Background
Despite the technical and medical improvements in the recent years, hepatic artery thrombosis (HAT) remains a devastating complication after living donor liver transplantation (LDLT). We ...described our surgical techniques and monitoring protocols for hepatic artery reconstruction. We reported one of the lowest incidence rates of HAT in the literature.
Methods
Between 2008 and 2015, a total of 325 LDLTs performed at our institute were retrospectively analyzed. Under microscope assistance, all hepatic artery anastomosis were performed in a risk‐free and back‐wall first manner. We collected donors’ and recipients’ demographics, operative procedures, and outcome.
Results
A total of 325 adult LDLTs were enrolled in the study. Of these, 297(91.4%) were right liver graft. The mean diameter of the hepatic arteries of the graft was 1.9 ± 0.3 mm. A single HA anastomosis was performed in 310 patients (95.4%). The 1‐, 3‐, and 5‐year overall patient survival rates were 84.8%, 76.8%, and 75.2%, respectively. Only one (0.3%) episode of HAT was encountered in our series. The patient was treated successfully with nonsurgical management.
Conclusion
Our study showed that the occurrence of HAT is avoidable. Identifying risk factors associated with HAT, meticulous surgical techniques, and careful routine flow monitoring are mandatory to avoid disastrous complications.
Long nerve grafts will affect muscle recovery. Aim of this study is to investigate if supercharged end-to-side (SETS) sensory nerve transfer to long nerve graft can enhance functional outcomes in ...brachial plexus animal model.
A reversed long nerve graft (20-23-mm) was interposed between C6 and musculocutaneous nerve (MCN) in 48 SD rats. The sensory nerves adjacent to the proximal and distal coaptation sites of the nerve graft were used for SETS. There were four groups with 12 rats in each: (A) nerve graft alone, (B) proximal SETS sensory transfer, (C) distal SETS sensory transfer, and (D) combined proximal and distal SETS sensory transfers. Grooming test at 4, 8, 12 and 16 weeks, and compound muscle action potentials (CMAP), biceps tetanic muscle contraction force, muscle weight and MCN axon histomorphologic analysis at 16 weeks were assessed.
Grooming test was significantly better in group C and D at 8 weeks (
= 0.02 and
= 0.04) and still superior at 16 weeks. There was no significant difference in CMAP, tetanic muscle contraction force, or muscle weight. The axon counts showed all experimental arms were significantly higher than the unoperated arms. Although the axon count was lowest in group C and highest in group D (
= 0.02), the nerve morphology tended to be better in group C overall.
Distal sensory SETS transfer to a long nerve graft showed benefits of functional muscle recovery and better target nerve morphology. Proximal sensory inputs do not benefit the outcomes at all.
Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to ...restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction.
A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed.
Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation SD = 6.29,
= 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (
< 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (
< 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (
< 0.05).
FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades.
III.
BACKGROUND:The anterolateral thigh flap is preferred at the authors’ institution for lower extremity reconstruction. When variations in vascular anatomy preclude flap harvest, the authors follow an ...algorithm for contingency planning. The authors compared outcomes of contingency strategies to anterolateral thigh flaps that go as planned.
METHODS:Between January of 2001 and February of 2012, 548 free anterolateral thigh flaps were planned for lower extremity reconstruction at Chang Gung Memorial Hospital. In 30 cases, the flap could not be used because perforators were not identified (n = 12), unreliably small (n = 14), or injured (n = 4). Using the authors’ algorithm, the flap was converted to an ipsilateral tensor fasciae latae (n = 21), anteromedial thigh (n = 5), or contralateral vastus lateralis myocutaneous flap (n = 4). Outcomes, including flap failure, necrosis, and re-exploration rate, were compared in successful cases and those that required conversion.
RESULTS:The incidence of unreliably small or absent perforators was 4.8 percent. Adding cases of iatrogenic perforator injury, the incidence was 5.5 percent. There was no difference in flap survival, flap loss, or need for re-exploration regardless of whether or not the anterolateral thigh flap was used. In 70 percent of cases, the authors favored the tensor fasciae latae flap; partial flap necrosis occurred in six of 21 cases, and total flap loss occurred in one.
CONCLUSIONS:Without preoperative imaging, dilemmas may be encountered in roughly one of 20 anterolateral thigh flaps raised. Using the authors’ algorithm, alternative options can reliably confer results comparable to those of planned anterolateral thigh flaps.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
Vascularized nerve grafts (VNGs) have been proposed as encouraging alternatives to conventional nerve grafting; however, there is ongoing debate regarding the clinical advantages of the approach ...compared with standard grafting. This review aims to gather and analyze reported cases of upper extremity nerve repair using VNGs documented in the published literature.
In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed/MEDLINE, Embase, and Cochrane were searched. Inclusion criteria for this review included the following: (1) human subjects or cadaveric studies, (2) describing a vascularized nerve grafting procedure or suggesting a nerve and vascular supply for a potential vascularized nerve graft, and (3) upper extremity nerve repair in clinical studies.
Data were extracted from 45 clinical studies. Of 535 patients, the most common injury pattern was root avulsion and rupture (88.7%). The most utilized VNG was the ulnar nerve (72.8%), followed by nerve to long head of triceps (8.8%) and sural nerve (8.2%); most common recipients were median (57.6%), axillary (12.5%), and musculocutaneous nerves (11.9%). Between patients who had medical research council scale scores, 69% had functional (M3 and above) motor and 72.7% sensory (S3<) recovery.
Vascularized nerve grafts can increase the odds of functional gain in challenging conditions such as large nerve gaps, nerve avulsions, ruptures, and scarred and irradiated beds. With the exception of well-known VNG options, literature on alternative VNGs is largely confined to case reports and series, with additional published cases, outcomes, and basic science research needed to establish the role of VNGs in nerve repair.
Our findings support the promise of VNGs for complex cases of nerve reconstruction. Evidence from published cases also indicates that VNGs enhance motor and sensory function recovery compared with traditional nerve grafting.
Abstract Background With the advent of the coronavirus disease 2019 (COVID-19) pandemic, some doubts have been raised regarding the potential respiratory problems that patients who previously ...underwent a phrenic nerve transfer could have. Objectives To analyze the effects of the coronavirus infection on two populations, one from Argentina and another from Taiwan. Specific objectives were: (1) to identify the rate of COVID in patients with a history of phrenic nerve transfer for treatment of palsy; (2) to identify the overall symptom profile; (3) to compare Argentinian versus Taiwanese populations; and (4) to determine if any phrenic nerve transfer patients are at particular risk of more severe COVID. Methods A telephonic survey that included data regarding the number of episodes of acute COVID-19 infection, the symptoms it caused, the presence or absence of potential or life-threatening complications, and the status of COVID-19 vaccination were studied. Intergroup comparisons were conducted using the nonparametric Mann–Whitney U test, with categorical variables conducted using either the Pearson χ2 analysis or the Fisher's exact test, as appropriate. Results A total of 77 patients completed the survey, 40 from Taiwan and 37 from Argentina. Fifty-five (71.4%) developed a diagnosis of COVID. However, among these, only four had any level of dyspnea reported (4/55 = 7.3%), all mild. There were also no admissions to hospital or an intensive care unit, no intubations, and no deaths. All 55 patients isolated themselves at home. Conclusions It can be concluded that an acute COVID-19 infection was very well tolerated in our patients. (Level of evidence 3b, case reports).
Arterialized tissues provide longevity and coverage of critically exposed tissue, and in pliable areas of the body, thin flaps are needed. Arterialized venous flaps provide all the aforementioned ...qualities, yet unpredictability in flap perfusion requires further investigation in experimental studies. Existing animal models are thicker in nature and rarely mimic commonly used venous flaps in clinical practice. A novel design of the rat’s tail provides an ideal model for arterialized venous flaps. Eleven venous flaps were harvested from the rats’ tail, all presenting with two parallel veins in configuration. Arterialization of veins using the femoral artery was done in either along-valve or against-valve fashion, with the purpose of testing the flap’s response to different clinical configurations. The vessel diameter and flap thickness were measured. Flap viability was monitored for 7 days after surgery to ensure stable flap viability. Thickness of the tail flap ranged from 1.0 to 1.2 mm, while the abdomen skin thickness ranged from 1.4 to 1.5 mm. The mean diameter of the lateral veins was 0.85 ± 0.08 mm, which was in between the average femoral artery diameter (mean 0.76 ± 0.1 mm) and the average femoral vein diameter (1.28 ± 0.2 mm). Four of the nine against-valve flaps achieved more than 50% flap survival, while all along-valve flaps achieved flap viability of more than 75%, as evident by indocyanine green imaging. This flap demonstrates similar properties to thin venous flaps used in clinical situations. Standardization of this model can push forth better understanding of the arterialization phenomenon in venous flaps for future studies.
Loss of elbow flexion is a common sequela of acute brachial plexus injuries (BPIs). The Mackinnon/Oberlin-II double fascicular transfer (DFT) is a widely used method to restore this function in acute ...C5-6 or C5-7 injuries. This study attempted to evaluate if this technique can be applied reliably for cases involving C8 and/or T1 injuries.
Adult patients with acute BPIs who underwent the Mackinnon/Oberlin-II DFT in our center between 2008 and 2018 were retrospectively identified. Group I (
= 37) included patients with only C5-6 or C5-7 injury, while group II (
= 32) patients presented C5-8 ± T1 injuries. The demographic data, pre- and postoperative neurologic evaluations, electrodiagnostic studies, and grip strength assessment were collected.
A total of 69 patients met the inclusion criteria. Preoperatively, the patients in group II presented poorer nerve conduction and electromyography in both the median and the ulnar nerves and the supply muscles. The percentage of M3 achievement in both groups was 91.9 versus 87.5% and M4 was 73.0 and 71.9%, respectively, which both were not statically significant but the achievement of group II was slower than the group I, 1 to 2 months slower, respectively. Both groups had 57.57 and 46.0% of the postoperative grip power compared with the healthy side, the result of shoulder abduction was not different (
= 0.480).
With careful preoperative evaluation, early intervention, appropriate intraoperative functional fascicle selection, and aggressive postoperative rehabilitation, indications for the Mackinnon/Oberlin-II DFT technique can safely include acute C5-8 injuries and even partial T1 acute BPIs.
The impact of the coronavirus disease 2019 (COVID-19) outbreak shut down most conferences. To minimalize the influence, virtual meetings sprang up subsequently. International Microsurgery Club (IMC), ...as one of the largest professionals-only online microsurgery education groups worldwide, began to host regular weekend webinars during the pandemic to fill the knowledge gap. This study aims to discuss how webinars have fundamentally changed the way knowledge is delivered and exchanged.
From February 29, 2020 to March 14, 2021, 103 IMC webinars were reviewed and analyzed in detail to determine the use, benefit, and effect. A comparison between webinars hosted by the different societies was made as well. A questionnaire survey focusing on attendees' behavior, attitude, and using habit about webinars was also made.
As for the 103 IMC webinar events, the peak participants were 112.3 people in average. The members requesting to join IMC abruptly increased during the pandemic, and the group activity increased dramatically. From the questionnaire (
= 68), the satisfaction level was high (8.88 ± 1.18/10). The respondents were most satisfied with the good quality of the speakers (73.5%). Not only hosts our webinar series but IMC also serves as the platform that welcomes webinars from other societies to share their information. In September 2020, International Microsurgery Webinar League was established via the significant webinar hosts, with more than 300 recorded webinar talks connected successfully.
As the knowledge revolution driven by COVID-19 will continue, IMC will keep playing an essential role in exploring new and emerging opportunities to improve knowledge dissemination worldwide beyond the space-time boundary.
BACKGROUNDBrachial plexus injuries are devastating. Current reconstructive treatments achieve limited partial functionality. Vascularized brachial plexus allotransplantation could offer the best ...nerve graft fulfilling the like-with-like principle. In this experimental study, we assessed the feasibility of rat brachial plexus allotransplantation and analyzed its functional outcomes.
METHODSA free vascularized brachial plexus with a chimeric compound skin paddle flap based on the subclavian vessels was transplanted from a Brown Norway rat to a Lewis rat. This study has 2 parts. Protocol I aimed to develop the vascularized brachial plexus allotransplantation (VBP-allo) model. Four groups are comparedno reconstruction, VBP-allo with and without cyclosporine A immunosuppression, VBP autotransplantation (VBP-auto). Protocol II compared the recovery of the biceps muscle and forearm flexors when using all 5, 2 (C5 + C6) or 1 (isolated C6) spinal nerve as the donor nerves. The assessment was performed on week 16 and included muscle weight, functionality (grooming tests, muscle strength), electrophysiology and histomorphology of the targeted muscles.
RESULTSProtocol I showed, the VBP-allo with cyclosporine A immunosuppression was electrophysiologically and functionally comparable to VBP-auto and significantly superior to negative controls and absent immunosuppression. In protocol II, all groups had a comparable functional recovery in the biceps muscle. Only with 5 donor nerves did the forearm show good results compared with only 1 or 2 donor nerves.
CONCLUSIONSThis study demonstrated a useful vascularized complete brachial plexus allotransplantation rodent model with successful forelimb function restoration under immunosuppression. Only the allotransplantation including all 5 roots as donor nerves achieved a forearm recovery.
PDF