The use of MatriDerm in early excision and simultaneous autologous skin grafting in burns--a pilot study

The application of dermal substitutes in deep partial and full-thickness burn wounds in a two-stage procedure prior to skin grafting has become increasingly popular. Synchronous application of dermal substitutes and skin graft has not yet been established as a standard procedure. In a consecutive study 20 wounds in 10 patients with severe burns (age 49.5+/-16.2 years; TBSA 45.6+/-14.5%) were treated with either simultaneous transplantation of Matriderm, a bovine based collagen I, III, V and elastin hydrolysate based dermal substitute and split-thickness skin grafting (STSG), or STSG alone after appropriate excision of the burn wound. The study was designed as a prospective intra-individual comparative study. After 1 week all wounds were assessed for the percentage of autograft survival. Autograft survival was not altered by simultaneous application of a dermal matrix (p=0.015). Skin elasticity was measured after 3-4 months with the Vancouver Burn Skin Score (VBSS). The VBSS demonstrated a significant increase of elasticity in the group with dermal substitutes (p=0.04) as compared with non-substituted wounds for sheet autograft, but not for meshed autograft (p=0.24). From this pilot study it can be concluded that simultaneous application of a dermal matrix is safe and feasible, yielding significantly better results with respect to skin elasticity. Skin elasticity was considerably improved by the collagen/elastin dermal substitute Matriderm in combination with sheet autograft.

Indocyanine Green Fluorescence for Free-Flap Perfusion Imaging Revisited: Advanced Decision Making by Virtual Perfusion Reality in Visionsense Fusion Imaging Angiography

BACKGROUND

Near-infrared indocyanine green video angiography (ICG-NIR-VA) has been introduced for free-flap surgery and may provide intraoperative flap designing as well as postoperative monitoring. Nevertheless, the technique has not been established in clinical routine because of controversy over benefits. Improved technical features of the novel Visionsense ICG-NIR-VA surgery system are promising to revisit the field of application. It features a unique real-time fusion image of simultaneous NIR and white light visualization, with highlighted perfusion, including a color-coded perfusion flow scale for optimized anatomical understanding.

METHODS

In a feasibility study, the Visionsense ICG-NIR-VA system was applied during 10 free-flap surgeries in 8 patients at our center. Indications included anterior lateral thigh (ALT) flap (n = 4), latissimus dorsi muscle flap (n = 1), tensor fascia latae flap (n = 1), and two bilateral deep inferior epigastric artery perforator flaps (n = 4). The system was used intraoperatively and postoperatively to investigate its impact on surgical decision making and to observe perfusion patterns correlated to clinical monitoring.

RESULTS

Visionsense ICG-NIR-VA aided assessing free-flap design and perfusion patterns in all cases and correlated with clinical observations. Additional interventions were performed in 2 cases (22%). One venous anastomosis was revised, and 1 flap was redesigned. Indicated by ICG-NIR-VA, 1 ALT flap developed partial flap necrosis (11%).

CONCLUSIONS

The Visionsense ICG-NIR-VA system allowed a virtual view of flap perfusion anatomy by fusion imaging in real-time. The system improved decision making for flap design and surgical decisions. Clinical and ICG-NIR-VA parameters correlated. Its future implementation may aid in improving outcomes for free-flap surgery, but additional experience is needed to define its final role.

Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years

BACKGROUND

Worldwide the incidence of necrotizing fasciitis (NF) is on the rise. This rapidly progressive infection is a true infectious disease emergency due to its high morbidity and mortality. The mainstay of therapy is prompt surgical debridement, intravenous antibiotics, and supportive care with fluid and electrolyte management. Because of its high mortality rate, patients are increasingly referred to burn centres for specialized wound and critical care issues.

METHODS

A retrospective chart review was performed of 34 consecutive patients over a 5-year period with NF of the upper and/or lower extremities that required surgical debridement and reconstruction.

RESULTS

The overall survival rate was 96%, with an average length of hospital stay of 64.0 ± 5.5 days. The time until the first operation was 1.3 days. The average age of the patients was 56.7 ± 10.6 years. The patients averaged 1.6 relevant comorbidities. One patient who had five comorbidities died. The affected total body surface (TBS) averaged 8.2 ± 2.1%.

CONCLUSION

Early recognition and treatment remain the most important factors influencing survival in NF. Yet, early diagnosis of the condition is difficult due to its similarities with other soft-tissue disorders. Repeated surgical debridement and incisional drainage continues to be essential for the survival. However, these infections continue to be a source of high morbidity, mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement and aggressive critical care management. Referral to a major burn centre may help to provide optimal surgical intervention, wound care and critical care management.

The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome

PURPOSE

To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN).

METHODS

A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included.

RESULTS

Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference.

CONCLUSIONS

Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects

OBJECTIVE

In some patients with chest wall defects, free tissue transfer is indicated. Complications arise if multiple operations have left the trunk devoid of recipient vessels. In such patients, an arteriovenous loop between the cephalic vein and the thoracoacromial artery can be used.

METHODS

A review of all our patients who underwent chest wall reconstruction with a cephalic vein-thoracoacromial artery loop between 2000 and 2009 was performed (n = 29, 19 women and 10 men). The mean age was 64.9 years. Underlying causes were sternal osteomyelitis (n = 20), tumor (n = 4), and osteoradionecrosis (n = 5). All patients were in American Society of Anesthesiologists classes III and IV. Flap selection, intraoperative and postoperative complications, operative time, time of ventilatory support, mean hospital stay, and midterm survival were recorded.

RESULTS

Twenty-five patients received a tensor fascia lata flap, 2 a vertical rectus myocutaneuos flap, and 2 a deep inferior epigastric perforator flap. Mean duration of surgery was 6.8 hours (4.7-10.5 hours). Two transplanted tissue flaps died and/or had to be removed and 4 were revised successfully. Seven patients had wound complications such as infection or prolonged wound healing. Mean time for ventilator support was 93.6 hours (4-463 hours). The median intensive care unit time was 11 days and the overall hospital stay 27.4 days (11-102 days). One-year survival in the whole group was 69.8%.

CONCLUSIONS

The concept of arteriovenous loops allows creation of neovessels at the recipient site and has proven to be a superb tool to facilitate free tissue transfer or to provide an exit strategy in situations with unexpected vascular problems at the recipient site.

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.

Influence of crosslinking on the stiffness and degradation of dermis-derived hydrogels

Natural hydrogels have been investigated for three-dimensional tissue reconstruction and regeneration given their ability to emulate the structural complexity of multi-component extracellular matrices (ECM). Hydrogels rich in ECM can be extracted and assembled from soft tissues, retain a composition specific to the tissue source, and stimulate vascularized tissue formation. However, poor mechanical properties and rapid degradation hinder their performance in regenerative applications. This study investigates the effect of glutaraldehyde (GA) crosslinking on the mechanical properties, biological activity, and degradation of dermis-isolated ECM-rich hydrogels. Compression tests indicated that hydrogel elastic moduli and yield stress values increased significantly with GA exposure time. Lyophilization was shown to decrease yield stress values with respect to non-lyophilized gels. Crosslinked ECM, unlike non-crosslinked gels, was resistant to pepsin degradation in vitro. In a rodent subcutaneous implant model, crosslinking for 0.5 hours or longer drastically slowed degradation relative to controls. Inflammation was low and mature vascularized granulation tissue was observed in all gels, with an increase in vessel density at 1 week in crosslinked gels relative to controls. These results support the potential use of dermis-derived hydrogels as materials for tissue engineering applications and suggest that crosslinking can enhance mechanical properties and prolong hydrogel lifetime while promoting vascularized tissue formation.

Single-stage Matriderm® and skin grafting as an alternative reconstruction in high-voltage injuries

This article presents a retrospective analysis of a series of nine patients requiring reconstruction of exposed bone, tendons or joint capsules as a result of acute high-voltage injuries in a single burn centre. As an alternative to free tissue transfer, the dermal substitute Matriderm(®) was used in a one-stage procedure in combination with split-thickness skin grafts (STSG) for reconstruction. Nine patients, in the period between 2005 and 2009 with extensive high-voltage injuries to one or more extremities which required coverage of exposed functional structures as bone, tendons or joint capsule, were included. A total of 11 skin graftings and 2 local flaps were performed. Data including regrafting rate, complications, hospital stays, length of rehabilitation and time until return to work were collected. Eleven STSG in combination with Matriderm(®) were performed on nine patients (success rate 89%). One patient died. One patient needed a free-flap coverage as a secondary procedure. The median follow-up was 30 months (range 6-48 months). The clinical results of these nine treated patients concerning skin-quality and coverage of exposed tendons or joint capsule were very good. In high-voltage injuries free-flap failure occurs between 10% and 30% if performed within the first 4-6 weeks after trauma. The use of single-stage Matriderm(®) and skin grafting for immediate coverage described in this article is a reliable alternative to selected cases within this period.

Long-term results and the Disabilities of the Arm, Shoulder, and Hand score analysis after modified Brooks and D'Aubigne tendon transfer for radial nerve palsy

PURPOSE

Radial nerve damage results in substantial functional limitations of the upper extremity. No detailed data exist regarding long-term results, patient satisfaction, and professional and social reintegration after tendon transfer for irreparable damage to the radial nerve. In this retrospective study, we investigated these data through the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

METHODS

Between 1995 and 2006, 77 patients underwent a modified Brooks and d'Aubigne surgical technique for radial nerve palsy in our department. In 19 cases, the flexor carpi radialis muscle was used as a donor instead of the flexor carpi ulnaris muscle. The mean follow-up period was 60 months (range, 24-150 months); motion of the wrist and finger joints and pinch-grip power were compared with the healthy side. We assessed the limitation in pursuing daily activities using the DASH score.

RESULTS

Wrist extension averaged 73% of the contralateral side, whereas the value for movement of digital extension was 32% and for thumb abduction in the palmar direction it was 80%. The power grip was reduced to 49% and the pinch grip was reduced to 28%. The mean DASH score was 15 +/- 9, the symptom score mean was 15 +/- 7, and the working score mean was 12 +/- 10. The mean total DASH score was 16 +/- 10. The proportion of patients who remained employed after surgical treatment was 89%.

CONCLUSIONS

Functional results, adequate patient satisfaction, and sufficient professional and social reintegration can be achieved after modified Brooks and d'Aubigne tendon transfer. Accordingly, the tendon transfer offers an important alternative-possibly the procedure of choice-to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important.

Long-Term Outcome after Successful Lower Extremity Free Flap Salvage

Background Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage.

Methods A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed.

Results The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7.

Conclusion Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

Characterization of opioid receptor types modulating acetylcholine release in septal regions of the rat brain

Presynaptic opioid receptors of the delta- and mu-types have been shown to inhibit the release of acetylcholine (ACh) in the rat striatum and hippocampus, respectively, but it is unknown whether opioid receptors modulate the release of ACh also in the region of origin of the hippocampal cholinergic innervation, the septum. To answer this question, slices (350 microm) of the medial septal area and of the diagonal band of Broca, as well as (for comparison) of the hippocampus, were prepared from adult male Wistar rats. The slices were incubated with [3H]choline, superfused in the presence of hemicholinium-3 (10 microM) and stimulated twice (S1, S2) by electrical fields (360 pulses, 3 Hz, 2 ms, 60 mA); opioid receptor agonists were present during S2. The preferential mu-agonist [D-Ala2,N-Me-Phe4,Gly-ol5]enkephalin (DAMGO) inhibited the evoked ACh release by maximally about 40% in hippocampal slices and acted even more strongly in the medial septal area, or the diagonal band of Broca (about 60% or 75% maximal inhibition, respectively). These effects were reduced or abolished by the preferential mu-antagonist naloxone, which showed no effects when given alone. Using naloxone in the presence of a cocktail of peptidase inhibitors, no evidence for an endogenous tone of opioid peptides was found in the medial septal area, diagonal band of Broca or the hippocampus. Using the preferential delta-agonist [D-Pen2, D-Pen5]enkephalin (DPDPE) and the delta-antagonist naltrindole, a delta-opioid receptor inhibiting evoked ACh release was clearly detectable both in the medial septal area and the diagonal band of Broca, but not in the hippocampus, whereas the preferential kappa-agonist trans-3,4-dichloro-N-methyl-N-[2(1-pyrrolidinyl)cyclo-hexyl] benzeneacetamide (U50,488H) had only weak or no effects. In addition to the functional experiments, double in-situ hybridization studies were performed, in which cells containing mRNA for choline acetyltransferase (ChAT) were labeled by an antibody-linked enzymatic staining procedure, whereas mRNAs for mu- or delta-opioid receptors were detected with radioactive probes. These experiments revealed that in the septal region mainly mu-opioid receptors were expressed by neurons positive for ChAT mRNA, whereas in the rat striatum the expression of delta-opioid receptors prevailed in those neurons. We conclude that in the septal area of the rat brain, in contrast to the rat striatum and hippocampus, both presynaptic mu- and delta-opioid receptors modulate the evoked release of ACh. Whether presynaptic mu- and delta-opioid receptors occur on the same or on different septal cells or axon terminals remains to be clarified.

Acute non-displaced fractures of the scaphoid: earlier return to activities after operative treatment. A controlled multicenter cohort study

INTRODUCTION

To investigate whether operative treatment leads to earlier return to previous activity level, 94 patients with the same number of isolated, acute, complete, stable and non-displaced fractures of the scaphoid mid-third were involved in a prospective, multicenter cohort study.

METHOD

Fractures were either fixed with a cannulated screw or immobilized with a short arm cast, and followed for 6 months.

RESULTS

By 15 weeks, patients receiving surgical treatment returned significantly earlier to their full time work and home activities, as well as achieved significantly better results for functional status, pain, and overall satisfaction. However, complication rates concerning union and secondary operative management were higher.

CONCLUSION

Operative treatment therefore primarily facilitates earlier return to previous activity level, as well as better functional status, less pain and higher patient satisfaction, yet conservative treatment seems to be safer and associated with a lower complication rate.

Duodenum preserving pancreatectomy in chronic pancreatitis: design of a randomized controlled trial comparing two surgical techniques [ISRCTN50638764]

Background

Chronic pancreatitis is an inflammatory disease which is characterized by an irreversible conversion of pancreatic parenchyma to fibrous tissue. Beside obstructive jaundice and pseudocyst formation, about half of the patients need surgical intervention due to untreatable chronic pain during the course of the disease. In most of the patients with chronic pancreatitis, the head of the pancreas is the trigger of the chronic inflammatory process. Therefore, resection of pancreatic head tissue must be the central part of any surgical intervention. However, it is unclear to which extent the surgical procedure must be radical in order to obtain a favourable outcome for the patients.

Design

A single centre randomized controlled, superiority trial to compare two techniques of duodenum preserving pancreatic head resection. Sample size: 65 patients will be included and randomized intraoperatively. Eligibility criteria: All patients with chronic pancreatitis and indication for surgical resection and signed informed consent. Cumulative primary endpoint (hierarchical model): duration of surgical procedure, quality of life after one year, duration of intensive care unit stay, duration of hospital stay. Reference treatment: Resection of the pancreatic head with dissection of the pancreas from the portal vein and transsection of the gland (Beger procedure). Intervention: Partial Resection of the pancreatic head without transsection of the organ and visualization of the portal vein (Berne procedure).

Duration: September 2003-October 2007.

Organisation/responsibility

The trial is conducted in compliance with the protocol and in accordance with the moral, ethical, regulatory and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and the Good Clinical Practice guideline (GCP). The Center for Clinical Studies of the Department of Surgery Heidelberg is responsible for planning, conducting and final analysis of the trial.

Postnatal development of opioid receptors modulating acetylcholine release in hippocampus and septum of the rat

The postnatal development of presynaptic opioid receptors inhibiting the release of acetylcholine (ACh) was studied in rat brain hippocampus, medial septum (MS) and diagonal band of Broca (DB). To this end, the corresponding brain slices (350 microm thick) of rats of various postnatal ages (postnatal day 4 [P4] to P16, and adult) were preincubated with [(3)H]choline and stimulated twice for 2 min (S(1), S(2): at 3 Hz, 2 ms, 60 mA) during superfusion with physiological buffer containing hemicholinium-3. In parallel, the activity of choline acetyltransferase (ChAT) was determined in crude homogenates of the tissues as a marker for the development of cholinergic neurons. At any postnatal age, the electrically evoked overflow of tritium from slices preincubated with [(3)H]choline was highest in the DB, followed by the MS and the hippocampus. The evoked [(3)H]overflow increased with postnatal age, reached about 50% (MS, DB) or 30% (hippocampus) of the corresponding adult levels at P16 and correlated significantly with the corresponding ChAT activities. Presence of the preferential mu-opioid receptor agonist DAMGO during S(2) significantly inhibited the evoked overflow of tritium already at P4 in DB and MS, whereas in the hippocampus significant inhibitory effects were first observed at P8 only. Moreover, adult levels of inhibition due to DAMGO were reached at P16 in the DB and MS but not in the hippocampus. In septal areas, also the effect of the preferential delta-opioid receptor agonist DPDPE on the evoked [(3)H]overflow was studied: in contrast to DAMGO, however, significant inhibitory effects of DPDPE were first observed at P12 only. In conclusion, the postnatal development of presynaptic mu-opioid receptors on cholinergic neurons in the DB and MS starts earlier than in the hippocampus and precedes that of presynaptic delta-opioid receptors.

Microsurgical reconstruction for post-traumatic defects of lower leg in the elderly: A comparative study

BACKGROUND

Lower leg microsurgical reconstruction in the elderly is challenging, especially for post - traumatic defects. The present study aimed to evaluate the risk factors, management and outcome of free tissue transfer in patients older than 65 years of post-traumatic defects.

METHODS

Retrospective chart review was performed for all patients older than 18 years undergoing free tissue transfer for post-traumatic lower leg reconstruction from April 2000 to November 2014. A comparative study was designed to identify risk factors and outcome.

RESULTS

In total, 197 patients (ages 18-64) and 44 patients (ages ≥65, average 71.7±6.3) were included and allocated into cohort 1 and 2, respectively. Cohort 2 had a higher rate of diabetes mellitus and/or peripheral artery disease (46.6%, P<0.01). There was no significant difference in major flap complications, donor site complications and amputation rates (P>0.05). A higher rate of intensive care unit (ICU) admission was observed in cohort 2 (37.8%, P<0.01). Comparable limb salvage rates were recorded (97.1% and 95.6%, P=0.59) with an average follow-up of 25.9±30.1months in cohort 1 and 23.7±16.6months in cohort 2.

CONCLUSION

Post-traumatic microsurgical free tissue transfer to the lower leg can be performed safely in patients older than 65 years with high success rate and manageable complications.

Indications and Outcomes of Prophylactic and Therapeutic Extracranial-to-intracranial Arterial Bypass for Cerebral Revascularization

Background:

Extracranial-to-intracranial (EC-IC) arterial bypass is a technically demanding procedure used to treat complex cerebral artery diseases. The indications, proper surgical techniques, and outcomes of this procedure have been under debate over the recent decades.

Methods:

Between January 2004 and December 2012, 28 patients, including patients with cerebral artery occlusion, intracranial aneurysm, cranial base tumor, and Moyamoya disease, underwent EC-IC bypass. Patients’ records were retrospectively reviewed for demography, indications, complications, high-flow versus low-flow bypass, patency rate of bypass, and neurological outcome. The patients were sorted into prophylactic (n = 16) and therapeutic (n = 12) groups based on the preoperative presentation of their neurological symptoms. Follow-up evaluation was performed at a mean of 32.7 ± 24.3 months.

Results:

The overall patency rate of bypass was 100%, the postoperative stroke rate was zero, and the surgical complication rate was 14.3%. There was no significant difference in the bypass patency rate between the 2 groups or between the high-flow and low-flow bypass patients. Patients who underwent prophylactic bypass had minimal surgical and total complications (P = 0.03 and P < 0.01, respectively) and a better neurological outcome. Surgical complications were more common in patients who underwent therapeutic bypass (25%).

Conclusions:

The collaboration of neurosurgeons and plastic surgeons in performing EC-IC bypass can result in excellent outcomes with a high bypass patency rate and few complications, particularly for prophylactic EC-IC bypass.

Microsurgical reconstruction of extensive lower extremity defects with the conjoined parascapular and latissimus dorsi free flap

BACKGROUND

Extensive lower extremity soft-tissue defects pose a reconstructive challenge. We present our experience with the conjoined parascapular and latissimus dorsi (CPLD) free flap.

METHODS

From October 2008 to October 2017, 69 patients (14 female, 55 male) with a mean age of 50 years (range: 16-79 years) underwent reconstruction of lower extremity defects with the CPLD free flap. Mean defect size was 24 × 36 cm (range: 14 × 20 to 45 × 80 cm).

RESULTS

Mean latissimus dorsi (LD) flap size was 19 × 28 cm (range: 14 × 20 to 28 × 42 cm) and mean parascapular (PSC) flap size was 8 × 25 cm (range: 5 × 12 to 11 × 33 cm). Six patients (9%) experienced a total of eight microvascular complications: arterial thrombosis (n = 1), venous thrombosis (n = 6), combined arterial and venous thrombosis (n = 1). The re-exploration rate was 13%. Major complications of the donor-site were seen in 9 patients (13%), of the flap in 13 patients (19%), and of both in 6 patients (9%). Fifteen patients experienced partial flap necrosis (22%). Three CPLD and one PSC flap were lost (5%). PSC flap length was a significant predictor of distal flap necrosis (χ² (1) = 13.2, p = .004, OR = 1.343, 95% CI [1.098-1.642]). PSC flap width was a significant predictor of donor-site revisions (χ² (1) = 15.9, p = .010, OR = 4.745, 95% CI [1.584-14.213]). Arterio-venous loops (AVLs) tended to increase the risk of microvascular thrombosis (χ² (1) = 3.7, p = .08, OR = 4.1, 95% CI [0.9-18.7]).

CONCLUSIONS

The CPLD free flap is an extremely large and highly reliable flap, allowing one-stage reconstruction of extensive lower extremity defects. It may overcome the need for multiple flaps in selected cases.

Protocol design and current status of CLIVIT: a randomized controlled multicenter relevance trial comparing clips versus ligatures in thyroid surgery

BACKGROUND

Annually, more than 90000 surgical procedures of the thyroid gland are performed in Germany. Strategies aimed at reducing the duration of the surgical procedure are relevant to patients and the health care system especially in the context of reducing costs. However, new techniques for quick and safe hemostasis have to be tested in clinically relevance randomized controlled trials before a general recommendation can be given. The current standard for occlusion of blood vessels in thyroid surgery is ligatures. Vascular clips may be a safe alternative but have not been investigated in a large RCT.

METHODS/DESIGN

CLIVIT (Clips versus Ligatures in Thyroid Surgery) is an investigator initiated, multicenter, patient-blinded, two-group parallel relevance randomized controlled trial designed by the Study Center of the German Surgical Society. Patients scheduled for elective resection of at least two third of the gland for benign thyroid disease are eligible for participation. After surgical exploration patients are randomized intraoperatively into either the conventional ligature group, or into the clip group. The primary objective is to test for a relevant reduction in operating time (at least 15 min) when using the clip technique. Since April 2004, 121 of the totally required 420 patients were randomized in five centers.

DISCUSSION

As in all trials the different forms of bias have to be considered, and as in this case, a surgical trial, the role of surgical expertise plays a key role, and will be documented and analyzed separately. This is the first randomized controlled multicenter relevance trial to compare different vessel occlusion techniques in thyroid surgery with adequate power and other detailed information about the design as well as framework. If significant, the results might be generalized and may change the current surgical practice.

[Vacuum-assisted closure therapy. Current status and basic research]

The gap between the broad clinical use of vacuum-assisted closure therapy (VT) and knowledge of the physiological mechanisms leading to its effectiveness is great. The value of the technique and its future development are dependent on research into these mechanisms. A meta-analysis evaluating the results of basic research on the effectiveness of VT was carried out based on peer reviewed publications. This is considered in relation to other therapeutic approaches of basic research to wound healing (growth factors etc.). Our study includes a concise description of the scientific background to the mechanisms of cell stimulation using basic work on tissue expansion, bone, vessel and nerve distraction as well as in vitro cell stimulation. Evaluation of the scientific data on all known effects of VT was made based on the results from experimental animal studies, the results of randomized clinical studies, observations on clinical applications and case reports. Assessment of the studies was based on design and significance as well as the appraisal of our own clinical experience. Data involving cellular effects (proliferation, synthesis, wound healing), systemic effects (mediators, systemic inflammatory disease), extracellular effects (perfusion, edema, local wound environment, stabilization, barriers) and complex effects of VT (inflammation, matrix function, blood supply) were examined. Systematic analysis of the data allows scientifically interested surgeons rapid access to the theme, the first, to this extent, extensive overview of the current scientific situation as well as a comprehensive bibliography for all areas involving the theme of mechanical cell stimulation. The authors list major areas for future research and encourage the development of multicenter studies.