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Free-flap reconstruction of the lower limb in octogenarians - A comparative analysis of indications, management, and outcomes. J Plast Reconstr Aesthet Surg 2023; 76:230-237. [PMID: 36527905 DOI: 10.1016/j.bjps.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 08/17/2022] [Accepted: 10/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Impaired microcirculation, along with an increase in chronic medical conditions in the geriatric cohort, may favor the development of soft-tissue defects in the lower extremity and equally impair the options for plastic-reconstructive surgery. In particular, outcome analyses in the increasing patient cohort ≥ 80 years (octogenarians) are limited. METHODS Setting 80 years as the cutoff, we conducted an age-related outcome analysis of all patients undergoing free-flap reconstruction of the lower extremity from 2014 to 2020, comprising the American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index (CCI) as the possible outcome predicting factors. RESULTS During the study period, a total of 424 free flaps were performed in 385 patients (∅: 54.7 years ± 16.1; range: 9-89), including 19 octogenarians. Compared with the younger patient cohort, there was a significantly higher rate of early flap revision (p = 0.023) and flap loss (p = 0.028). Furthermore, the mean length of hospital (60.6 ± 37.6 vs. 51.1 ± 37.0) and intensive care unit/intermediate care stay (6.5 ± 15.0 vs. 3.5 ± 8.5) was extended (n.s.). The ASA score presented an independent predictor for major surgical [odds ratio (OR): 1.66; p = 0.041) and medical complications (OR: 3.97; p<0.001). Neither the CCI nor the ASA served as an independent predictor for total flap loss. CONCLUSION Free-flap reconstruction of the lower extremity in octogenarians is associated with a higher risk of flap revision and flap loss. Considering the prolonged immobilization associated with increased morbidity following limb amputation, it presents still a reasonable option to achieve limb salvage in carefully chosen patients. An adequate tool to predict the success of free-flap survival is still unavailable.
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Sayyahmelli S, Sayyahmelli S, Ozaydin B, Erginoglu U, Keleş A, Sun Z, Başkaya MK. Safety and efficacy of microsurgery for complex cranial pathologies in the ultra-geriatric population. Clin Neurol Neurosurg 2022; 223:107500. [DOI: 10.1016/j.clineuro.2022.107500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/26/2022]
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Cinclair R, Shang Z, Aly A, Kenkel J. The Impact of Comorbidities on Patient Outcomes in the Upper Body Lift: A Retrospective Review. Aesthet Surg J Open Forum 2022; 4:ojac063. [PMID: 36128596 PMCID: PMC9475277 DOI: 10.1093/asjof/ojac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Nonsurgical and surgical weight loss options have improved over the past several decades resulting in an increased number of patients who present with body contour deformities. This review focuses on the upper truncal deformity. This deformity is discernable by its residual tissue laxity in the upper arm, back, lateral chest, and breast. Objective The purpose of this study is to evaluate the morbidity of this procedure when these regions are treated in one operative setting. Methods A retrospective chart review of patients who underwent an upper body lift for truncal deformities after massive weight loss by the senior author between August 2006 and December 2019 was performed. Patient comorbidities and demographics, preoperative parameters, operative factors, and minor and major complications were assessed. Results No intraoperative or major complications occurred. The overall complication rate was 71% (20/28), which were all minor and most related to wound breakdown. Using logistical regression analysis, we found that neither BMI nor amount of weight resected contributed to a higher complication rate in this cohort. Simple matching coefficients analysis identified anemia, hypertension, lifetime smoking history, celecoxib use, and multiple concurrent procedures as comorbidities and intraoperative factors with an increased risk for adverse outcomes. Conclusions This review helps define the role of upper body lift in the care of patients with massive weight loss and addresses the morbidity of a comprehensive approach to upper body deformity. Appropriate patient selection, preoperative patient counseling, sound operative technique, and supportive postoperative care can help to avoid adverse outcomes. Level of Evidence 4
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Affiliation(s)
- Richard Cinclair
- Corresponding Author: Mr Richard Cinclair III, Department of Plastic Surgery, University of Texas Southwestern, 1801 Inwood Road 5th Floor, Dallas, TX 75390, USA. E-mail: ; Instagram: @treycinclair
| | - Zhiguo Shang
- Department of Bioinformatics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Al Aly
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; and a body contouring section editor for Aesthetic Surgery Journal
| | - Jeffrey Kenkel
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; editor-in-chief of ASJ Open Forum; and associate editor of Aesthetic Surgery Journal
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Zeller J, Kiefer J, Braig D, Winninger O, Kraus D, Hagelstein S, Eisenhardt SU. Oncological Safety and Recurrence in the Surgical Treatment of Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma of the Scalp. Cancers (Basel) 2022; 14:cancers14122869. [PMID: 35740535 PMCID: PMC9221451 DOI: 10.3390/cancers14122869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 11/27/2022] Open
Abstract
Simple Summary Atypical fibroxanthoma and pleomorphic dermal sarcoma represent two tumors on the spectrum of a rare dermal sarcoma entity. Close clinical presentation and nearly identical histologic features but distinct prognoses make proper treatment strategies challenging. We performed a retrospective analysis of 32 patients with AFX or PDS in the scalp to provide guidance regarding the extent of radical excision to achieve stable oncological outcomes and whether radical tumor resection on the scalps required complex soft-tissue reconstruction. Compared to AFX, PDS shows a more aggressive growth pattern with frequent satellite metastases and distant metastases. These require extensive resections for local control to achieve long-term remission in most PDS patients. Despite the limited elasticity of the scalp, plastic reconstructive procedures can obtain reliable soft tissue reconstruction, even for complete scalp defects. Due to their rarity, managing these tumors requires an interdisciplinary setting in a specialized sarcoma center. Abstract Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are two distinct designations for a rare dermal sarcoma entity. These tumors arise predominantly in the sun-damaged skin of elderly patients. Although both AFX and PDS have a similar clinical presentation and nearly identical genetic features, they significantly differ in prognosis. Here we present a retrospective single-center chart review analyzing the outcomes of patients treated for dermal sarcoma. The radicality of the tumor-resection extent and soft-tissue reconstructive options were assessed. Patients between January 2010 and August 2021 were included. We recorded resection margins, tumor recurrence, overall survival, number of operations until complete tumor resection, and reconstructive procedures; any complications were recorded. Furthermore, we analyzed a subgroup of patients with satellite metastases. A total of 32 patients met the inclusion criteria (30 male, 2 female, median age of 77.5 years (interquartile range (IQR) 74–81)). Histopathology revealed AFX in 14 patients and PDS in 18 patients. Margin-free resection was achieved in 31 cases, and 27 patients were remission free over the reported period. The local recurrence rate was 5, and distant metastasis was detected in four cases. Of all the PDS cases, nine presented with satellite metastasis. No AFX had satellite metastases. Due to their rarity, managing these tumors requires an interdisciplinary setting in a specialized sarcoma center.
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Affiliation(s)
- Johannes Zeller
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
- Correspondence:
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
| | - David Braig
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Oscar Winninger
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
| | - Daniel Kraus
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
| | - Salome Hagelstein
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
| | - Steffen U. Eisenhardt
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany; (J.K.); (D.B.); (O.W.); (D.K.); (S.H.); (S.U.E.)
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Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study. Spinal Cord 2022; 60:477-483. [PMID: 34621008 PMCID: PMC9209324 DOI: 10.1038/s41393-021-00717-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. OBJECTIVE The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined. SETTING University hospital with a spinal cord injury unit. METHODS A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis. RESULTS The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = -18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing. CONCLUSION The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.
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Lopez DJ, Holm SA, Korten B, Baum JI, Flanders JA, Sumner JP. Comparison of patient outcomes following enterotomy versus intestinal resection and anastomosis for treatment of intestinal foreign bodies in dogs. J Am Vet Med Assoc 2021; 258:1378-1385. [PMID: 34061615 DOI: 10.2460/javma.258.12.1378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To quantify the relative risk of intestinal dehiscence in dogs undergoing intestinal resection and anastomosis (IRA), compared with enterotomy, for surgical management of small intestinal foreign bodies, and to evaluate the association between nasogastric tube placement for early enteral nutrition (EEN) and hospitalization time. ANIMALS 211 dogs undergoing 227 surgeries for intestinal foreign body removal. PROCEDURES Medical records were reviewed for dogs undergoing a single-site sutured enterotomy or IRA for foreign body intestinal obstruction between May 2008 and April 2018. Multivariable logistic regression was used to quantify the association between surgical procedure and dehiscence. Multiple linear regression was used to quantify the association of nasogastric tube placement with total hospitalization time. RESULTS Dehiscence rates were 3.8% (7/183) and 18.2% (8/44) for enterotomy and IRA, respectively. Overall dehiscence rate for all surgeries was 6.6% (15/227). The odds of intestinal dehiscence for IRA were 6.09 times (95% CI, 1.89 to 19.58) the odds for enterotomy. An American Society of Anesthesiologists score > 3 (OR, 4.49; 95% CI, 1.43 to 14.11) and an older age (OR, 1.02 [95% CI, 1.01 to 1.02] for each 1-month increase in age) were significantly associated with greater odds of intestinal dehiscence, regardless of surgical procedure. Placement of a nasogastric tube was not associated with intestinal dehiscence or decreased total hospitalization time when controlling for the year of surgery. CONCLUSIONS AND CLINICAL RELEVANCE Patients undergoing IRA were at a significantly higher risk of intestinal dehiscence, compared with patients undergoing enterotomy. Although this finding should not be used to recommend enterotomy over IRA, this information may be useful in guiding owner expectations and postoperative monitoring.
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Sun ZY, Chen YM, Xie L, Yang X, Ji T. Free flap reconstruction in paediatric patients with head and neck cancer: clinical considerations for comprehensive care. Int J Oral Maxillofac Surg 2020; 49:1416-1420. [PMID: 32273164 DOI: 10.1016/j.ijom.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 01/13/2020] [Accepted: 03/04/2020] [Indexed: 11/24/2022]
Abstract
Free flap reconstruction after resection in paediatric patients with head and neck cancer (HNC) has various clinical challenges, which have not yet been fully investigated. This retrospective study was implemented to investigate these factors. Paediatric patients (≤14 years old) who underwent free flap reconstructions following surgery for HNC at a tertiary referral centre during the years 2009-2018 were included. Clinical, pathological, and imaging data were collected and analysed. Overall, 47 patients were included, 26 male and 21 female. Thirty-four patients were ASA status I and 13 were ASA status II. The median operative time was 415 minutes, while the median intraoperative blood loss was 500 ml. Seventeen patients had a tracheotomy. Fourteen medical complications (six pulmonary infection, six diarrhoea, two pulmonary aspiration) and six surgical complications (one haematoma beneath flap, two wound dehiscence, one salivary fistula, one effusion, one tracheotomy haemorrhage) were observed. Tracheotomy was associated with medical complications (P = 0.003) and total complications (P = 0.024). It was confirmed that microvascular reconstruction can be adopted in paediatric HNC patients, while tracheotomy and nasal feeding tubes should be used with caution. Comprehensive preoperative assessment, gentle handling of the tissues during operative procedures, and appropriate postoperative management will reduce the risk of complications.
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Affiliation(s)
- Z Y Sun
- Department of Maxillofacial Surgery, Jiamusi Central Hospital, Heilongjiang, China.
| | - Y M Chen
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
| | - L Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Huangpu District, Shanghai, China.
| | - X Yang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
| | - T Ji
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
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Wan M, Zhang JX, Ding Y, Jin Y, Bedford J, Nagarajan M, Bucevska M, Courtemanche DJ, Arneja JS. High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Plast Surg (Oakv) 2020; 28:57-66. [PMID: 32110646 PMCID: PMC7016398 DOI: 10.1177/2292550319880921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors. METHODS A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation. RESULTS We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood. CONCLUSIONS The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.
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Affiliation(s)
- Melissa Wan
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacques X. Zhang
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yichuan Ding
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yiwen Jin
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Bedford
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Mahesh Nagarajan
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marija Bucevska
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Douglas J. Courtemanche
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Jugpal S. Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
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Heine-Geldern A, Broer P, Prantl L, Brebant V, Anker A, Kehrer A, Thiha A, Lonic D, Ehrl D, Ninkovic M, Heidekrueger P. Impact of intraoperative use of vasopressors in lower extremity reconstruction: Single centre analysis of 437 free gracilis muscle and fasciocutaneous anterolateral thigh flaps. Clin Hemorheol Microcirc 2019; 71:193-201. [DOI: 10.3233/ch-189411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A. Heine-Geldern
- Department of Plastic, Hand, and Reconstructive Surgery, BG Unfallklinik, Frankfurt, Germany
| | - P.N. Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University, Munich, Germany
| | - L. Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - V. Brebant
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A.M. Anker
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A. Kehrer
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - A. Thiha
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - D. Lonic
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - D. Ehrl
- Department of Hand, Plastic, and Aesthetic Surgery, Ludwig-Maximilians University Munich, Campus Großhadern, Munich, Germany
| | - M. Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University, Munich, Germany
| | - P.I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
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Zhang R, Dippon J, Friedel G. Refined risk stratification for thoracoscopic lobectomy or segmentectomy. J Thorac Dis 2019; 11:222-230. [PMID: 30863592 DOI: 10.21037/jtd.2018.12.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Given the wide adoption of thoracoscopic lobectomy and positive effect of the thoracoscopic approach for improving postoperative outcomes, questions have arisen regarding the validity of previously published risk assessment models. We sought to review the reliability of the established predictors for patients undergoing thoracoscopic lobectomy. Methods From January 2009 to May 2017, 606 patients (275 women, 331 men; median age 67 years) underwent thoracoscopic lobectomy or segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Logistic regression analyses were performed to determine the predictors of postoperative complications, followed by assessments of causal inference. Results The postoperative mortality, pulmonary complication, cardiovascular complication and overall morbidity rates were 1.0%, 8.9%, 5.8% and 18.0%, respectively. While the American Society of Anesthesiologists physical status (ASA-PS) emerged as an independent morbidity predictor, only a slightly significant association between lung function determinants and overall morbidity was found in the univariable regression analyses. Regarding causal inference, inverse probability of treatment weighting using propensity scores revealed 2- and 1.7-fold increases in the odds of cardiopulmonary complications and overall morbidity in patients with ASA-PS grade 3 or 4 compared with those with ASA-PS grade 1 or 2 (OR =2.116, 95% CI: 1.252-3.577, P=0.005; OR =1.740, 95% CI: 1.095-2.765, P=0.019, respectively). Conclusions Our results suggested that the current physiologic evaluation algorithm is also applicable to major lung resection via thoracoscopic approach. ASA-PS is an easily assessable factor capable of predicting major complications following thoracoscopic lobectomy in patients properly selected in compliance with the current guideline. It is recommended to incorporate the ASA-PS into the existing algorithm for more accurate risk stratification in this patient population.
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Affiliation(s)
- Ruoyu Zhang
- Department of General and Thoracic Surgery, Justus-Liebig-University Giessen, Giessen, Germany.,Department of Thoracic Surgery, Chest Hospital Schillerhoehe, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Jürgen Dippon
- Department of Mathematics, University Stuttgart, Stuttgart, Germany
| | - Godehard Friedel
- Department of Thoracic Surgery, Chest Hospital Schillerhoehe, Robert-Bosch-Krankenhaus, Stuttgart, Germany
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Ehrl D, Brueggemann A, Broer PN, Koban K, Giunta R, Thon N. Scalp Reconstruction after Malignant Tumor Resection: An Analysis and Algorithm. J Neurol Surg B Skull Base 2019; 81:149-157. [PMID: 32206533 DOI: 10.1055/s-0039-1683371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/12/2019] [Indexed: 01/22/2023] Open
Abstract
Background An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm 2 , whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm 2 . The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.
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Affiliation(s)
- Denis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexandra Brueggemann
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Konstantin Koban
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Riccardo Giunta
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, Munich, Germany
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Portier K, Ida KK. The ASA Physical Status Classification: What Is the Evidence for Recommending Its Use in Veterinary Anesthesia?-A Systematic Review. Front Vet Sci 2018; 5:204. [PMID: 30234133 PMCID: PMC6128170 DOI: 10.3389/fvets.2018.00204] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022] Open
Abstract
Background: The effectiveness of the American Society of Anesthesiologists (ASA) Physical Status (PS) classification to identify the animals at a greater risk of anesthesia-related death and complications is controversial. In this systematic review, we aimed to analyze studies associating the ASA PS scores with the outcome of anesthesia and to verify whether there was any evidence for recommending the use of the ASA PS in veterinary patients. Methods: Research articles found through a systematic literature search were assessed for eligibility, and data were extracted and analyzed using random-effects analysis. Results: A total of 15 observational prospective and retrospective studies including 258,298 dogs, cats, rabbits, and pigs were included. The analysis found consistency between the studies showing that dogs, cats and rabbits with an ASA-PS ≥III had 3.26 times (95% CI = 3.04–3.49), 4.83 times (95% CI = 3.10–7.53), and 11.31 times (95% CI = 2.70–47.39), respectively, the risk of anesthesia-related death within 24 h (dogs) and 72 h (cats and rabbits) after anesthesia compared with those with an ASA PS <III. In addition, the analysis showed that dogs and cats with ASA PS ≥III had 2.34 times the risk of developing severe hypothermia during anesthesia (95% CI = 1.82–3.01). Conclusions: The simple and practical ASA PS was shown to be a valuable prognostic tool and can be recommended to identify an increased risk of anesthetic mortality until 24–72 h after anesthesia, and a greater risk of development severe intraoperative hypothermia.
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Affiliation(s)
- Karine Portier
- Univ Lyon, VetAgro Sup, GREAT, Marcy l'Etoile, France.,Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Bron, France
| | - Keila Kazue Ida
- Anesthésiologie et Réanimation Vétérinaires, Département de Clinique des Animaux de Compagnie et des Équidés, Université de Liège, Liège, Belgium
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Park JH, Kim DH, Kim BR, Kim YW. The American Society of Anesthesiologists score influences on postoperative complications and total hospital charges after laparoscopic colorectal cancer surgery. Medicine (Baltimore) 2018; 97:e0653. [PMID: 29718883 PMCID: PMC6393129 DOI: 10.1097/md.0000000000010653] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The aim of this study was to investigate the influence of American Society of Anesthesiologists (ASA) scores on postoperative complication rates and total hospital charges following laparoscopic surgery for colorectal cancer.All patients (n = 664) underwent laparoscopic colorectal cancer surgery. A group of patients with an ASA score of 1 or 2 (n = 575) and a group of patients with an ASA score of 3 (n = 89) were compared.The mean age was higher in the group of patients with an ASA score of 3 than in the group of patients with an ASA score of 1 or 2 (70 vs 67 years). The rate of ICU admission (27% vs 15%) was higher in the ASA score 3 group. The mean hospital stay (14 vs 12 days) was longer in the ASA score 3 group. Postoperative 30-day complications (38% vs 27%), 30-day mortality (2% vs 0%), and a Clavien-Dindo classification of ≥3 (21% vs 11%) occurred more frequently in the ASA score 3 group. Mean total hospital charges were significantly higher in the ASA score 3 group (13,906 vs 11,575 USD). Independent risk factors that affected postoperative complications were older age [≥80 years, hazard ratio (HR) = 2.8], an ASA score of 3 (HR = 1.6), and the presence of a primary rectal tumor (HR = 1.6). Postoperative complication rates were 21.9%, 28.5%, and 38.2% in the ASA score 1, 2, and 3 groups, respectively. Total hospital charges were 14,376 USD and 10,877 USD in the groups with and without postoperative complications, respectively. Mean total hospital charges were 10,769 USD, 11,756 USD, and 13,906 USD in the ASA score 1, 2, and 3 groups, respectively.Preoperative ASA scores may be a predictor of postoperative complications and hospital costs when planning laparoscopic surgery for colorectal cancer.
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Affiliation(s)
| | | | - Bo-Ra Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Kaiho Y, Masuda H, Takei M, Hirayama T, Mitsui T, Yokoyama M, Kitta T, Kawamorita N, Nakagawa H, Iwamura M, Arai Y. Surgical and Patient Reported Outcomes of Artificial Urinary Sphincter Implantation: A Multicenter, Prospective, Observational Study. J Urol 2018; 199:245-250. [DOI: 10.1016/j.juro.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Yasuhiro Kaiho
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Urology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hitoshi Masuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Takahiro Hirayama
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takahiko Mitsui
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeya Kitta
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Kawamorita
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Haruo Nakagawa
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masatsugu Iwamura
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoichi Arai
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Alkhalid Y, Lagman C, Sheppard JP, Nguyen T, Prashant GN, Ziman AF, Yang I. Restrictive transfusion threshold is safe in high-risk patients undergoing brain tumor surgery. Clin Neurol Neurosurg 2017; 163:103-107. [PMID: 29096136 DOI: 10.1016/j.clineuro.2017.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/07/2017] [Accepted: 10/20/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess the safety of a restrictive threshold for the transfusion of red blood cells (RBCs) compared to a liberal threshold in high-risk patients undergoing brain tumor surgery. PATIENTS AND METHODS We reviewed patients who were 50 years of age or older with a preoperative American Society of Anesthesiologists physical status class II to V who underwent open craniotomy for tumor resection and were transfused packed RBCs during or after surgery. We retrospectively assigned patients to a restrictive-threshold (a pretransfusion hemoglobin level <8g/dL) or a liberal-threshold group (a pretransfusion hemoglobin level of 8-10/dL). The primary outcome was in-hospital mortality rate. Secondary outcomes were in-hospital complication rates, length of stay, and discharge disposition. RESULTS Twenty-five patients were included in the study, of which 17 were assigned to a restrictive-threshold group and 8 patients to a liberal-threshold group. The in-hospital mortality rates were 12% for the restrictive-threshold group (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.07-12.11) and 13% for the liberal-threshold group. The in-hospital complication rates were 52.9% for the restrictive-threshold group (OR 1.13, 95% CI 0.21-6.05) and 50% for the liberal-threshold group. The average number of days in the intensive care unit and hospital were 8.6 and 22.4 days in the restrictive-threshold group and 6 and 15 days in the liberal-threshold group, respectively (P=0.69 and P=0.20). The rates of non-routine discharge were 71% in the restrictive-threshold group (OR 2.40, 95% CI 0.42-13.60) and 50% in the liberal-threshold group. CONCLUSIONS A restrictive transfusion threshold did not significantly influence in-hospital mortality or complication rates, length of stay, or discharge disposition in patients at high operative risk.
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Affiliation(s)
- Yasmine Alkhalid
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Alyssa F Ziman
- Department of Pathology, & Laboratory Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States; Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, CA, United States; Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, United States.
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Heidekrueger PI, Ehrl D, Ninkovic M, Thiha A, Prantl L, Herter F, Mueller C, Broer PN. The spreaded gracilis flap revisited: Comparing outcomes in lower limb reconstruction. Microsurgery 2017; 37:873-880. [DOI: 10.1002/micr.30245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/22/2017] [Accepted: 09/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Paul Immanuel Heidekrueger
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Denis Ehrl
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Milomir Ninkovic
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Aung Thiha
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Lukas Prantl
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Frank Herter
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Camillo Mueller
- Department for Plastic and Hand SurgeryCHUV Centre de la MainLausanne Switzerland
| | - Peter Niclas Broer
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
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Thorarinsson A, Fröjd V, Kölby L, Lidén M, Elander A, Mark H. Patient determinants as independent risk factors for postoperative complications of breast reconstruction. Gland Surg 2017; 6:355-367. [PMID: 28861376 DOI: 10.21037/gs.2017.04.04] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling. METHODS We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications. RESULTS Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially. CONCLUSIONS Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.
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Affiliation(s)
- Andri Thorarinsson
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Victoria Fröjd
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lidén
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Mark
- Department of Plastic Surgery, Sahlgrenska University Hospital, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Chen XF, Chen YM, Gokavarapu S, Shen QC, Ji T. Free flap reconstruction for patients aged 85 years and over with head and neck cancer: clinical considerations for comprehensive care. Br J Oral Maxillofac Surg 2017; 55:793-797. [PMID: 28735639 DOI: 10.1016/j.bjoms.2017.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 07/07/2017] [Indexed: 11/27/2022]
Abstract
We aimed to identify and evaluate the clinical challenges involved in microvascular flap reconstructions of defects caused by resection of head and neck cancer among patients aged 85 and over. We designed a retrospective study of patients who were treated in the head and neck department of a tertiary referral centre from 2005 to 2015, and all patients aged 85 years and over who had reconstructions with microvascular flaps for head and neck cancer were entered into the study. A total of 24 patients fulfilled the criteria, of whom 15 were men and nine were women. The median (range) duration of stay in hospital was 23 (14-59) days. Eighteen patients had an American Society of Anesthesiologists (ASA) score grade II and six patients grade III. The median (range) operating time was 420 (310-705)minutes, and operative blood loss 550 (200-1500)ml. Sixteen patients had prophylactic tracheostomies, nine of whom developed postoperative surgical complications, seven associated with the tracheostomy (p=0.005). Resections of head and neck cancer and microvascular reconstructions in patients aged 85 and over are associated with a high incidence of postoperative complications. Medical complications tend to be associated with the tracheostomy while surgical complications are potentially associated with the ASA score. Although the morbidity is high, complex resections and microvascular reconstructions are successful with optimum recovery, and age did not seem to influence the outcome. However, it is necessary to avoid prophylactic tracheostomy if possible in these patients.
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Affiliation(s)
- X F Chen
- Department of Otolaryngology, The Affiliated Second Hospital of Fujian Medical University, Quanzhou, 362000.
| | - Y M Chen
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital School of Medicine, Shanghai Jiao Tong University.
| | - S Gokavarapu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital School of Medicine, Shanghai Jiao Tong University.
| | - Q C Shen
- Medical Record Office, Ninth People's Hospital School of Medicine, Shanghai Jiao Tong University.
| | - T Ji
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital School of Medicine, Shanghai Jiao Tong University.
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Villanueva NL, Kenkel JM. Commentary on: Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures. Aesthet Surg J 2017; 37:695-697. [PMID: 28449037 DOI: 10.1093/asj/sjw283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nathaniel L. Villanueva
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Dr Kenkel is the Associate Editor of Aesthetic Surgery Journal
| | - Jeffrey M. Kenkel
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Dr Kenkel is the Associate Editor of Aesthetic Surgery Journal
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21
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Heidekrueger PI, Ninkovic M, Heine-Geldern A, Herter F, Broer PN. End-to-end versus end-to-side anastomoses in free flap reconstruction: single centre experiences. J Plast Surg Hand Surg 2017; 51:362-365. [DOI: 10.1080/2000656x.2017.1283321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Paul I. Heidekrueger
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Munich, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Munich, Germany
| | - Albrecht Heine-Geldern
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Munich, Germany
| | - Frank Herter
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Munich, Germany
| | - P. Niclas Broer
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Munich, Germany
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Kang HW, Seo SP, Kim WT, Kim YJ, Yun SJ, Lee SC, Choi YD, Ha YS, Kim TH, Kwon TG, Byun SS, Jeh SU, Kim WJ. Impact of the ASA Physical Status Score on Adjuvant Chemotherapy Eligibility and Survival of Upper Tract Urothelial Carcinoma Patients: a Multicenter Study. J Korean Med Sci 2017; 32:335-342. [PMID: 28049247 PMCID: PMC5220002 DOI: 10.3346/jkms.2017.32.2.335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/16/2016] [Indexed: 11/24/2022] Open
Abstract
The aim of the present multi-institutional study was to assess the influence of the American Society of Anesthesiologists Physical Status (ASA-PS) classification on adjuvant chemotherapy eligibility and survival in a multi-institutional cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). We retrospectively reviewed data from 416 patients who underwent RNU for UTUC at four Korean institutions between 2001 and 2013. The ASA-PS classification was obtained from the anesthesia chart. Locally advanced UTUC was defined as ≥ pT3 and/or pN1 disease. The influence of ASA-PS score on survival was evaluated by Kaplan-Meier analyses and a multivariate Cox regression model. Patients with a higher ASA-PS class were less likely to be eligible for adjuvant chemotherapy in locally advanced UTUC (P = 0.016). Kaplan-Meier estimates showed that the high-risk ASA-PS group has a poorer overallsurvival (OS) and cancer-specific survival (CSS) compared to low risk ASA-PS groups in both the total and locally advanced UTUC cohorts. Based on multivariate Cox regression analysis, the high-risk ASA-PS category was an independent predictor for overall mortality (OM) (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.017-3.619; P = 0.044) and cancer-specific mortality (CSM) (HR, 2.120; 95% CI, 1.023-4.394; P = 0.043). In conclusion, high-risk ASA-PS score was independently associated with a lower survival rate in patients with UTUC after RNU. However, the influence of ASA-PS classification on survival was limited to locally advanced UTUC. The lower eligibility of patients in the high-risk ASA category for adjuvant chemotherapy may contribute to the lower survival rate in this group.
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Affiliation(s)
- Ho Won Kang
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sung Pil Seo
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Won Tae Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yong June Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seok Joong Yun
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sang Cheol Lee
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Young Deuk Choi
- Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Sok Ha
- Departments of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae Hwan Kim
- Departments of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae Gyun Kwon
- Departments of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seok Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seong Uk Jeh
- Department of Urology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Wun Jae Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea.
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Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47:2828-2832. [PMID: 27771041 DOI: 10.1016/j.injury.2016.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/09/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. PATIENTS AND METHODS Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients' demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. RESULTS Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p>0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p>0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). CONCLUSION This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible.
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Affiliation(s)
- Paul I Heidekrueger
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany.
| | - Denis Ehrl
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - Albrecht Heine-Geldern
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
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Heidekrueger PI, Heine-Geldern A, Ninkovic M, Herter F, Schmauss D, Aung T, Broer PN. Microsurgical reconstruction in patients greater than 80 years old. Microsurgery 2016; 37:546-551. [DOI: 10.1002/micr.30132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/11/2016] [Accepted: 11/11/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Paul I. Heidekrueger
- Department of Plastic; Reconstructive, Hand-, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University; Munich Germany
| | - Albrecht Heine-Geldern
- Department of Plastic; Reconstructive, Hand-, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University; Munich Germany
| | - Milomir Ninkovic
- Department of Plastic; Reconstructive, Hand-, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University; Munich Germany
| | - Frank Herter
- Department of Plastic; Reconstructive, Hand-, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University; Munich Germany
| | - Daniel Schmauss
- Department for Plastic Surgery and Hand Surgery; Klinikum Rechts der Isar Technical University Hospital; Munich Germany
| | - Thiha Aung
- Center of Plastic; Hand and Reconstructive Surgery, University Medical Center Regensburg; Germany
| | - P. Niclas Broer
- Department of Plastic; Reconstructive, Hand-, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University; Munich Germany
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Klein H, Fuchs N, Mehra T, Schweizer R, Giesen T, Calcagni M, Huber G, Giovanoli P, Plock J. Extending the limits of reconstructive microsurgery in elderly patients. J Plast Reconstr Aesthet Surg 2016; 69:1017-23. [DOI: 10.1016/j.bjps.2016.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/03/2016] [Accepted: 01/24/2016] [Indexed: 11/25/2022]
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Märdian S, Krapohl BD, Roffeis J, Disch AC, Schaser KD, Schwabe P. Complete major amputation of the upper extremity: Early results and initial treatment algorithm. J Trauma Acute Care Surg 2015; 78:586-93. [PMID: 25710431 DOI: 10.1097/ta.0000000000000548] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic major amputations of the upper extremity are devastating injuries. These injuries have a profound impact on patient's quality of life and pose a burden on social economy. The aims of the current study were to report about the initial management of isolated traumatic major upper limb amputation from the time of admission to definitive soft tissue closure and to establish a distinct initial management algorithm. METHODS We recorded data concerning the initial management of the patient and the amputated body part in the emergency department (ED) (time from admission to the operation, Injury Severity Score [ISS], cold ischemia time from injury to ED, and total cold ischemia time). The duration, amount of surgical procedures, the time to definitive soft tissue coverage, and the choice of flap were part of the documentation. All intraoperative and postoperative complications were recorded. RESULTS All patients were successfully replanted (time from injury to ED, 59 ± 4 minutes; ISS16; time from admission to operating room 57 ± 10 minutes; total cold ischemia time 203 ± 20 minutes; total number of procedures 7.3 ± 2.5); definitive soft tissue coverage could be achieved 23 ± 14 days after injury. Two thromboembolic complications occurred, which could be treated by embolectomy during revision surgery, and we saw one early infection, which could be successfully managed by serial debridements in our series. CONCLUSION The management of complete major amputations of the upper extremity should be reserved for large trauma centers with enough resources concerning technical, structural, and personnel infrastructure to meet the demands of surgical reconstruction as well as the postoperative care. Following a distinct treatment algorithm is mandatory to increase the rate of successful major replantations, thus laying the foundation for promising secondary functional reconstructive efforts. LEVEL OF EVIDENCE Therapeutic study, level V.
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Affiliation(s)
- Sven Märdian
- From the Center for Musculoskeletal Surgery, Charite Universitatsmedizin Berlin, Berlin, Germany
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Venous Thromboembolism following Elective Aesthetic Plastic Surgery: A Longitudinal Prospective Study in 1254 Patients. PLASTIC SURGERY INTERNATIONAL 2014; 2014:565793. [PMID: 25374678 PMCID: PMC4206918 DOI: 10.1155/2014/565793] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/28/2014] [Accepted: 09/28/2014] [Indexed: 11/29/2022]
Abstract
Background. Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Healthy patients submitted to elective aesthetic plastic surgeries (EAPS) have risk factors to develop VTE not well established yet. The objective of this study was to examine the incidence and risk factors for VTE in these patients. Methods. Longitudinal, prospective (minimum follow-up of 3 months), observational study. Comprehensive information on patient characteristics and surgeries performed was obtained. Preoperative, intraoperative, and postoperative risk factors were analyzed for their association with VTE. Results. A total of 1254 patients were included in the study. Postoperative VTE occurred in 17 (1,35%) of patients. VTE was more frequent in patients more than 40 years old (82.3%). Smoking, patients with 2 or 3 pregnancies, and hormone replacement therapy, and oral contraceptives use presents higher levels of VTE. In this study we have not found any correlation between liposuction, augmentation mammoplasty, mastopexy, and rhinoplasty as an isolated risk factor for VTE. Conclusions. The incidence of VTE in patients undergoing EAPS was 1.35%. Patients with more than 40 years of age, tobacco users, patients with 2 or more pregnancies, and hormone replacement therapy or oral contraceptives use presents higher levels of VTE.
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