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Nolte S, Kneser U, Bigdeli AK, Aman M, Struebing F, Tisch M, Gazyakan E. [Interdisciplinary defect reconstruction of upper aerodigestive fistulas-case series and treatment algorithm]. HNO 2023; 71:795-801. [PMID: 37707515 DOI: 10.1007/s00106-023-01358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Persistent complex defects and dysfunctions of the upper aerodigestive tract after tumor surgery represent a major challenge. The aim of this study was to evaluate the effectiveness of an interdisciplinary approach using the free anterolateral thigh flap (ALT) as a reconstruction option in the upper aerodigestive tract. MATERIALS AND METHODS The retrospective study identified 5 patients with complex defects after laryngectomy/pharyngolaryngectomy (LE/PLE) and multiple revision surgeries between 2017 and 2023. The operations were performed by an interdisciplinary team from otolaryngology, plastic surgery, and visceral/thoracic surgery. The results of the microsurgical reconstruction were analyzed. RESULTS There was an average of six previous operations. The defects included tracheoesophageal fistulas, pharyngocutaneous fistulas, neopharyngeal stenosis, and combinations thereof. Successful reconstruction was achieved in 100% of patients using the ALT flap. In 2 patients, ALT flow-through flaps were used with an additional free jejunal interposition (JI) and in 3 patients split-ALT flaps were used. The major complication rate was 40% and the minor complication rate was 20%. CONCLUSION Complex defects of the upper aerodigestive tract with multiple previous operations can be successfully reconstructed. Because of its versatility, the ALT flap seems to be a very good option. Prerequisite for this is an interdisciplinary treatment approach with a critical assessment of patient- and disease-specific factors.
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Affiliation(s)
- S Nolte
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - U Kneser
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - A K Bigdeli
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - M Aman
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - F Struebing
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - M Tisch
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - E Gazyakan
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland.
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Nagel SS, Thomas B, Fischer S, Diehm Y, Ziegler B, Bigdeli AK, Schmidt VJ, Kneser U, Radu CA. Random-pattern versus perforator-based adipocutaneous skin paddles for postoperative monitoring of free muscle flaps-a comparative retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; 74:747-754. [PMID: 33189621 DOI: 10.1016/j.bjps.2020.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/31/2020] [Accepted: 10/10/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Free microvascular muscle flaps represent well-established reconstructive options for complex soft tissue defects. However, due to their lack of cutaneous capillary beds, they are difficult to monitor postoperatively. To this end, random and axial-pattern adipocutaneous skin paddles are often included. The objective of the study was to compare the impact of random-pattern versus perforator-based adipocutaneous skin paddles on operative efficacy and muscle flap safety. METHODS Between August 2014 and July 2016, a total of 120 free muscle flaps were included in this retrospective monocentric cohort study. Based on their skin-paddle type, they were either grouped into a 'perforator-based' (group Pb) or 'random-pattern' (group Rp) cohort. The electronic medical records and operative reports of all patients were subsequently reviewed and patient, defect, and flap characteristics of both groups were compared. The effect of the competing skin paddle types on the overall operative time, incidences of flap loss or microvascular complications, and total length of hospital stay were then assessed. RESULTS Group Pb comprised 72 flaps, whereas 48 flaps constituted group Rp. Patient, defect, and flap characteristics were similar between both groups. Groups Pb and Rp were comparable regarding patient age (group Pb: 61 (10-90) vs. Rp: 59 (13-81), p = 0.556), ASA (American Society of Anesthesiologists) class (group Pb: 3 (1-4) vs. Rp 3 (1-3), p = 0.977), and comorbidities, summarized by the Charlson comorbidity index (CCI; group Pb: 1 (0-4 vs. Rp: 1 (0-5), p = 0.295). Both types of monitoring skin paddles were equally reliable. There was no significant difference in the mean operation time between both groups (group Pb: 373 ± 122 min vs. Rp: 342 ± 84 min, p = 0.124). In-patient treatment after flap surgery and total length of hospital stay were significantly shorter in group Pb (group Pb: 24 ± 10 days vs. Rp: 32 ± 17 days, p = 0.002 and group Pb: 39 ± 15 vs. Rp: 48 ± 24, p = 0.022). CONCLUSION Perforator-based skin paddles are a reliable tool for postoperative perfusion monitoring of free muscle flaps and help avoid additional surgical interventions as opposed to their random-pattern counterparts. Thus, the overall and postoperative length of hospital stay is significantly reduced.
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Affiliation(s)
- S S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - B Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Y Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - B Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - A K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - V J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - C A Radu
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany.
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Abstract
BACKGROUND Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. METHODS Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.
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Affiliation(s)
- T Cordts
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
| | - A K Bigdeli
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - C Hirche
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - J F Hernekamp
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie, Martin Luther Krankenhaus, Berlin, Deutschland
| | - P A Grützner
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - G Reiter
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - U Kneser
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
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Michel S, Bigdeli AK, Schramm R, Beiras-Fernandez A, Wolf M, Sodian R, Schmitz C, Kaczmarek I. Hit early and hard – successful treatment of invasive pulmonary aspergillosis with the combination of voriconazole and micafungin in heart transplant recipients. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kaczmarek I, Zaruba MM, Bigdeli AK, Sadoni S, Schramm R, Überfuhr P, Reichart B, Meiser B. Prospective randomized 3-arm trial comparing tacrolimus with mycophenolate mofetil (MMF) or sirolimus with calcineurininhibitor-free immunosuppression (Sirolimus/MMF) after heart transplantation: 5-year results. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Beiras-Fernandez A, Michel S, Bigdeli AK, Sodian R, Beiras A, Kaczmarek I, Vicol C, Kur F. PF4-positive thrombi adhering to the ventricles of Excor-VADs in patients with HIT II. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kowert A, Bigdeli AK, Juchem G. Use of steerable 4 French lumenless pacing leads in patients with difficult venous access. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Bigdeli AK, Michel S, Sodian R, Schmitz C, Kaczmarek I. Berlin Heart EXCOR assist device outflow cannulas – a modified implantation technique. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kaczmarek I, Eifert S, Beiras-Fernandez A, Bigdeli AK, Meiser B, Überfuhr P, Reichart B. Gender does matter – gender specific outcome analysis of 1000 heart transplants at a single centre. Thorac Cardiovasc Surg 2010. [DOI: 10.1055/s-0029-1247076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kofler S, Shvets N, Bigdeli AK, König MA, Kaczmarek P, Deutsch MA, Vogeser M, Steinbeck G, Reichart B, Kaczmarek I. Proton pump inhibitors reduce mycophenolate exposure in heart transplant recipients-a prospective case-controlled study. Am J Transplant 2009; 9:1650-6. [PMID: 19519820 DOI: 10.1111/j.1600-6143.2009.02682.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This prospective study investigates the impact of proton pump inhibitors (PPI) on mycophenolic acid (MPA) pharmacokinetics in heart transplant recipients receiving mycophenolate mofetil (MMF) and tacrolimus. MPA plasma concentrations at baseline (C(0 h)), 30 min (C(0.5 h)), 1(C(1 h)) and 2 h (C(2 h)) were obtained by high-performance liquid chromatography (HPLC) in 22 patients treated with pantoprazole 40 mg and MMF 2000 mg. Measurements were repeated 1 month after pantoprazole withdrawal. A four-point limited-sampling strategy was applied to calculate the MPA area under the curve (MPA-AUC). Predose MPA concentrations with PPI were 2.6 +/- 1.6 mg/L versus 3.4 +/- 2.7 mg/L without PPI (p = ns). Postdose MPA concentrations were lower with PPI at C(0.5 h) (8.3 +/- 5.7 mg/L vs. 18.3 +/- 11.3 mg/L, p = 0.001) and C(1 h) (10.0 +/- 5.6 mg/L vs. 15.8 +/- 8.4 mg/L, p = 0.004), without significant differences at C(2 h) (8.3 +/- 6.5 mg/L vs. 7.6 +/- 3.9 mg/L). The MPA-AUC was significantly lower with PPI medication (51.2 +/- 26.6 mg x h/L vs. 68.7 +/- 30.3 mg x h/L; p = 0.003). The maximum concentration of MPA (MPA-C(max)) was lower (12.2 +/- 7.5 mg/L vs. 20.6 +/- 9.3 mg/L; p = 0.001) and the time to reach MPA-C(max) (t(max)) was longer with PPI (60.0 +/- 27.8 min vs. 46.4 +/- 22.2 min; p = 0.05). This is the first study to document an important drug interaction between a widely used immunosuppressive agent and a class of drugs frequently used in transplant patients. This interaction results in a decreased MMF drug exposure which may lead to patients having a higher risk for acute rejection and transplant vasculopathy.
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Affiliation(s)
- S Kofler
- Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig Maximilians University Munich, Munich, Germany
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Bigdeli AK, Beiras-Fernandez A, Kaczmarek I, Sadoni S, Brenner P, Schmoeckel M, Nikolaou K, Reichart B. Successful pulmonary thromboendarterectomy for right atrial thrombosis in a heart transplant recipient: a case report. EXP CLIN TRANSPLANT 2007; 5:621-3. [PMID: 17617056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Acute massive or submassive pulmonary embolism is a life-threatening condition with a poor prognosis. It causes sudden hemodynamic deterioration and warrants immediate surgery. We report the case of a 41-year-old male heart transplant recipient who had not been treated prophylactically for thrombosis, who was referred to our center because of exertional dyspnea after immobilization owing to an injury in one of his legs. Transesophageal echocardiography revealed a large, mobile, right atrial mass originating from a pacemaker lead. Furthermore, contrast-enhanced computed tomography scanning of the chest revealed multiple pulmonary emboli resulting in subtotal occlusion of both pulmonary arteries. Although typically reserved for patients with chronic thromboembolic pulmonary hypertension, surgical thromboendarterectomy was successfully performed. Six months after discharge, the patient is well and has a New York Heart Association class 1 rating. This is the first report of a successful pulmonary thromboendarterectomy in a heart transplant recipient.
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Affiliation(s)
- A K Bigdeli
- Department of Cardiac Surgery, Ludwig-Maximilians University, Munich, Germany
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Schmauss D, Kaczmarek I, Tenderich G, Groetzner J, Deutsch MA, Schulz U, Wahlers T, Koerfer R, Bigdeli AK, Reichart B. Einfluss des Spender-Serumnatriumspiegels in der Herztransplantation. Z Herz- Thorax- Gefäßchir 2006. [DOI: 10.1007/s00398-006-0549-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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