Ventral Hernia Reconstruction with GORE ENFORM Biomaterial

Introduction: Ventral hernia repair (VHR) is one of the most common surgeries performed in the United States. Degradable mesh is the recommended choice for patients presenting with high-risk co-morbidities or increased risk for infection. GORE® ENFORM BiomaterialTM is a biosynthetic degradable mesh that has recently been approved for use in ventral hernia reconstruction with no reports of its clinical outcomes. Methods: This study was a single surgeon case series. Patients were included in the study if they underwent VHR with GORE® ENFORM BiomaterialTM. The decision to use GORE® ENFORM BiomaterialTM was the senior surgeon's decision based on the patient's center for disease control classification. Patient comorbidities, hernia characteristics, postoperative hernia recurrence, and surgical site occurrences (SSOs) were collected at in-patient follow-up appointments and chart review. Patients were asked to complete preoperative and postoperative patient-reported outcomes (PROs) using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity short form 3a and the hernia-specific quality of life (HerQLes) survey. Results: A total of 15 patients were included in this study. The average length of follow-up was 315 days. Postoperatively, 26.7% of patients had an SSO with 4 surgical site infections. Two patients required an operative washout with mesh removal. One patient experienced hernia recurrence. Eight of the 15 patients completed preoperative and postoperative PROs. Conclusion: This is the first clinical study to report the outcomes of ventral hernia repair using ENFORM mesh. These results show that Enform mesh is an option to consider in complex ventral hernia reconstruction.

Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction

BACKGROUND

 Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within 1 year. There is a paucity of data regarding the potential consequences when TEs have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications.

METHODS

 This is a single-center retrospective review of patients who underwent TE placement for breast reconstruction from 2015 to 2021. Complications were compared between patients who had a TE for >1 year and <1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications.

RESULTS

 A total of 582 patients underwent TE placement and 12.2% had the expander for >1 year. Adjuvant chemoradiation, body mass index (BMI), overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Rate of return to the operating room was higher in patients who had TEs in place >1 year (22.5 vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and reoperation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%).

CONCLUSION

 Indwelling TEs for >1 year are associated with higher rates of infection, readmission, and reoperation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time interval prior to final reconstruction.

Left atrial appendage volume as a prognostic Indicator of long-term mortality in Cancer survivors treated with thoracic radiation

BACKGROUND

Cancer survivors with prior chest radiation therapy (CXRT) frequently present with atrial fibrillation, heart failure, and have higher overall long-term mortality. There are no data examining the utility of left atrial (LA) and LA appendage (LAA) volume-indices to predict clinical outcomes in these patients.

OBJECTIVES

We examined the prognostic value of cardiac phase-dependent 3-D volume-rendered cardiac computerized tomography (CT)-derived LA and LAA volume-indices to predict mortality and major adverse cardiac events (MACE) in cancer survivors treated with thoracic irradiation.

METHOD

We screened 625 consecutive patients with severe aortic stenosis who had undergone transcatheter aortic valve replacement from 2012 to 2017. Based on the gated cardiac CT image quality, we included 184 patients (CXRT:43, non-CXRT:141) for further analysis. We utilized multiplane-3D-reconstructed cardiac CT images to calculate LA and LAA volume-indices, and examined the prognostic role of CCT-derived LA and LAA volume-indices in predicting the all-cause mortality, cardiovascular (CV) mortality, and MACE. We used multivariate cox-proportional hazard analysis to identify the clinical predictors of survival.

RESULTS

Overall, the CXRT group had significantly elevated LAA volume-index compared to non-CXRT group (CXRT:11.2 ± 8.9 ml/m²; non-CXRT:8.6 ± 4.5 ml/m², p = 0.03). On multivariate cox-proportional hazard analysis, the elevated LAA volume and LAA volume-index were the strongest predictors of reduced survival in CXRT group compared to non-CXRT group (LAA volume: RR = 1.03,95% CI 1.0-1.01, p = 0.01; and LAA volume index: RR = 1.05, 95% CI 1.0-1.01, p = 0.03). LAA volume > 21.9 ml was associated with increased mortality. In contrast, LA volume was not a significant predictor of mortality.

CONCLUSION

We describe a novel technique to assess LA and LAA volume using 3-D volume-rendered cardiac CT. This study shows enlarged LAA volume rather than LA volume carries a poor prognosis in cancer-survivors treated with prior CXRT. Compared to conventionally reported markers, LAA volume of > 21.9 ml was incremental to that of other risk factors.

Distribution of wounding patterns in casualties from mass shooting events

Introduction

The incidence and severity of public mass shootings, and mass casualty incidents (MCI), continues to rise. Understanding the wounding pattern and incidence of potentially preventable death after these incidents is key not only to Health System and Trauma Center emergency response planning but also to community outreach and initial emergency interventions.

Methods

A retrospective study of autopsy reports after events with at least 10 fatalities exclusive of the assailants identified via the Federal Bureau of Investigation database from 1 January 1999 to 31 December 2020 was performed. Sites of injury, identification of weaponry, and identification of potentially survivable wounds were compiled.

Results

Nine events including 203 victims were reviewed. Overall, 56% of gunshots were to the head/neck/face; 37% were to the chest; 43% were to the abdomen/torso/back; 31% were to the lower extremity; and 36% were to the upper extremity. On average, there were 29 fatalities per event.

Conclusion

Emergency response disaster care strategy should focus on immediate point of care at the site of wounding by both the civilian population and medical personnel, as well as rapid extrication of victims for definitive medical care. Review of these autopsy results indicates exsanguination, often treatable, is the primary cause of death—supporting community education efforts in hemorrhage control. The location of the wounding patterns seen in this study warrants primary integration of craniomaxillofacial, orthopedic trauma, neurotrauma, and surgical critical care/trauma surgical specialists into the initial response team for MCI.

Using Radiographic Domain for Evaluating Indications in Abdominal Wall Transplantation

BACKGROUND

There is currently no description of abdominal domain changes in small bowel transplantation population or consensus of criteria regarding which patients are at high risk for immediate postoperative abdominal wall complications or would benefit from abdominal wall vascularized composite allotransplantation.

METHODS

A retrospective chart review was performed on 14 adult patients receiving intestinal or multivisceral transplantation. Preoperative and postoperative computed tomography scans were reviewed, and multiple variables were collected regarding abdominal domain and volume and analyzed comparing postoperative changes and abdominal wall complications.

RESULTS

Patients after intestinal or multivisceral transplantation had a mean reduction in overall intraperitoneal volume in the immediate postoperative period from 9031 cm3 to 7846 cm3 (P = 0.314). This intraperitoneal volume was further reduced to an average of 6261 cm3 upon radiographic evaluation greater than 1 year postoperatively (P = 0.024). Patients with preexisting abdominal wound (P = 0.002), radiation, or presence of ostomy (P = 0.047) were significantly associated with postoperative abdominal wall complications. No preoperative radiographic findings had a significant association with postoperative abdominal wall complications.

CONCLUSIONS

Computed tomography imaging demonstrates that intestinal and multivisceral transplant patients have significant reduction in intraperitoneal volume and domain after transplantation in the acute and delayed postoperative setting. Preoperative radiographic abdominal domain was not able to predict patients with postoperative abdominal wall complications. Patients with abdominal wounds, ostomies, and preoperative radiation therapy were associated with acute postoperative abdominal complications and may be considered for need of reconstructive techniques including abdominal wall transplantation.

Microsurgery Fellowship Website and Social Media Presence: Are Programs Optimizing Recruitment Strategy?

BACKGROUND

 Microsurgery fellowship applicants make decisions for future training based on information obtained from colleagues, mentors, and microsurgery fellowship program Websites (MFWs). In this study, we sought to evaluate the accessibility and quality of available information by microsurgery programs by analyzing the most commonly used web resources and social media outlets for applicants.

METHODS

 The San Francisco (SF) Match and American Society of Reconstructive Microsurgery Websites were queried in April 2020 for microsurgery fellowship programs (MFPs) participating in the SF Match. Twenty-two independent variables of information were assessed on MFWs based on previously published data. Social media presence was also assessed by querying Facebook, Instagram, and Twitter for official hospital, plastic surgery residency, and microsurgery fellowship accounts.

RESULTS

 All 24 MFWs participating in the SF Match had a webpage. Program description, faculty listing, operative volume, and eligibility requirements were listed for all programs (100%). The majority of MFWs listed affiliated hospitals (75%), provided a link to the fellowship application (66.7%), listed interview dates (66.7%), and highlighted research interests (50%). A minority of MFWs provided information on conference schedule (37.5%), current fellow listing (25%), previous fellow listing (16.67%), and positions held by previous fellows (8.33%). No MFWs (0%) presented information on selection process, or rotation schedule.All hospitals with an MFP had a Facebook page and nearly all had Instagram (83.3%) and Twitter accounts (95.8%). Plastic surgery residency programs at the same institution of an MFP had social media presence on Facebook (38.9%), Twitter (38.9%), and Instagram (66.7%). Only three MFPs had Facebook accounts (12.5%) and none had Instagram or Twitter accounts.

CONCLUSION

 As the field of microsurgery continues to grow, the need for effective recruitment and training of microsurgeons continues to be essential. Overall, we conclude that both the accessibility and quality of information available to applicants are limited, which is a missed opportunity for recruitment.

Th17 cell inhibition in a costimulation blockade-based regimen for vascularized composite allotransplantation using a nonhuman primate model

Vascularized composite allotransplantation (VCA) is challenged by the morbidity of immunosuppression required to prevent rejection. The use of highly specific biologics has not been well explored in VCA. Given that psoriasis is T-cell mediated, as is rejection of skin-containing VCAs, we sought to assess the role of ustekinumab and secukinumab, which are approved to treat psoriasis by inhibiting Th17 cells. We combined these agents with belatacept and steroids in a VCA nonhuman primate model. Group I consisted of belatacept and steroids, group II was belatacept, ustekinumab with steroid taper, and group III was belatacept, secukinumab with steroid taper. Three animals were transplanted in each group. In group I, the mean graft survival time until the first sign of rejection was 10 days whereas in group II and III it was 10.33 and 11 days, respectively. The immunohistochemistry analysis showed that the number of IL-17a⁺ cells and the intensity of IL-17a expression were significantly reduced in both dermis and hypodermis parts in groups II and III when compared to group I (P < 0.01). Ustekinumab and secukinumab led to less T-cell infiltration and IL-17a expression in the allograft but provided no benefit to belatacept and steroids in VCA survival.

Surgical Techniques for Revascularization in Abdominal Wall Transplantation

BACKGROUND

 Abdominal wall vascularized composite allotransplantation (AW-VCA) can be considered as a technically feasible option for abdominal wall reconstruction in patients whose abdomen cannot be closed using traditional methods. However, successful initial abdominal wall revascularization in the setting of visceral organ transplantation can pose a major challenge as graft ischemia time, operating in a limited surgical field, and variable recipient and donor anatomy must be considered. Several techniques have been reported to accomplish abdominal wall revascularization.

METHODS

 A literature review was performed using PubMed for articles related to "abdominal wall transplantation (AWT)." The authors of this study sorted through this search for relevant publications that describe abdominal wall transplant anatomy, technical descriptions, and outcomes of various techniques.

RESULTS

 A total of four distinct revascularization techniques were found in the literature. Each of these techniques was described by the respective authors and reported varying patient outcomes. Levi et al published a landmark article in 2003 that described technical feasibility of AWT with anastomosis between donor external iliac and inferior epigastric vessels with recipient common iliac vessels in end-to-side fashion. Cipriani et al described a microsurgical technique with anastomosis between donor and recipient inferior epigastric vessels in an end-to-end fashion. Giele et al subsequently proposed banking the abdominal wall allograft in the forearm to reduce graft ischemia time. Recently, Erdmann et al described the utilization of an arteriovenous loop for synchronous revascularization of abdominal wall and visceral transplants for reduction of ischemia time, operative time, while eliminating the need for further operations.

CONCLUSION

 Vascularized composite allotransplantation continues to advance with improving immunotherapy and outcomes in solid organ transplantation. Optimizing surgical techniques remains paramount as the field continues to grow. Refinement of the presented methods will continue as additional evidence and outcomes become available in AW-VCA.

The Essential Local Muscle Flaps for Lower Extremity Reconstruction

BACKGROUND

 Lower extremity reconstruction is often a challenging prospect with major implications on a patient's quality of life. For complex defects of the lower extremity, special consideration must be given to ensure suitable and durable coverage. In the following article, we present the essential local muscle flaps for lower extremity reconstruction and discuss guiding principles for the reconstructive surgeon to consider.

METHODS

 A thorough literature review was performed using PubMed to identify commonly used local muscle flaps for lower extremity reconstruction. Common considerations for each identified flap were noted.

RESULTS

 The essential local muscle flaps for lower extremity reconstruction were identified and classified based on anatomical region of the defect to be reconstructed. General considerations and postoperative management were discussed to aid in operative decision making.

CONCLUSION

 While many factors must be taken into account when performing lower extremity reconstruction, there are numerous reliable local muscle flaps which can be used to successfully provide durable coverage for a variety of soft tissue defects of the lower extremity.

Small bowel and abdominal wall transplantation: A novel technique for synchronous revascularization

Abdominal wall transplantation (AWT) was introduced in 1999 in the context of reconstruction of complex abdominal wall defects in conjunction with visceral organ transplantation. As of recently, 38 cases of total AWT have been performed worldwide, about half of which were performed in the United States. While AWT is technically feasible, one of the major challenges presenting to the reconstructive surgeon is time to revascularization of the donor abdominal wall (AW), given the immediate proximity of the visceral organ and AWT. The authors report a novel AW revascularization technique during a synchronous small bowel and AWT in a 37-year-old man.

Differential response to salinity and water deficit stress in Polypogon monspeliensis (L.) Desf. provenances during germination

The effects of provenance, salinity (0, 100, 200, 300 and 400 mm NaCl) and water deficit (0, -0.6, -1.1, -1.6 and -2.1 MPa mannitol solutions) on germination success of Polypogon monspeliensis were investigated. Eight Tunisian provenances from different bioclimatic origins were considered. Seed mass varied significantly between populations. Germination percentage was significantly affected by provenance, salinity and their interaction. Even at 300 mm NaCl, germination percentage of Tabarka, Kelbia and Kebili ranged from ca. 60% to ca. 85%, whereas Monastir, Gabes and El Haouaria succeeded in germinating in 200 mm NaCl. The 300 mm NaCl treatment highly reduced germination of Monastir and El Haouaria, and inhibited that of Gabes. Soliman and El Jem were the least salt-tolerant provenances. The severity of water deficit impact on seed germination was also provenance-dependent, especially at osmotic potentials of -1.1 to -1.6 MPa. At -1.6 MPa, germination percentage of Tabarka, Monastir and Kebili was close to 80%, while that of Gabes, El Jem and Kelbia was 0%, 5% and 20%, respectively. Regardless of provenance, germination was strongly impaired at -2.1 MPa. The variability of stress tolerance in P. monspeliensis could be of practical significance in programmes aimed at restoring arid and salt-affected lands since it allows use of provenances that germinate and establish successfully under unfavourable conditions prevailing in such zones.

Treatment of cholera-like diarrhoea with oral rehydration

Cholera diarrhoea remains a major global health problem that has caused seven pandemics. The pathogenesis of cholera is attributable to the production of cholera toxin by the causative pathogen, Vibrio cholerae. The toxin causes increased production of cyclic adenosine monophosphate and this results in massive water and electrolyte secretion into the intestinal lumen. These changes manifest clinically as the painless defecation of voluminous stools that resemble 'rice water', leading to severe dehydration. The cornerstone in the management of cholera diarrhoea is the use of oral rehydration solutions (ORS) to replace the water and electrolytes lost as stools. The World Health Organization recommends the use of ORS of 'reduced osmolarity' for the treatment of acute non-cholera diarrhoea and the use of rice-based ORS for the management of cholera diarrhoea. Although several attempts have been made to improve ORS, studies to evaluate some of the modifications, which include the addition of amylase-resistant starch, the use of amino acids (such as glycine, alanine and glutamine) as sodium cotransporters, and zinc-supplemented ORS, are still needed.

Interactive effects of salinity, nitrate, light, and seed weight on the germination of the halophyte Crithmum maritimum

Interaction of salinity, nitrate, light, and seed weight on the germination of Crithmum maritimum was investigated. Seeds of three size categories were germinated at 0-200 mM NaCl with either 0, 5 or 20 mM KNO 3 . Experiments were done under darkness, white light, or red light. Regardless of seed weight, germination was maximal in distilled water. Under salinity, the smallest seeds showed the highest germination percentage. Salt impact was amplified by darkness, but was mitigated by nitrate supply, red light and their combination. At the same PPFD, germination of T2 seeds was higher, when exposed to red light than under white light, suggesting that germination was more influenced by the light type than by the PPFD. As a whole, not only salinity, nutrient availability, seed weight, and light, but also their interaction may control the germination of this halophyte.