on outcomes. METHODS: Nationwide Inpatient Sample from 2003 to 2009 was used to perform cross-sectional analysis of all adult patients who underwent TT and UT for benign or malignant conditions. Logistic regression was used to evaluate outcomes and to provide correlation between outcome and surgeon volume. Surgeon volume was categorized as low or high (performing <10 or >99 thyroid operations/year, respectively). RESULTS: A total of 62,722 procedures were included. Most cases were TT (57.9 %) performed for benign disease. There was a significantly increased risk of complication after TT compared to UT (20.4 vs. 10.8 %: p < 0.0001). High-volume surgeons performed only 5.0 % of the procedures overall, with 62.6 % of the high-volume surgeon procedures being TTs. Low-volume surgeons were more likely to have postoperative complications after TT compared to high-volume surgeons (odds ratio 1.53, 95 % confidence interval 1.12, 2.11, p = 0.0083). Mean charges were significantly higher for TT compared to lobectomy ($19,365 vs. $15,602, p < 0.0001), and length of stay was longer for TT compared to lobectomy (1.63 vs. 1.29 days, p < 0.0001). CONCLUSIONS: TT is associated with a significantly higher risk of complications compared to UT even among high-volume surgeons. Higher surgeon volume is associated with improved patient outcomes.

Molecular deficiency (ies) in MT1 melatonin signaling pathway underlies the melatonin-unresponsive phenotype in MDA-MB-231 human breast cancer cells.

Melatonin has been shown repeatedly to inhibit the growth of human breast tumor cells in vitro and in vivo. Its antiproliferative effects have been well studied in MCF-7 human breast cancer cells and several other estrogen receptor α (ERα)-positive human breast cancer cell lines. However, the MDA-MB-231 breast cancer cell line, an ERα-negative cell line widely used in breast cancer research, has been shown to be unresponsive to melatonin's growth-suppressive effect in vitro. Here, we examined the effect of melatonin on the cell proliferation of several ERα-negative breast cancer cell lines including MDA-MB-231, BT-20, and SK-BR-3 cells. Although the MT1 G-protein-coupled receptor is expressed in all three cell lines, melatonin significantly suppressed the proliferation of SK-BR-3 cells without having any significant effect on the growth of MDA-MB-231 and BT-20 cells. We confirmed that the MT1-associated Gα proteins are expressed in MDA-MB-231 cells. Further studies demonstrated that the melatonin unresponsiveness in MDA-MB-231 cells may be caused by aberrant signaling downstream of the Gαi proteins, resulting in differential regulation of ERK1/2 activity.

Atypical mycobacterial infections of peritoneal dialysis catheter exit sites--a Louisiana issue.

Exit-site infections involving peritoneal dialysis catheters are a cumbersome issue that can be difficult to manage. Such infections are usually due to gram-positive organisms and are often treated successfully with oral and/or topical antibiotics. Infections associated with Mycobacterium sp. are much more rare and difficult to treat. We report our experience with four cases of exit-site infections with Mycobacterium sp. in the New Orleans area, along with a review of risk factors and current literature.

Indocyanine Green-Based Fluorescence Imaging to Guide Local Tissue Rearrangement of a Complex Morel-Lavallee Lesion About a Hip: A Technical Trick.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/icg-based-fluorescence-imaging.

Virtual Surgical Subinternships: Course Objectives and a Proposed Curriculum.

BACKGROUND: Due to the recent COVID-19 pandemic, patient care and medical education have faced many significant changes. The Association of American Medical Colleges and the American Council of Academic Plastic Surgery officially recommended halting all student rotations and interviews for the year. This change has unfortunately fallen squarely at the onset of a vital season for education and recruitment of plastic surgery subinterns. This article presents a curriculum for a single institution's virtual surgical subinternship to help inspire ideas and inspiration for programs developing their own virtual subinternships. METHODS: The goals for the virtual surgical subinternship are focused on student preparation for residency and remain similar to those outlined by the core competencies for in-person rotations. The first virtual subinternship in plastic surgery modeled after the curriculum presented was offered as a 2-week course starting May of 2020. RESULTS: The components of the curriculum include a self-study syllabus, virtual case reviews, virtual suture laboratory, educational teleconferences, participation in research, and mentorship meetings. The 2-week course has approximately 25 hours of conferences and teaching, involving direct interaction with residents and faculty, and approximately 15 hours of self-directed learning. CONCLUSIONS: To the authors' knowledge, this was the first virtual subinternship offered for rising fourth-year medical students. They strongly encourage other residency training programs to offer similar virtual learning opportunities for medical students, particularly for those without access to a home plastic surgery training program. The curriculum presented in this article is simply to provide ideas, inspiration, and a potential framework for programs wishing to create similar virtual learning opportunities.

Long-Term Outcomes in Complex Abdominal Wall Reconstruction Repaired With Absorbable Biologic Polymer Scaffold (Poly-4-Hydroxybutyrate).

Introduction: After promising early outcomes in the use of absorbable biologic mesh for complex abdominal wall reconstruction, significant criticism has been raised over the longevity of these repairs after its 2-year resorption profile. Methods: This is the long-term (5-year) follow-up analysis of our initial experience with the absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) mesh compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our clinical analysis was performed using Stata 14.2 and Excel 16.16.23. Results: After a 5-year follow-up period, the P4HB group (n = 31) experienced lower rates of reherniation (12.9% vs 38.1%; P = 0.017) compared with the porcine cadaveric mesh group (n = 42). The median interval in months to recurrent herniation was similar between groups (24.3 vs 20.8; P = 0.700). Multivariate logistic regression analysis on long-term outcomes identified smoking (P = 0.004), African American race (P = 0.004), and the use of cadaveric grafts (P = 0.003) as risks for complication while smoking (P = 0.034) and the use of cadaveric grafts (P = 0.014) were identified as risks for recurrence. The long-term cost analysis showed that P4HB had a $10,595 per case costs savings over porcine cadaveric mesh. Conclusions: Our study identified the superior outcomes in clinical performance and a value-based benefit of absorbable biologic P4HB scaffold persisted after the 2-year resorption timeframe. Data analysis also confirmed the use of porcine cadaveric grafts independently contributed to the incidence of complications and recurrences.

Subpectoral Implant Repositioning With Partial Capsule Preservation: Treating the Long-Term Complications of Subglandular Breast Augmentation.

BACKGROUND: Patients with long-term complications associated with subglandular breast augmentation are being seen in increasing numbers in the Southern California community. Late deformities include a characteristic "slide-down" deformity as well as capsular contracture, implant wrinkling, and nipple-areola complex enlargement. Repositioning the implant to a subpectoral pocket is a recognized revisionary technique to treat this problem; however, technical details of how this is accomplished are lacking in the literature. OBJECTIVES: To review our technique for treating long-term complications associated with subglandular implants using subpectoral repositioning with partial capsule preservation and mastopexy, without the need for an acellular dermal matrix (ADM) or mesh. METHODS: A retrospective review of all patients undergoing subpectoral repositioning over the course of 6 years was performed. Patient data and long-term outcomes were assessed. A technique is presented utilizing a partial capsulectomy that preserves a portion of the capsule as an ADM/mesh equivalent, ensuring adequate implant coverage and preventing window shading of the pectoralis major muscle. RESULTS: Twenty-four patients with subglandular implants and slide-down deformity as well as other associated complications including capsular contracture, implant wrinkling, and enlarged areolas underwent revision surgery with a subpectoral site change. Often, patients presented many years after their initial augmentation (mean 18 years, range 4-38 years). The average patient follow-up was 3.1 years (range 1.0-6.8 years). Two patients required minor revisions with local anesthetic, while another 2 revisions required general anesthesia. CONCLUSIONS: Long-term deformities associated with subglandular breast augmentation can reliably be corrected by subpectoral repositioning, mastopexy, and utilization of residual breast capsule in the place of an ADM or mesh.

Treatment of Nasal Aging and Possible Long-term Nasal Enhancement with Fat Using Injectable Tissue Replacement.

This article addresses nasal aging using a minimally invasive procedure with an algorithm that includes the diagnosis of a patient's nose within the context of the individual's facial anatomy. Pyriform augmentation for the elevation of tip projection and columellar strutting with injectable fat are, to our knowledge, applied for the first time as important steps in minimally invasive rhinoplasties. This procedure offers patients with more subtle nasal changes with aging or other causes to be treated with potentially long-lasting improvements, which can be easily retreated. New techniques using injectable liquid cartilage grafts are being explored.

Hemostatic agent use in thyroid surgery: a meta-analysis.

BACKGROUND: The use of hemostatic agents in thyroid surgery has been widely reported in the literature. The aim of this study is to assess the safety and efficacy of hemostatic agents in comparison to conventional techniques for hemostasis by meta-analysis of the current literature. METHODS: Articles were identified from PubMed and EMBASE using the following keyword searches: "hemostatic agent and thyroid surgery" and "hemostatic agent and thyroidectomy". Outcomes included total operative time, estimated blood loss, length of hospital stay, and intraoperative and postoperative complications. Data were extracted following review of appropriate studies by two independent authors and outcome differences were calculated using analysis of variance and the Bonferroni method. RESULTS: Thirty-four publications were identified and 10 studies met our inclusion criteria, totaling 941 patients, 519 (55.1%) of which received a hemostatic agent during thyroid surgery. Of these patients who had hemostatic agents, 369 (71%) received a hemostatic gel and 150 (29%) received an oxidized cellulose patch. Outcome measures in each of these groups were compared with the patients receiving only conventional methods of hemostasis. The risk of hematoma formation in the hemostatic gel group was comparable to conventional hemostatic methods (95% CI: 0.33, 2.59). This was also true when comparing conventional hemostasis to the patch (95% CI: 0.64, 15.24). No difference in the risk for seroma formation was found between the conventional and hemostatic gel groups (95% CI: 0.26, 3.95). Drain output was significantly less in the gel group 40.75±35.6 mL compared to 66.26±31.2 mL in the conventional group (95% CI: -23.422, -7.460). Patients who received hemostatic agents had shorter hospital stays when compared to the conventional group (95% CI: -1.057, -0.203). CONCLUSIONS: Our meta-analysis suggests that the use of a hemostatic agent in thyroid surgery yields minimal advantages for the management of perioperative bleeding risk.

Ethnic and economic disparities effect on management of hyperparathyroidism.

BACKGROUND: Successful parathyroidectomy requires advanced surgeon experience. We aim to examine population characteristics at risk of being managed by low-volume surgeons. METHODS: A cross-sectional study was performed utilizing the Nationwide Inpatient Sample database, 2004 to 2009. The study population included adult inpatients who underwent parathyroidectomy for primary hyperparathyroidism. RESULTS: A total of 3,503 discharge records were included. Men, Hispanics, and those with Medicaid/Medicare health coverage were more likely to be managed by low-volume surgeons (P < .05 each). Low-volume surgeons were more likely to operate in rural (odds ratio [OR], 3.99; 95% confidence interval [CI], 1.95 to 8.16; P < .001) or nonteaching hospitals (OR, 2.15; 95% CI, 1.42 to 3.27; P < .001). Southern region of the United States had a high prevalence of low-volume surgeons compared with other regions (Southern: 51.3%, Northeast: 24.3%, Midwest: 25.6%, and West: 27.6%, P < .001). Operations by the low-volume surgeons associated with a higher risk of postoperative complications (OR, 1.81; 95% CI, 1.11 to 2.97) and a hospital stay more than 2 days (OR, 7.12; 95% CI, 3.75 to 13.45; P < .001). CONCLUSIONS: Certain populations are at risk of management by low-volume surgeons based on their demographic and economic characteristics.