Introduction
Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a ...single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation.
Patient and Methods
Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33–66 years) with an average BMI of 34.8 kg/m2 (range: 17.6–53.6 kg/m2). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment.
Results
One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four‐limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow‐up was 15.8 months (range: 12.6–28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis.
Conclusion
Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
The premise that allogeneic red blood cell transfusion (RBCT) contributes to adverse oncologic outcomes after surgery remains controversial. We examined the effects of RBCT during and ...after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) on disease recurrence and survival.
Methods
A prospective database of 220 patients undergoing PD for PDAC from 2000 to 2008 was reviewed and transfusion data collected. Univariate and multivariate analyses were performed for factors influencing RBCT, recurrence-free survival (RFS), and overall survival (OS). The effect of amount and timing (intraoperative vs. postoperative) of RBCT was analyzed.
Results
One hundred forty-seven patients (67%) received RBCT: 70 (32%) received 1 to 2 units, and 77 (35%) received >2 units. Median RFS and OS for the entire cohort was 12 and 16 months, respectively. RBCT of >2 units was associated with reduced RFS (9 vs. 15 months;
P
= 0.033) and OS (14 vs. 20 months;
P
= 0.003). Stratified by timing of transfusion, postoperative RBCT was associated with shortened RFS and OS. Controlling for age, body mass index, comorbidities, tumor factors, and major complications, each incremental unit of postoperative RBCT was associated with reduced RFS (hazard ratio 1.10, 95% confidence interval 1.02–1.18) and OS (hazard ratio 1.08, 95% confidence interval 1.03–1.12). Low hemoglobin and presence of comorbidities were the only preoperative factors independently associated with RBCT.
Conclusions
Allogeneic red blood cell transfusion after PD for PDAC is independently associated with earlier cancer recurrence and reduced survival, in particular when administered postoperatively and in larger quantities. Blood-conservation methods are especially indicated for patients with preoperative anemia and medical comorbidities.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Management of neuroendocrine tumor liver metastasis (NELM) remains controversial, with some advocating an aggressive surgical approach while others have adopted a more conservative ...strategy. We sought to define the efficacy of the surgical management of NELM in a large multicenter international cohort of patients.
Methods
We identified 339 patients who underwent surgical management for NELM from 1985 to 2009 from an international database of eight major hepatobiliary centers. Relevant clinicopathologic data were assessed using Kaplan–Meier and Cox regression models.
Results
Most patients had a pancreatic (40%) or small bowel (25%) neuroendocrine tumor (NET) primary. The majority of patients (60%) had bilateral liver disease. At surgery, 78% of patients underwent hepatic resection, 3% ablation alone, and 19% resection + ablation. Major hepatectomy was performed in 45% of patients, and 14% underwent a second liver operation. Carcinoid was the most common NET histological subtype (53%). Median survival was 125 months, with overall 5- and 10-year survival of 74%, and 51%, respectively. Disease recurred in 94% of patients at 5 years. Patients with hormonally functional NET who had R0/R1 resection benefited the most from surgery (
P
= 0.01). On multivariate analyses, synchronous disease hazard ratio (HR) = 1.9, nonfunctional NET hormonal status (HR = 2.0), and extrahepatic disease (HR = 3.0) remained predictive of worse survival (all
P
< 0.05).
Conclusions
Liver-directed surgery for NELM is associated with prolonged survival; however, the majority of patients will develop recurrent disease. Patients with hormonally functional hepatic metastasis without prior extrahepatic or synchronous disease derive the greatest survival benefit from surgical management.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Infection is a dreaded complication of implant-based breast reconstruction (IBR). There is a paucity of literature on the outcomes of a secondary reconstruction after infected IBR explantation.
We ...conducted a retrospective study of patients who underwent a second IBR following a failed infected device between January 2006 and December 2019. Surgical and patient-reported outcomes (BREAST-Q) were collected and analyzed.
A total of 6093 IBRs were performed during the study period, 298 (5%) of which involved device removal due to infection. Eighty-three patients ultimately received 92 second-attempt IBR. Thirty-six percent of cases developed at least one postoperative complication, with infection (23 breasts; 25%) being the most common. Compared with first-attempt IBR, we found significantly higher infection rates among second-attempt cases (9% vs. 21%, respectively; p = 0.0008). Patient-reported satisfaction with the breast and sexual well-being were lower in second-attempt than in first-attempt IBR (p=0.018, p=0.002, respectively) reported in the literature. Mean follow-up was 41±35 months. If we exclude patients with prior radiation and those who received device exchange, success rate is 88%.
It is reasonable to offer women second-attempt IBR after explantation due to infection. However, this patient population has a higher infection and explantation rate and lower patient-reported satisfaction than patients undergoing first-attempt IBR. Because of these increased surgical risks and elevated complication rates, patients must be given reasonable expectations during preoperative discussions and when providing informed consent for second-attempt IBR.
Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast ...reconstruction failure caused by infection, others argue that a second attempt is acceptable.
The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.
A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent). No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).
Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.
Therapeutic, III.
Predatory journals have exploited the open access publishing model and are considered as a major threat to the integrity of scientific research. The goal of this study was to characterize predatory ...publishing practices in plastic surgery.
To identify potentially predatory journals in the field of plastic surgery, the authors searched the Cabells' Predatory Reports and Beall's List using preidentified keywords. For presumed legitimate open access journals, the Directory of Open Access Journals (DOAJ) was queried. The characteristics of potentially predatory journals were compared to those of legitimate open access plastic surgery journals.
The authors identified a total of 25 plastic surgery-focused journals. Out of the 25 potentially predatory journals, only 15 journals had articles published within the last 5 years, with a mean number of articles of 33 ± 39 (range, 2 to 159 articles). The mean number of predatory violations according to Cabells' criteria was 6.8 ± 1.4 (range, 3 to 9). Using the DOAJ database, the authors identified a total of 24 plastic surgery-related journals. Compared to potentially predatory journals, journals from the DOAJ were more likely to be indexed in PubMed (0 versus 50 percent, respectively, p < 0.0001). Time to publication was significantly higher in journals from the DOAJ (17 ± 7 versus 4 ± 1 weeks; p = 0.006). Despite higher article processing charges in the DOAJ group, this difference was not statically significant ($1425 ± $717 versus $1071 ± $1060; p = 0.13).
Predatory journals are pervasive in the medical literature and plastic surgery is no exception. Plastic surgeons should practice due diligence when choosing a target journal for their articles. Journals with predatory practices should be distinguished from legitimate open access publication platforms.
A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice ...reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI.
An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed.
In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin).
Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.
Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and ...skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection.
Therapeutic, IV.
Postoperative hematoma and venous congestion after free tissue transfer may occur independently or concurrently. We aimed to explore the association between these two events.
All free flap ...reconstructions for head and neck (HN) and breast from a single institution between 2004 and 2014 were retrospectively reviewed for reoperation for venous congestion and/or hematoma.
There were 2985 free flap cases for HN reconstruction and 2345 cases for breast reconstruction. In HN, 100 patients developed a hematoma (3.4%) and 84 patients developed venous congestion (2.8%). The prevalence of hematoma was 17.8% and 2.9% in the presence and absence of congestion, respectively (p<0.001). Among the 15 patients who had both hematoma and venous congestion were separate events that occurred from 1 to 9 days apart in 8 patients. Hematoma caused the compression of the pedicle vein in 4 patients, while venous congestion possibly caused hematoma in 3 patients. In breast, 56 patients developed a hematoma (2.4%) and 64 patients developed venous congestion (2.7%). The prevalence of hematoma was 12.5% and 2.1% in the presence and absence of congestion, respectively (p<0.001). In the 8 patients who developed both, hematoma and congestion were separate events in 4 patients. Venous congestion caused hematoma in 3 patients, and hematoma caused venous congestion in 1 patient.
Although postoperative hematoma and venous congestion often present concurrently, most events are not causally associated. When related, however, venous congestion leading to hematoma is more common in breast reconstruction, while hematoma preceding venous congestion is more common in HN reconstruction.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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