Evaluation of anterolateral thigh flap dimensions with virtual flap models

Free flaps are commonly used for head and neck reconstruction. However, flap dimensions are still evaluated by visual and tactile assessment. The aim of this study was to enable preoperative planning of flap dimensions for soft tissue reconstruction based on clinical parameters. Computed tomography records from 230 patients dated from 2009 to 2019 were analysed retrospectively. A virtual, three-dimensional anterolateral thigh flap model was standardized, aligned to segmented leg models in two positions, and flap thicknesses and volumes were determined. Associations of flap thickness and volume with clinical parameters were evaluated, and an approximative calculation method was derived. The laterally positioned anterolateral thigh flap showed an average (interquartile range) thickness of 15.6 mm (8.7 mm) and volume of 1.5 cm³ (0.9 cm³) per cm². The medially positioned anterolateral thigh flap showed an average (interquartile range) thickness of 16.3 mm (8.7 mm) and volume of 1.6 cm³ (0.9 cm³) per cm². For both flap positions, leg circumference was the strongest predictor of flap thickness (β = 0.545, P < 0.001 and β = 0.529, P < 0.001) and flap volume (β = 0.523, P < 0.001 and β = 0.480, P < 0.001). Flap dimensions can be calculated based on leg circumference, and this preoperative planning of flap dimensions can help the surgeon to select the appropriate flap.

638 The Implication of Telephone Consultations During COVID-19 Pandemic on Informed Consent

Aim

Is to find whether telephone consultations have affected patient’s comprehension of the proposed surgical management and possible risks until the day of surgery and accordingly ability for informed consent.

Method

This study included a sample of patients admitted to QEQM hospital for elective day case surgery during November 2020 and had only telephone consultation when referred for surgery. A feedback survey assessing quality of information given to patients before and on day of surgery was filled by the patients after the procedure.

Results

The sample included 40 patients undergoing different procedures [cholecystectomy (25), inguinal hernia repair (25), rectal examination under anaesthesia (5), ventral hernia repair (2), incisional hernia (2), inguinal lymph node biopsy (1)]. It was found that 27.5% of patients didn’t have thorough explanation of possible risks and no explanation about postoperative care in 35%.20% were not provided a leaflet about procedure, 57.5% had concerns before surgery and 75% of patients wished for a leaflet with illustrative diagrams, explanation of risks with their management to be able to take the right decision and majority of these patients were from cholecystectomy subgroup.

Conclusions

The lack of face-face appointment affected greatly the informed consent process resulting in patient dissatisfaction which raised the need for new leaflets containing diagrammatic explanation of procedures and possible risks with their management to ensure fulfilment of autonomy principle.

465 No Role for Postoperative Antibiotics in Uncomplicated Appendicitis

Introduction

Several studies have shown benefit from use of preoperative antibiotics in reducing postoperative infection after appendectomy as well as efficacy of postoperative antibiotics in complicated appendicitis (defined as perforated appendix or presence of pus in peritoneum). While for uncomplicated appendicitis, several studies showed no benefit from antibiotics postoperatively but there are no clear NICE guidelines till now and so surgeons have different practice based on their preferences.

Method

This study included patients who had appendectomy for uncomplicated appendicitis in Worthing hospital from 1st July 2019 till 30th June 2020. The end point was 30-day follow up postoperatively for wound infection or collection.

Results

90 patients were admitted with uncomplicated appendicitis with age 6-80 years (mean of 31.3). 46 patients (51%) did not receive postoperative antibiotics (group A) and 44 (49%) received postoperative antibiotics (group B) with a variable practice from one dose to 8-day course. postoperatively, only 1 patient (2.1%) in group A developed wound infection requiring drainage while none in group B developed complications (p-value=1).

Conclusions

Administration of postoperative antibiotics in uncomplicated appendicitis showed no superiority over non-administration. in addition, they add extra cost on NHS. So, their routine use postoperatively is not recommended, however, larger studies are required to confirm this.

459 Implication of Changes in Management of Acute Pancreatitis During COVID-19 Pandemic

Introduction

when COVID-19 pandemic stroked the country, the Royal College of Surgeons recommended cholecystectomy for gall stone pancreatitis could be delayed up to 12 weeks during Covid-19 pandemic. This may have exposed patients to recurrent gall stone morbidity and serious complications.

Method

Patients admitted with gall stone pancreatitis during Covid-19 period 12^th March 2020 till 15^th June 2020 to Western Sussex hospitals were analysed retrospectively for a period of 3 months post index submission. The endpoints were readmission rates and complication relating to gall stones.

Results

Conclusions

Delaying cholecystectomy for gallstone pancreatitis to 3 months is associated with significant readmission rates and serious complications. Cholecystectomy for gallstone pancreatitis should be categorised as 1B or 2 during Covid-19 period.

Correlation between extent of sinus surgery, radiographic disease, and postoperative outcomes

BACKGROUND

The extent of endoscopic sinus surgery (ESS) required for optimal outcomes in chronic rhinosinusitis (CRS) is undefined. We evaluated whether concordance between the extent of surgery and degree of radiographic disease influences postoperative outcomes.

METHODS

247 CRS patients who underwent ESS were retrospectively assigned a concordance score reflecting the similarity between the extent of surgery and degree of radiographic disease. 0 points were assigned when sinusotomy was performed on a diseased sinus, or no sinusotomy was performed on a nondiseased sinus; plus 1 for sinusotomy on a nondiseased sinus; and -1 for a diseased sinus left unopened. The total possible score ranged from minus 10 to plus 10. Patients were divided into 5 subgroups according to variance from complete concordance. SNOT-22 scores and revision rates were compared at 6 and 24 months.

RESULTS

All five subgroups had similar preoperative SNOT-22 scores and improved at 6 months postoperatively. At 6 months postoperatively, the most conservatively operated and most extensively operated subgroups each achieved equivalent improvements in SNOT-22 as the completely concordant subgroup. At 24 months, the most extensively operated subgroup had a 12.5-point smaller improvement in SNOT-22 scores compared to the completely concordant subgroup. Multivariate analysis showed no association between concordance score and revision rate.

CONCLUSIONS

Symptom improvement and revision rates after ESS do not appear to correlate with the degree of concordance between extent of surgery and radiographic disease. More extensive surgery than indicated by CT confers neither greater symptomatic improvement nor long-term detriment.

Evaluation of the bactericidal effect of cold atmospheric pressure plasma on contaminated human bone: an in vitro study

The use of cold atmospheric pressure plasma (CAPP) as a bacterial decontaminant for chronic wounds has shown good results. The purpose of this in vitro study was to evaluate the bactericidal effects of CAPP on the cancellous area of the bone. Sterile glass slides and processed sterile human bone allografts 1, 2, 3, and 4mm thick were used for initial contamination and further CAPP treatment. Each block was contaminated with Staphylococcus aureus suspension on one side. Each slide was turned 180° and treated on the reverse side. The bacterial count in colony-forming units (CFU) was then measured and compared with that of a control group, and the bactericidal effects of CAPP in relation to bone density evaluated. A significant reduction in count was measured between treated and untreated groups (groups A-D: p<0.01 and group E: p=0.04). A strong positive linear relation was found between bone density and the S aureus count (r=0.844, p=0.156). Treatment with CAPP had a bactericidal effect on bone structures with a penetration depth of up to 4mm. It might be used for all diseases involving infected bone, and so extends the existing range of treatments.

Investigation of phenolic leaf extract of Heimia myrtifolia (Lythraceae): Pharmacological properties (stimulation of mineralization of SaOS-2 osteosarcoma cells) and identification of polyphenols

Evaluation of the activity of an aqueous alcoholic extract obtained from the leaves of Heimia myrtifolia (Lythraceae) by determining its stimulating effect on two human osteoblastic cell lines HOS58 and SaOS-2 indicated its potential for use in the prevention and treatment of osteoporosis. In addition, the extract was found to significantly increase the mineralization of cultivated human bone cell SaOS-2, in which a strong dose-dependent increase was observed. A phytochemical investigation of the extract also confirmed that H. myrtifolia is capable of synthesizing and accumulating appreciable amounts of several phenolics, thus leading to the isolation and characterization of sixteen of these constituents. Identified among these isolates were a new natural product, 1,6-di-O-dehydrotrigalloyl-β-D-(4)C(1)-glucopyranose, and a rare natural product (this marks its second report), 5,7,4'-trihydroxy-3-methoxyflavanone (dihydrokaempferol-3-O-methyl ether). Structures of these isolates were fully elucidated on the basis of conventional methods of analysis and confirmed by ESI/MS and (1)H and (13)C-NMR analysis.

Spicatic acid: A 4-carboxygentisic acid from Gentiana spicata extract with potential hepatoprotective activity

Due to our interest in bioactive plant derived materials, the hepatoprotective activity of the aqueous alcoholic extract of Gentiana spicata AEGS (Gentianaceae) on carbon tetrachloride treated rats was investigated. CCl4 used at a concentration of 1 mL/kg.b.wt. significantly increased the levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). However, pre-treatment with AEGS and its individual components significantly prevented the increase in these enzymes, which are the major indicators of liver injury. Biochemical assays of liver homogenate showed that AEGS and its components restored reduced glutathione (GSH) depletion reduced the level of thiobarbituric acid reactive substances (TBARS). Furthermore, liver histological observation also showed an obvious amelioration in liver cell necrosis, liver lesions, and fatty changes in pre-treated groups. Phytochemical investigation of the extract showed high phenolic content and led to the isolation and identification of the new carboxygentisic acid, 1,4-dicarboxy 2,5-dihydroxybenzene, for which we suggest the name spicatic acid, together with the known flavonoids, quercetin 3-O-[(2,3,4-triacetyl-α-rhamnopyranosyl)1'''→6''] 3-acetyl-β-galactopyranoside and quercetin 3-O-[(2,3,4-triacetyl-α-rhamnopyranosyl)1'''→6'']-4-acetyl-β-galactopyranoside, epicatechin, catechin and their gallolyated derivatives. All structures were elucidated on the basis of conventional analytical methods and confirmed by high resolution ESIMS, 1D- and 2D-NMR data. The new phenolic 4-carboxygentisic acid, spicatic acid is of special interest as it represents the first phenolic acid in nature which bears two carboxyl functions in one aromatic ring.

Traitement de l'incontinence urinaire d'effort par bandelette TVT-O: résultats immédiats et à un an

OBJECTIVE

To compare one-year results between the classic retropupubic (TVT) and the in-out transobturator approaches (TVT-O) of tension-free vaginal tape for the treatment of stress urinary incontinence (SUI).

PATIENTS AND METHODS

The first 82 patients operated for SUI by TVT-O in our institution were included in the analysis. Patients were evaluated at 1 and 12 months. The global satisfaction rate was assessed at 12 months by a self-reported questionnaire. Results were compared to those of the first 124 patients operated of SUI by TVT in the same institution and by the same surgeons between 1996 and 1999.

RESULTS

Except a younger mean age in the TVT-O group (57 versus 60 years), no other preoperative parameter was significantly different between the TVT and the TVT-O groups. The mean operating time was shorter in the TVT-O group (15 versus 30 minutes, P<0.001). No intraoperative complication occurred. The rate of bladder perforation was significantly lower in the TVT-O group (0 versus 8.8%, P=0.004). The rate of post-voiding residual less than 100 ml was higher in the TVT-O group (88 versus 61%, P<0.001). In the TVT-O group, 40% of patients had postoperative inguinal pain (mean=9 days, range 2-15 days). After 12 months from TVT-O, 85% of patients were completely dry, 6% had de novo over bladder activity, and 93.5% of patients were satisfied with the treatment they received. The 12-month results were not significantly different between the TVT and the TVT-O groups.

DISCUSSION AND CONCLUSION

With a follow-up of 12 months, TVT-O is as efficient as TVT and has a lower risk of bladder injury, a cut by half operating time, and less postoperative dysuria.

Outcome after treatment of detrusor–sphincter dyssynergia by temporary stent

OBJECTIVES

To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent.

MATERIALS AND METHODS

Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case.

RESULTS

The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD).

CONCLUSION

After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.

Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique

Neurogenic sphincter incompetence, in the absence of detrusor dysfunction, results in stress urinary incontinence. Management is exclusively surgical. The available artificial sphincters ensure continence, provided intermittent self-catheterization is performed when necessary for neurogenic bladder. Artificial urinary sphincter is the reference treatment, historically and based on published cohort studies. However, it is associated with a higher morbidity in this population than in the non-neurological population. Although the surgical implantation technique is not modified in females as a result of the neurological disorder it is modified in males, as periprostatic implantation may be necessary, requiring specific training in this technique and rigorous patient selection. Other more recent prosthetic treatments are being developed, but are still at the stage of evaluation: periurethral fascia sling, periurethral injections and periurethral balloon implantation. These techniques eliminate the need to manipulate a pump to open the sphincter for self-catheterization. They appear to be promising, but their long-term results are unknown. In conclusion, operative indications for SUI due to neurogenic sphincter incompetence must be based on a multidisciplinary diagnostic assessment and explicit patient information.

Chapitre H - Les conséquences neuro-urologiques de la chirurgie de l’incontinence urinaire d’effort et de la statique pelvienne

It is difficult to prove the neurourological origin of a voiding disorder, pain or postoperative functional disorders after stress urinary incontinence and pelvic repair surgery and their incidence is difficult to evaluate. The purpose of this chapter is to review the data of the literature concerning complications of this type of surgery, possibly related to a neurological injury, regardless of the site. The most frequently encountered postoperative problem is acute urinary retention. Prevention of acute urinary retention must be based on preoperative assessment looking for risk factors and the quality of postoperative resumption of voiding after removal of the bladder catheter Medium-term and long-term de novo dysuria and/or urgency must be analysed according to a neurourological approach, looking for obstruction (that must be removed) and complications related to the implanted prosthetic material or to the operative technique. The most difficult symptom to assess is postoperative pelvic pain "induced" by surgery. It can be accentuated by a previously undiagnosed concomitant spinal or regional lesion (hip) and the diagnostic assessment must be based on a multidisciplinary approach. This review emphasizes the low level of proof of data of the literature in this field and supports the impression that prospective data from homogeneous cohorts must be recorded in registries, for example, despite the difficulty of long-term evaluation (> 5 years). In the future, patients in whom prosthetic material is implanted should probably be encouraged to more readily cooperate in this field to ensure continuing improvement of the quality of surgical care.

Chapitre B-3 A - Traitement chirurgical des dysfonctions neurologiques des sphincters urinaires

The treatment of neurogenic detrusor-sphincter dyssynergia is primarily medical (drugs and catheterization). Some patients may not be eligible for or fail to respond to these treatment options and endoscopic sphincterotomy or permanent prosthesis may be indicated. In this article, the authors review the indications, results and contraindications of these various treatments.

Chapitre B-3 B - Hypertrophie Bénigne de la Prostate et neuro-urologie

Benign prostatic hyperplasia, which is usually treated conservatively (except in the presence of complications) in non-neurological patients, needs to be managed even more cautiously in patients with neurogenic bladder. The treatment decision must include analysis of the previous voiding mode. The development of detrusor-sphincter dyssynergia in an elderly man with a neurological disease must raise the suspicion of prostatic obstruction. The difficulty of establishing a diagnosis of obstruction, that cannot always be confirmed by clinical tools, urodynamic assessment or the search for renal complications, may lead to temporary prostatic stenting as a diagnostic procedure. Certain situations are more specifically encountered in patients with neurogenic bladder: spinal cord injury patients with reflex voiding, patients with stroke and its sequelae, ageing men and diabetic patients.

[Junctional epidermolysis bullosa. Identification of a new mutation in two Lebanese families]

BACKGROUND

Junctional epidermolysis bullosa (JEB) represents a genetically heterozygous group of bullous disorders characterized by dermo-epidermal separation resulting from mutations affecting the main dermo-epidermal adhesion factor, laminin-5, its cellular receptor, integrin alpha6B4, or collagen XVII. We report the identification of a new mutation of LAMA3, encoding laminin-5 alpha3 subunit in two unrelated Lebanese families.

PATIENTS AND METHODS

Two female newborn, descending from 1st degree consanguineous marriages, presented a lethal form of EBJ-Herlitz. Histologic, ultrastructural and immunofluorescence studies were performed in order to ascertain the diagnosis and to direct genetic analysis. Mutation search was conducted through direct DNA sequencing of patients and ascendants.

RESULTS

Immunohistology of frozen skin samples revealed an extremely reduced immunoreactivity for the alpha3 laminin-5 subunit. The two patients were homozygous carriers (parents heterozygous) of a new missense mutation of LAMA3 gene (exon 32: 4300 insA) encoding the alpha3 subunit of laminin-5. Resulting messenger RNA, rapidly degraded, induced an extremely reduced synthesis of alpha3-polypeptide, truncated in its Cterminal domain.

DISCUSSION

LAMB3 gene recurrent mutations R636X and R42X account for about 50p. 100 of EBJ cases affecting Caucasians while mutation Q1083X, affecting the same gene, is recurrent in Arab populations. The newly identified mutation results in extremely reduced synthesis of alpha3 chain and truncation of its C-terminal domain, which is crucial for the intermolecular interactions of laminin-5. Our data are in accordance with recent reports suggesting geographical specificity of EBJ mutations linked to founder effects which are amplified by consanguineous marriages in genetically isolated populations. Otherwise, the observation of other unexplored cases of bullous dermatoses with early demise originating from the same region of the two families herein reported highlights the need for the implementation of a prenatal and postnatal diagnostic strategy regarding these genodermatoses. These studies should target LAMA3 and other genes involved in JEB too.

["Post traumatic" leptospirosis complicated by acute respiratory insufficiency]

INTRODUCTION

Leptospirosis is a rare cause of alveolar haemorrhage. The diagnosis is often delayed particularly when the mode of infection is atypical. These serious complications require prompt antibiotic treatment.

CASE REPORT

A 21-year-old man was involved in a road accident and found lying unconscious in a roadside ditch containing stagnant water. Ten days later he presented with bilateral interstitial pneumonia and rapidly increasing hypoxaemia associated with cholestasis and liver cell necrosis. Broncho-alveolar lavage revealed alveolar haemorrhage. There was satisfactory resolution following antibiotic therapy.

CONCLUSIONS

The diagnosis of leptospirosis was considered initially despite negative serology (Martin and Petit) and confirmed by sero-conversion 20 days after the onset of symptoms.

[Efficacy of botulinum toxin A for the treatment of detrusor hyperreflexia]

OBJECTIVE

To determinate the efficacy of botulinum toxin to treat refractory urinary incontinence due to bladder hyperreflexia.

METHOD

The international medical literature was reviewed from the Medline and Pubmed database.

DISCUSSION

The usual first line treatment of detrusor hyperreflexia is parasympathicolytic drugs and self cathterization. In case of lack of efficacy or severe side effects, a surgical procedure (enterocystoplasty) can be performed. 300 units of Botox injected into the detrusor permit a significant increase of bladder capacity and a significant decrease of maximal detrusor pressure for at last 6 months. But we did not find any double blind controlled studies in this indication and no fundamental studies focused on the mechanism of action of botulinum toxin on the bladder muscle. It is now impossible to conclude on the long term efficacy and toxicity.

CONCLUSION

Botulinum toxin injected into the detrusor muscle seems to be an efficient treatment of bladder hyperreflexia for 6 months in patients resistant to parasympathicolytic drugs. Long term efficacy and mechanism of action is actually not known.

[Hirsutism]

Hirsutism is a common medical condition that can lead to major psychological and social distress. Patient's complaint is usually cosmetic in nature, but hirsutism can sometimes signal a serious underlying disorder. Detailed medical history and physical examination help identify patients in whom extensive work-up is warranted. Therapy that is directed at suppressing androgen secretion, inhibiting the conversion of testosterone to dihydrotestosterone, or blocking the effects of androgens on their receptors, can be rewarding both for the treating physician and the patient. This article reviews the different agents used against hirsutism and addresses the evolution of their indications based on published clinical studies.

[Erythromelanosis follicularis faciei and colli]

BACKGROUND

Erythromelanosis follicularis of the face and neck, originally described in Japan by Kitamura et al. in 1960, is characterized by a clinical set of three: well-demarcated erythema, hyperpigmentation and follicular papules. It affects the face and the neck generally on both sides. Since the original description, it has seldom been reported in the literature.

CASE REPORTS

This paper reports two patients with unilateral presentation.

DISCUSSION

Having discussed the various differential diagnoses all published cases were listed and analyzed. The prevalence of this disease appears higher than is shown by the limited number of cases reported in the literature. It deserves more recognition. Its nosologic and aetiologic frames still remain to be clarified.