A randomized trial of early endovenous ablation in venous ulceration: a critical appraisal: Original Article: Gohel MS, Heatly F, Liu X et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med 2018; 378:2105-114

AIM

Gohel et al. aimed to compare early endovenous ablation vs. deferred endovenous ablation of superficial venous reflux with regard to time to healing of venous leg ulcers, rate of healing at 24 weeks, recurrence rate, ulcer-free time and health-related quality of life.

SETTING AND DESIGN

This multicentre, parallel-group (ratio 1 : 1), randomized controlled trial was conducted in a vascular surgery department setting at 20 participating centres across the U.K.

STUDY EXPOSURE

A total of 450 patients with venous leg ulcers were randomly assigned to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group).

OUTCOMES

The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life.

TRIAL INTERVENTIONS

Endovenous laser or radiofrequency ablation, ultrasound-guided foam sclerotherapy, or nonthermal, nontumescent methods of treatment (such as cyanoacrylate glue or mechanochemical ablation) were performed either alone or in combination. The treating clinical team determined the method and strategy of endovenous treatment.

RESULTS

The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group. Furthermore, more patients had healed ulcers with early intervention [hazard ratio for ulcer healing 1·38, 95% confidence interval (CI) 1·13-1·68; P = 0·001]. The median time to ulcer healing was 56 days (95% CI 49-66) in the early-intervention group and 82 days (95% CI 69-92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85·6% in the early-intervention group and 76·3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrolment was 306 days (interquartile range 240-328) in the early-intervention group and 278 days (interquartile range 175-324) in the deferred-intervention group (P = 0·002). The most common complications were pain and deep vein thrombosis (DVT) (early-intervention group: pain, six of 28; DVT, nine of 28; deferred-intervention group: pain, six of 24; DVT, three of 24).

CONCLUSIONS

Gohel et al. conclude that early endovenous ablation of superficial venous reflux results in faster healing of venous leg ulcers than deferred endovenous ablation. Patients assigned to the early-intervention group also had longer ulcer-free time during the first year after randomization.

[Skin ulcerations due to CINCA syndrome and its successful treatment with prostaglandin E1]

Chronic infantile neurological cutaneous and articular syndrome (CINCA) is a disorder with a defect in the CIAS1 (NLRP3) gene and the altered gene product cryopyrin leads to inflammasome activation with increased IL-1beta synthesis. The activation pathway of the transcription factor NF-κB is also affected, which plays a role in angiogenesis. With respect to the angiogenesis stimulating ability of prostaglandin E₁, we treated a female patient with CINCA syndrome and conventionally non-responsive skin ulcers with prostaglandin E₁ infusions (6 μg/kg bw/24 h/5 day) followed by wound healing lasting over 3 weeks. After 1 year of periodic infusions, the skin defects were permanently closed.

Indocyanine green-augmented diode laser treatment of port-wine stains: clinical and histological evidence for a new treatment option from a randomized controlled trial

BACKGROUND

Complete clearance of port-wine stains (PWS) is difficult to achieve, mainly because of the resistance of small blood vessels to laser irradiation. Indocyanine green (ICG)-augmented diode laser treatment (ICG+DL) may overcome this problem.

OBJECTIVES

To evaluate the feasibility of ICG+DL therapy of PWS and to compare the safety and efficacy of ICG+DL with the standard treatment, flashlamp-pumped pulsed dye laser (FPDL).

METHODS

In a prospective randomized controlled clinical study, 31 patients with PWS were treated with FPDL (λ(em)=585 nm, 6 J cm(-2) , 0.45 ms pulse duration) and ICG+DL (λ(em)=810 nm, 20-50 J cm(-2) , 10-25 ms pulse duration, ICG-concentration: 2 mg kg(-1) body weight) in a split-face modus in one single treatment setting that included histological examination (haematoxylin and eosin, CD34). Two blinded investigators and the patients assessed clearance rate, cosmetic appearance and side-effects up to 3 months after treatment.

RESULTS

ICG+DL therapy induced photocoagulation of medium and large blood vessels (>20 μm diameter) but not of small blood vessels. According to the investigators' assessment, clearance rates and cosmetic appearance were better after ICG+DL therapy than after FPDL treatment (P=0.114, P=0.291, respectively), although not up to a statistically significant level, whereas patients considered these parameters superior (P=0.003, P=0.006, respectively). On a 10-point scale indicating pain during treatment, patients rated ICG+DL to be more painful (5.81 ± 2.12) than FPDL treatment (1.61 ± 1.84).

CONCLUSION

ICG+DL represents a new and promising treatment modality for PWS, but laser parameters and ICG concentration need to be further optimized.

Clinical, histopathological and immunohistochemical assessment of human skin field cancerization before and after photodynamic therapy

BACKGROUND

The field cancerization concept in photodamaged patients suggests that the entire sun-exposed surface of the skin has an increased risk for the development of (pre)-malignant lesions, mainly epithelial tumours. Topical photodynamic therapy (PDT) is a noninvasive therapeutic method for multiple actinic keratosis (AK) with excellent outcome.

OBJECTIVES

To evaluate the clinical, histological and immunohistochemical changes in human skin with field cancerization after multiple sessions of PDT with methyl-aminolaevulinate (MAL).

METHODS

Twenty-six patients with photodamaged skin and multiple AK on the face received three consecutive sessions of MAL-PDT with red light (37 J cm(-2)), 1 month apart. Biopsies before and 3 months after the last treatment session were taken from normal-appearing skin on the field-cancerized area. Immunohistochemical stainings were performed for TP-53, procollagen-I, metalloproteinase-1 (MMP-1) and tenascin-C (Tn-C).

RESULTS

All 26 patients completed the study. The global score for photodamage improved considerably in all patients (P < 0·001). The AK clearance rate was 89·5% at the end of the study. Two treatment sessions were as effective as three MAL-PDT sessions. A significant decrease in atypia grade and extent of keratinocyte atypia was observed histologically (P < 0·001). Also, a significant increase in collagen deposition (P = 0·001) and improvement of solar elastosis (P = 0·002) were noticed after PDT. However, immunohistochemistry showed only a trend for decreased TP-53 expression (not significant), increased procollagen-I and MMP-1 expressions (not significant) and an increased expression of Tn-C (P = 0·024).

CONCLUSIONS

Clinical and histological improvement in field cancerization after multiple sessions of MAL-PDT is proven. The decrease in severity and extent of keratinocyte atypia associated with a decreased expression of TP-53 suggest a reduced carcinogenic potential of the sun-damaged area. The significant increase of new collagen deposition and the reduction of solar elastosis explain the clinical improvement of photodamaged skin.

Skin signs in diabetes mellitus

Diabetes mellitus is the most common endocrine disorder with continuously increasing prevalence. Blood vessels, nerves, eyes, kidneys and skin are affected, which causes both an enormous financial burden and a reduced quality of life of the affected patients. Long-standing diabetes may impair skin homeostasis resulting in skin manifestations in at least one third of all diabetics. The skin involvement may be the first presenting sign of diabetes, thus the respective skin signs should lead to diabetes focused diagnostic. Besides, the skin signs may be considered as a marker for the course of the disease or for the success of therapeutic interventions.

Cytokines, chemokines and growth factors in wound healing

In wound healing, a variety of mediators have been identified throughout the years. The mediators discussed here comprise growth factors, cytokines and chemokines. These mediators act via multiple (specific) receptors to facilitate wound closure. As research in the last years has led to many new findings, there is a need to give an overview on what is known, and on what might possibly play a role as a molecular target for future wound therapy. This review aims to keep the reader up to date with selected important and novel findings regarding growth factors, cytokines and chemokines in wound healing.

[Cutaneous amyloidosis]

Amyloids are common protein aggregates in nature. Some amyloids fulfill important biological tasks while others are known to cause diseases. Despite the fact that the ultrastructure of amyloid is highly conserved, the mechanism of amyloidogenesis remains a challenging research topic. In humans, amyloidoses may develop in the skin or lead to skin signs due to secondary cutaneous involvement. An accurate diagnostic procedure is crucial for planning the therapy of this heterogeneous group of diseases. Therefore, the aim of this paper is to give an overview on the different kinds of amyloidoses as well as on diagnostic and therapeutic approaches. Furthermore, the discrimination between functional and disease-causing amyloid is briefly presented.

[Cutaneous wound healing. Therapeutic interventions]

In modern medicine chronic wounds are an interdisciplinary major therapeutic and financial issue. Essential for therapy is both the causal treatment of the underlying disease and the symptomatic treatment depending on the phase of wound healing. The physiological process of cutaneous wound healing is divided into three overlapping phases: inflammation, proliferation and tissue remodelling. The choice of a suitable therapy depends on the extent of the wound, the localization, exudation and bacterial infestation. In recent years a number of novel findings were made about this complex biological process and the insights gained have resulted in new therapeutic concepts. In the following article we give an overview about possible therapeutic options and present the various modern wound dressings.

Improvements in high resolution ultrasound for postoperative investigation of capillary microperfusion after free tissue transfer

INTRODUCTION

High resolution ultrasound (US) techniques as implemented in the latest generation of US machines provide imminently better resolution compared to previous high resolution models. This improvement is based on advanced transducer technologies as well as updated post-processing procedures. Furthermore, matrix linear transducers providing frequencies from 6 to 15 MHz are now available. The aim of the study was the evaluation of these new techniques for the immediate postoperative investigation of microcirculation after free tissue transfer by supplemental use of Contrast-Enhanced Ultrasound Imaging (CEUS).

PATIENTS AND METHODS

To this end, we investigated 12 patients who underwent free tissue transfer in order to cover tissue defects in various body regions. We utilized the new GE Logiq E9 equipped with a linear 6-9 MHz and a matrix 6-15 MHz probe as well as the GE Logiq 9 with the previous version of the linear 6-9 MHz probe. Both machines provide the modalities of SRI, Cross Beam and THI. The perfusion curves were quantitatively analyzed using digital cine sequences (Qontrast, Bracco, Italy). Furthermore, two independent investigators evaluated the digitally recorded images with respect to the resolution of details based on a scale ranging from 0 to 5, and after application of 2.4 ml SonoVue (Bracco, Italy), evaluated the image quality regarding the representation of tissue perfusion.

RESULTS

None of the free flaps showed clinical or laboratory signs of flap failure during the hospital stay. Several flaps showed typical perfusion patterns relating to the flap type. The combination of SRI, Cross Beam and THI allows, in most cases, a more exact differentiation of tissue graft outlines and tissue composition, in particular the tissue texture, compared to the use of B-scan only. In addition, the high resolution matrix technology combined with the broader spectrum of 6-15 MHz considerably improves the representation of image details compared to multifrequency probes with 6-9 MHz. The use of updated post-processing procedures as well as new transducer technologies in CEUS also results in improved resolution and thus achieves a higher score compared to previous models.

CONCLUSION

At present, these new US technologies combined with the updated 6-9 MHz probe provide the optimal assessment of perfusion in cutaneous, subcutaneous and deeper tissue layers. The additional use of new multifrequency 6-15 MHz matrix probes improves the resolution in the B-mode to an even higher degree.

The impact of the pH value on skin integrity and cutaneous wound healing

The process of cutaneous wound healing comprises three overlapping major phases: inflammation, proliferation and tissue remodelling. However, while mechanisms are studied scientifically on the cellular and subcellular level, there is still a lack of knowledge concerning basic clinical parameters like wound pH or pO2. It could be proven that wound healing is affected by wound pH changes as they can lead to an inhibition of endogenous and therapeutically applied enzymes. Besides, the conformational structure of proteins and their functionality in wound healing is altered. Furthermore, the likelihood of bacterial colonization, which is a common problem in chronic wound pathogenesis, is affected by wound pH alterations. However, wound pH is rarely taken into account in current wound therapy strategies. A routinely performed monitoring of the wound pH and a subsequently adapted wound therapy would most possibly improve chronic wound therapy.

Evaluation of microcirculation of free flaps of the lower leg by contrast harmonic imaging (CHI) with time intensity curve (TIC) analysis

PURPOSE

The aim of the prospective study was to evaluate the macro- and microcirculation in the center and periphery of free flaps with high resolution vascular ultrasound.

MATERIAL

Fifteen patients with free parascapular flaps after lower limb trauma were examined six months postoperative. All ultrasound investigations were performed by one experienced examiner with a multi-frequency linear transducer (5-9 MHz, Logiq 9, GE). Flow evaluation was angle-optimized using digital image technology with the color coded Doppler sonography (CCDS) with measurement of the peak systolic, peak diastolic flow velocities and the resistance index (RI). Contrast harmonic imaging (CHI) with time intensity curve (TIC) analysis was used for quantitative evaluation of the tissue perfusion. Through a peripheral cubital cannula, a first bolus injection was made of 2.4 ml Sonovue to evaluate the perfusion near the flap center and the distal part of the flap.

RESULTS

The combined analysis of all 15 patients showed in the center and in the periphery of the flap a significant increase (p<0.01; Wilcoxon signed rank test) of the perfusion (relative units = RUs) in the period of 90-120 s after contrast medium application (center: baseline perfusion 2.23+/-0.31 RUs to 5.25+/-0.90 RUs after contrast medium; periphery: baseline perfusion 3.07+/-0.44 RUs to 5.80+/-0.57 RUs after contrast medium). The separate analysis of the non-bypass group (n=9) and bypass group (n=6) showed a clearly higher central flap perfusion after contrast medium application for the bypass group. The combined analysis of all patients showed RI-values amounting to 0.79+/-0.03. The RI-values of the bypass group were significantly higher than RI-values of the non-bypass group (p<0.05; t-test; p<0.05; Mann-Whitney rank sum test).

CONCLUSION

The high-resolution ultrasound represents an ideal method for detection of the flow and patency of the bypass and the small vessels of the free flap. The patency of microvascular anastomosis as well as the perfusion and microcirculation in different flap territories and tissue layers can be investigated using dynamic contrast-enhanced ultrasound with subtraction modalities.

A new method to quantify the effect after subcutaneous injection of lipolytic substances

BACKGROUND

Increasing numbers of patients request lipolytic injection therapy for aesthetic indications. However, only the clinical results of these therapies have been published to date. In most cases, pre- and postprocedure photographs and measurements have been presented. As with every other medical procedure, it is necessary to ensure that the results of lipolytic injections are quantified on an objective and scientific basis with comparable data.

METHODS

In the past, the size of fat tissue could not be measured properly with conventional ultrasound systems. High-resolution, real-time three-dimensional (RT-3D) ultrasound is a fairly new method for measuring the volume of tissue. Therefore, this study aimed to measure the interscapular fat bodies of New Zealand rabbits before and after lipolytic therapy with Lipostabil, phosphatidycholine and orciprenalin (Alupent).

RESULTS

The ultrasound-controlled injection of the lipolytic substances into the interscapular fat body ensured a precise injection. The RT-3D ultrasound data were compared with the magnetic resonance imaging (MRI) measurements performed at the same time. The greatest decrease in volume, up to 44%, was measured with orciprenalin (Alupent). There was a significant correlation between the data from ultrasound imaging and MRI.

CONCLUSION

The data suggest that RT-3D ultrasound imaging could be a simple and fast method for proving the effects on volume size after lipolytic procedures. Of the three investigated substances, orciprenalin (Alupent) showed the highest lipolytic effect in our animal model.

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.

Transcutaneous pO2 measurement during tourniquet-induced venous occlusion using dynamic phosphorescence imaging

A sufficient oxygen supply in skin grafts requires a functioning microcirculation. Venous occlusion impairs the microcirculation and is therefore a major threat of healing. Luminescence life time imaging (LLI) enables the non-invasive and two-dimensional assessment of the transcutaneous oxygen partial pressure (p(tc)O2). In the current trial this new device was applied for monitoring of venous congestion. A tourniquet on the upper arm was inflated up to 40-50 mmHg and released after 10 min in eight healthy volunteers. The p(tc)O2 was measured at the lower arm every minute prior to, during and up to 10 min after cuff occlusion (40 degrees C applied skin temperature) using LLI of platinum(II)-octaethyl-porphyrin immobilized in a polystyrene matrix. For validation the polarographic Clark electrode technique was applied in close proximity and measurement was performed simultaneously. p(tc)O2 measurements prior to (Clark: 50.68+/-5.69 mmHg vs. LLI: 50.89+/-4.96 mmHg) and at the end of the venous congestion (Clark: 16.41+/-4.54 mmHg vs. LLI: 23.82+/-3.23 mmHg) did not differ significantly using the Clark electrode vs. LLI. At the initial congestion respectively reperfusion phase the Clark electrode measured faster decreases respectively increase of p(tc)O2 due to oxygen consumption of this method. This experimental trial demonstrates the applicability of LLI to quantify the p(tc)O2 under changing venous blood flow. The use of planar transparent sensors allows the non-invasive generation of two-dimensional maps of surface pO2 what makes this method particular suitable for monitoring of skin grafts.

Does the surface structure of implants have an impact on the formation of a capsular contracture?

BACKGROUND

The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture.

METHODS

This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker's clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis.

RESULTS

The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 +/- 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05).

CONCLUSIONS

The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.

[Reduction of the amputation rate in bone and soft tissue sarcoma by interdisciplinary cooperation]

On the basis of three patients with bone and soft tissue sarcoma,we would like to illustrate the necessity of a well working inter-disciplinary cooperation of radiologists, internal oncologists, radiation therapists, orthopaedic surgeons and plastic surgeons. Functional extremity preservation in sarcoma patients can be achieved by a good interdisciplinary management without im-pairing the total prognosis of the patients. Patients with sarcoma should be treated in centres in which all specialised divisions are experienced and well trained in the treatment of tumour patients. Only then can a promising approach be achieved.

Histologische und immunhistochemische Untersuchungen bei Kapselkontraktur nach glatten Brustimplantaten

INTRODUCTION

A prospective study was performed to analyse the cellular and molecular composition of fibrous capsules around silicone breast implants. The necessity of an exact histological classification for comparing objectively the different findings of capsular contracture is shown.

PATIENTS AND METHODS

The prospective study (investigation time 1/2003 to 6/2005) included 24 female patients (average age: 40+/-12 years) with contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor). In each patient the baker score was determined preoperatively. Samples of capsular tissue from all patients were evaluated histologically and immunohistochemically and classified according to the histological classification introduced by Wilflingseder and co-workers.

RESULTS

All capsules showed the same basic histological structure with a three-layer composition. For the correlation analysis we had to exclude one patient with repeated implant change. There was no correlation between the patient's age, time of implantation, length of implant period, and capsular contracture. Greater amounts of silicone particles were associated with increased degrees of capsular contracture (Baker: r = 0.687, n = 23, p < or = 0.001; Wilflingseder: r = 0.784, n = 23, p < or = 0.001). High silicone amounts were associated with an increased local inflammation (r = 0.489, n = 23, p , 0.05). A moderate to severe local inflammation was found in 23 patients (95.8%). In summary, there was a positive correlation (r = 0.797, n = 23; p , or = 0.001) between the clinical classification (Baker score I to IV) and the histological classification (Wilflingseder score I to IV).

CONCLUSIONS

We demonstrated in our study, in spite of using implants with high gel cohesiveness (fourth generation), the presence of vacuolated macrophages with microcystic structures containing silicone and silicone particles in the capsular tissue. Greater capsular thickness was associated with an increased number of silicone particles ans silicone-loaded macrophages in the peri-implant capsule. The histological classification introduced by Wilflingseder and co-workers takes into consideration this pathogenetic mechanism of inflammatory reaction which seems to be one of the major key factors in the development of capsular contracture.