Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression

BACKGROUND

There is no definitive objective measure for diagnosis of thoracic outlet syndrome (TOS), and functional capacity testing on standardized rehabilitation exercises before and after an anterior scalene muscle block (ASMB) has the potential to serve as a predictor of response to surgery and to improve diagnostic accuracy in these cases.

METHODS

Patients evaluated for TOS underwent ASMB as a diagnostic test and were retrospectively reviewed. Functional capacity scores were recorded for patients performing repetitive motion exercises immediately before ASMB, 15 minutes after ASMB, and at a minimum of 6 weeks after thoracic outlet decompression (TOD). The primary outcome of interest was correlation between the pre- to post-ASMB difference and the pre-ASMB to postoperative difference with respect to 3 functional work capacity scores.

RESULTS

The average change in time-to-fatigue and work product between pre- and post-ASMB of all exercises was an increase of 39.5% and 53.8%, respectively. The greatest pre-ASMB to post-TOD difference was seen for the Extremity Abduction Stress Test with an average improvement of 109.7% and 150.4% for time-to-fatigue and work product, respectively. The degree of percent improvement post-ASMB correlated positively with the degree of percent improvement post-TOD for all exercises with respect to work product and time-to-fatigue.

CONCLUSIONS

Patient response to ASMB as measured by functional capacity on rehabilitation exercises predicted objective functional outcomes following TOD. Post-ASMB outcomes correlated with post-TOD outcomes. The ASMB can be used to assist in diagnosing TOS and provide a surrogate for expectation in patients considering undergoing neurogenic TOD.

Salvage of Intraoral Dehiscence With a Superficial Temporal Artery Islandized Flap (STAIF)

Intraoral dehiscence compromises free fibula flaps following mandibular reconstruction. Salivary contamination risks thrombosis of microvascular anastomosis and hardware infection. The superficial temporal artery islandized flap (STAIF) provides a non-microsurgical reconstructive option for regaining intraoral competency for a time-sensitive complication. The STAIF is based on the superficial temporal artery coursing along the anterior hairline. The flap is mapped with the assistance of the Doppler probe. The width of the skin paddle is dependent upon the ability to close the donor site. The flap is taken down to the level of the zygomatic arch and tunneled into the mouth. We present a case of a patient who underwent mandibular reconstruction with a free fibula flap after a traumatic shotgun wound. The patient developed repeated intraoral dehiscence following failed local buccal and floor of mouth flaps leading to salivary contamination of the flap and hardware. The intraoral dehiscence was successfully salvaged on the third attempt with a STAIF. Intraoral dehiscence requires urgent attention to prevent loss of the free fibula flap after mandibular reconstruction. The STAIF is a non-microsurgical option for restoring intraoral competency. This robust, axially vascularized skin paddle may be split for intra- and extraoral coverage, as was performed in this case, and is an essential tool in the reconstructive armamentarium.

Applying GPT-4 to the Plastic Surgery Inservice Training Examination

BACKGROUND

The recent introduction of Generative Pre-trained Transformer (GPT)-4 has demonstrated the potential to be a superior version of ChatGPT-3.5. According to many, GPT-4 is seen as a more reliable and creative version of GPT-3.5.

OBJECTIVE

In conjugation with our prior manuscript, we wanted to determine if GPT-4 could be exploited as an instrument for plastic surgery graduate medical education by evaluating its performance on the Plastic Surgery Inservice Training Examination (PSITE).

METHODS

Sample assessment questions from the 2022 PSITE were obtained from the American Council of Academic Plastic Surgeons website and manually inputted into GPT-4. Responses by GPT-4 were qualified using the properties of natural coherence. Incorrect answers were stratified into the consequent categories: informational, logical, or explicit fallacy.

RESULTS

From a total of 242 questions, GPT-4 provided correct answers for 187, resulting in a 77.3% accuracy rate. Logical reasoning was utilized in 95.0% of questions, internal information in 98.3%, and external information in 97.5%. Upon separating the questions based on incorrect and correct responses, a statistically significant difference was identified in GPT-4's application of logical reasoning.

CONCLUSION

GPT-4 has shown to be more accurate and reliable for plastic surgery resident education when compared to GPT-3.5. Users should look to utilize the tool to enhance their educational curriculum. Those who adopt the use of such models may be better equipped to deliver high-quality care to their patients.

Performance of ChatGPT on the Plastic Surgery Inservice Training Examination

BACKGROUND

Developed originally as a tool for resident self-evaluation, the Plastic Surgery Inservice Training Examination (PSITE) has become a standardized tool adopted by Plastic Surgery residency programs. The introduction of large language models (LLMs), such as ChatGPT (OpenAI, San Francisco, CA), has demonstrated the potential to help propel the field of Plastic Surgery.

OBJECTIVES

The authors of this study wanted to assess whether or not ChatGPT could be utilized as a tool in resident education by assessing its accuracy on the PSITE.

METHODS

Questions were obtained from the 2022 PSITE, which was present on the American Council of Academic Plastic Surgeons (ACAPS) website. Questions containing images or tables were carefully inspected and flagged before being inputted into ChatGPT. All responses by ChatGPT were qualified utilizing the properties of natural coherence. Responses that were found to be incorrect were divided into the following categories: logical, informational, or explicit fallacy.

RESULTS

ChatGPT answered a total of 242 questions with an accuracy of 54.96%. The software incorporated logical reasoning in 88.8% of questions, internal information in 95.5% of questions, and external information in 92.1% of questions. When stratified by correct and incorrect responses, we determined that there was a statistically significant difference in ChatGPT's use of external information (P < .05).

CONCLUSIONS

ChatGPT is a versatile tool that has the potential to impact resident education by providing general knowledge, clarifying information, providing case-based learning, and promoting evidence-based medicine. With advancements in LLM and artificial intelligence (AI), it is possible that ChatGPT may be an impactful tool for resident education within Plastic Surgery.

Treatment of Symptomatic Lymphedema in the Hand with Omental Flow-through Flap

Vascularized lymph node transfer (VLNT) is a surgical option to improve physiologic lymphatic drainage. This technique transfers healthy vascularized lymphatic tissue from various available donor sites to the existing lymphatics of the affected area. Here, we present a successful case halting the size progression and reversing lymphedema symptoms in a patient treated with vascularized omental lymph node transfer. A 56-year-old man presented with stage III malignant sarcoma of his left medial upper arm. Two-years after excision, flap reconstruction, and radiation brachytherapy, worsening diffuse left arm edema developed, causing pain, decreased range of motion, and paresthesia. A vascularized omental lymph node transfer was performed. The omental flap required a flow-through design, requiring anastomosis of both gastroepiploic arteries to obtain Dopplerable signals. The patient experienced progressive relief of lymphedema symptoms after this transfer. Treatment outcomes with the use of VLNT have been largely encouraging; however, objective measures of improvement and timing of neolymphangiogenesis in recipient lymph node sites still need to be defined. Understanding omental VLNT flow dynamics and expected time point changes during the postoperative course will define expected outcomes and allow for treatment of a greater number of patients affected by lymphedema.

Correction: Autologous Muscle-Derived Nerve Wrap for Prevention of Symptomatic Microneuromas in Primary Nerve Repair

[This corrects the article DOI: 10.7759/cureus.22513.].

Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery

Background

The traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves.

Methods

Using 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves.

Results

Through the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM.

Conclusions

A single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.

Autologous Muscle-Derived Nerve Wrap for Prevention of Symptomatic Microneuromas in Primary Nerve Repair

Regeneration of peripheral nerves after repair is incomplete. Painful microneuromas may form at the site of an appropriately performed primary microsurgical nerve repair leading to a persistent Tinel's sign and hypersensitivity in that location. Here, we describe an autologous option using a free muscle-derived nerve wrap with the intent to capture axonal escape at the site of primary nerve coaptation. We demonstrate this technique on a patient undergoing primary nerve repair of a laceration to the superficial branch of the radial nerve using extensor digitorum communis muscle as a donor graft. This has become our preferred technique over commercially available nerve wraps as the muscle wrap is autologous, not limited by cost, and has the potential to limit microneuroma formation at the coaptation site.

Reconstruction of a Giant Congenital Melanocytic Nevus Defect With a Submental Flap in a Global Health Setting

Excision of a facial congenital melanocytic nevus (CMN) is a common reason for consultation in pediatric plastic surgery. Facial nevi are generally small and uncomplicated to remove and become more complex when large or giant. The available resources determine treatment and excision options. The indication for excision is generally based on esthetic criteria; however, the risk of melanoma increases with the nevi diameter. This patient with a giant CMN (GCMN) was encountered on an international medical mission trip. The palm-sized lesion spanned from her left zygomatic arch down to the jawline. Due to the esthetic impact and lack of resources to continue monitoring the lesion, complete excision was performed. The resultant defect was reconstructed with a pedicled submental flap. This article presents management and reconstruction of a facial GCMN encountered in the global setting and presents a brief literature review of GCMN.

Sentinel Lymph Node Biopsy, Lymph Node Dissection, and Lymphedema Management Options in Melanoma

Melanoma tumor thickness and ulceration are the strongest predictors of nodal spread. The recommendations for sentinel lymph node biopsy (SLNB) have been updated in recent American Joint Committee on Cancer and National Comprehensive Cancer Network guidelines to include tumor thickness ≥0.8 mm or any ulcerated melanoma. Mitotic rate is no longer considered an indicator for determining T category. Improvements in disease-specific survival conferred from SLNB were demonstrated through level I data in the Multicenter Selective Lymphadenectomy Trial (MSLT) I. The role for completion lymph node dissection has evolved to less surgery in lieu of recent domestic (MSLT II) and international (Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial [DeCOG-SLT]) level I data having similar melanoma-specific survival. Treatment options for the prevention of treatment of lymphedema have progressed to include immediate lymphatic reconstruction, lymphovenous anastomosis, and vascularized lymph node transfer.

Necrotizing fasciitis secondary to lake water inoculation with Aeromonas sobria: A case report

RATIONALE

Necrotizing fasciitis (NF) is a rapidly progressing bacterial soft tissue infection with a high mortality rate. It is characterized by significant soft tissue destruction with associated sepsis. The mainstay of treatment is coverage with appropriate broad-spectrum antibiotic therapy and emergent surgical debridement.

PATIENT CONCERNS

A previously healthy 66-year-old female presented with a deep laceration to her right, posterior calf with subsequent contamination with lake water. After the wound was irrigated and closed, the patient developed NF.

DIAGNOSIS

Laceration of the right lower extremity complicated by NF secondary to Aeromonas sobria.

INTERVENTIONS

The patient underwent emergent surgical debridements with intravenous broad-spectrum antibiotics and negative pressure wound therapy. The lower extremity was reconstructed with split-thickness skin grafts.

OUTCOMES

The patient's initial penetrating trauma was closed in the emergency room, and the patient was discharged home with antibiotics. She returned the next day with unstable vitals and was admitted to the intensive care unit. Her condition continued to deteriorate, and she underwent serial surgical debridements. Her condition improved and was discharged home after 13 days in the hospital.

LESSONS LEARNED

Close monitoring for NF is important for tissue infections sustained in aquatic environments. Timely identification and surgical management of NF increases overall survival.

Unique Complications of Venous Anastomotic Couplers: A Systematic Review of the Literature

Background Anastomotic couplers expedite venous microvascular anastomoses and have been established as an equivalent alternative to hand-sewn anastomoses. However, complications unique to the coupler such as palpability and extrusion can occur. The purpose of this study was to perform a systematic review of the literature to assess complications distinct to the venous anastomotic coupler.

Methods A Medline, PubMed, EBSCO host search of articles involving anastomotic venous couplers was performed. Studies involving arterial anastomotic couplers, end-to-side anastomoses, and reviews were excluded. Data points of interest were flap failure, venous thrombosis, hematoma, partial flap necrosis, infection, coupler extrusion, and coupler palpability.

Results The search identified 165 articles; 41 of these met inclusion criteria. A total of 8,246 patients underwent 8,955 venous-coupled anastomoses. Combined reoperation rate was 3.3% and all-cause unsalvageable flap failure was 1.0%. Complications requiring reoperation included venous thrombosis (2.0%), hematoma (0.4%), partial flap necrosis (0.4%), and infection (0.3%). Eight patients had palpable couplers and 11 patients had extrusion of couplers (head/neck, hand, and feet) and required operative management.

Conclusion Venous couplers remain an equivalent alternative to conventional hand-sewn anastomosis. However, venous coupler extrusion and palpability in the late postoperative period is a complication unique to anastomotic couplers, particularly in radiated head and neck, feet and hand free flaps. Removing extruded venous couplers is safe after tissue integration 3 weeks postoperatively. Coupler palpability and extrusion should be integrated into preoperative patient counseling and assessed in follow-up examinations.

Video: minimally invasive Ivor-Lewis esophagogastrectomy for gastric cardia cancer

INTRODUCTION

Gastric cardia cancer with involvement of the esophagus may require an esophagogastrectomy to obtain negative tumor margins. Multiple studies have shown that minimally invasive esophagectomy is a safe approach for the treatment of esophageal cancer [1-3]. We describe the technique of a minimally invasive Ivor-Lewis esophagectomy in a 55-year-old patient with a gastric cardia tumor.

METHODS

In the laparoscopic phase, diagnostic laparoscopy was negative for metastasis. The stomach and distal esophagus were mobilized. The stomach was divided distal to the tumor and a thin gastric conduit was created. The specimen was removed through an extended abdominal port. In the thoracoscopic phase, the esophagus was mobilized. To ensure adequate proximal margins the esophageal stump was divided 1 cm below the azygous vein. A gastroesophageal anastomosis was created using a circular stapler.

RESULTS

Total operative time was 210 min (laparoscopic time, 135 min; thoracoscopic time, 75 min). There were no intraoperative complications. Tumor margins were negative and there were 44 lymph nodes harvested. On postoperative day 2 the patient was transferred to the surgical floor and started on enteral feeds. On postoperative day 4 the esophagram was negative for leaks or obstruction. Patient was started on an oral diet and discharged on postoperative day 5. Final pathology revealed a T3N1M0 (stage III) gastric cardia tumor. The patient underwent adjuvant chemoradiation therapy and at 15 months postoperatively the patient was recurrence free.

CONCLUSION

We recently reported our experience with 104 minimally invasive esophagectomy procedures, of which seven patients had a diagnosis of gastric cardia cancer [4]. The mean number lymph nodes harvested was 23 ± 12. Minimally invasive Ivor-Lewis esophagogastrectomy for the treatment of gastric cardia cancer is technically feasible and safe for large gastric cardia tumors.

Natural orifice management of anastomotic leaks after minimally invasive esophagogastrectomy

A leak after an esophagectomy can lead to significant morbidity and mortality. The treatment options for postoperative leaks include reoperation with pleural drainage and placement of T-tube drainage catheter to control the gastrointestinal leak or complete gastrointestinal diversion, depending on the extent of the leak and tissue viability of the gastric conduit. Both these options require an invasive reoperation. In selected cases, endoscopic deployment of a covered esophageal stent may be an effective minimally invasive option in the management of an esophageal leak. This report describes the indications and techniques for management of an esophageal leak using the natural orifice for drainage of a mediastinal abscess and deployment of an esophageal stent.