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Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Introduction: In pediatric liver transplantation (pLT), hepatic artery thrombosis (HAT) is associated with inferior transplant outcome. Hepatic artery reconstruction (HAR) using an operating microscope (OM) is considered to reduce the incidence of HAT. Methods: HAR using an OM was compared to a historic cohort using surgical loupes (SL) in pLT performed between 2009 and 2020. Primary endpoint was the occurrence of HAT. Secondary endpoints were 1-year patient and graft survival determined by Kaplan-Meier analysis and complications. Multivariate analysis was used to identify independent risk factors for HAT and adverse events. Results: A total of 79 pLTs were performed [30 (38.0%) living donations; 49 (62.0%) postmortem donations] divided into 23 (29.1%) segment 2/3, 32 (40.5%) left lobe, 4 (5.1%) extended right lobe, and 20 (25.3%) full-size grafts. One-year patient and graft survival were both 95.2% in the OM group versus 86.2% and 77.8% in the SL group (p = .276 and p = .077). HAT rate was 0% in the OM group versus 24.1% in the SL group (p = .013). One-year patient and graft survival were 64.3% and 35.7% in patient with HAT, compared to 93.9% and 92.8% in patients with no HAT (both p < .001). Multivariate analysis revealed HAR with SL (p = .022) and deceased donor liver transplantation (DDLT) (p = .014) as independent risk factors for HAT. The occurrence of HAT was independently associated with the need for retransplantation (p < .001) and biliary leakage (p = .045). Conclusion: In pLT, the use of an OM is significantly associated to reduce HAT rate, biliary complications, and graft loss and outweighs the disadvantages of delayed arterial perfusion and prolonged warm ischemia time (WIT).

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft-to-recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients

Activation of non-neuronal microglia is thought to play a causal role in spinal processing of neuropathic pain. To specifically investigate microglia-mediated effects in a model of neuropathic pain and overcome the methodological limitations of previous approaches exploring microglia function upon nerve injury, we selectively ablated resident microglia by intracerebroventricular ganciclovir infusion into male CD11b-HSVTK–transgenic mice, which was followed by a rapid, complete, and persistent (23 weeks) repopulation of the CNS by peripheral myeloid cells. In repopulated mice that underwent sciatic nerve injury, we observed a normal response to mechanical stimuli, but an absence of thermal hypersensitivity ipsilateral to the injured nerve. Furthermore, we found that neuronal expression of calcitonin gene–related peptide (CGRP), which is a marker of neurons essential for heat responses, was diminished in the dorsal horn of the spinal cord in repopulated mice. These findings identify distinct mechanisms for heat and mechanical hypersensitivity and highlight a crucial contribution of CNS myeloid cells in the facilitation of noxious heat.

The method of choice for treatment of sacral chordomas is en bloc tumor removal via sacrectomy or sacral amputation in varying degrees depending on the initial tumor extent. Besides local tumor control, the preservation of neurological function is equally important to minimize postoperative bladder and bowel dysfunction. Removal of sacral tumors is complicated by the complex regional anatomy of the pelvis and the surrounding visceral and retroperitoneal structures. We aim to describe the surgical workflow for a fully navigated high sacral amputation facilitated by integration of an intraoperative computed tomography (iCT)-based spinal navigation system. An iCT-based spinal navigation system (AIRO® CT scanner, Brainlab AG, Feldkirchen, Germany) was used to perform intraoperative navigation with an image-guidance system and infrared tracking camera (BrainLab CurveTM, Brainlab AG, Feldkirchen, Germany) in combination with the spinal navigation set by Brainlab (Brainlab AG, Feldkirchen, Germany) to perform a fully navigated high sacral amputation. We demonstrate the successful implementation of iCT-based spinal navigation during high sacral amputation and the key advantages of this technique throughout the surgery. iCT-based spinal navigation is a useful complementing technique for en bloc high sacral amputations that renders the surgery safer and more accurate.

Background Breast cancer is the most common cancer affecting women in Germany. Despite breast-conserving therapy (BCT) being carried out in almost 70% of cases, a high number of women still require complete mastectomy. Prophylactic mastectomy is also indicated for women with a BRCA 1/2 gene mutation. In addition to implant-based heterologous breast reconstruction, autologous breast reconstruction using a DIEP flap has been found to be beneficial, particularly for patients who had prior radiotherapy. This study aims to show that DIEP flap reconstruction surgery is the method of choice for autologous breast reconstruction with a low rate of complications. Patients and Methods Autologous breast reconstruction using a DIEP flap was performed in 1124 patients between July 2004 and December 2014. Retrospective study criteria included potential risk factors such as age, BMI, smoking, chemotherapy and/or radiotherapy, and comorbidities as well as outcome parameters such as postoperative complications. Outcomes were evaluated with a mean follow-up of 24 months. Results A total of 1124 patients underwent 1274 free DIEP flap breast reconstructions, of which 150 were bilateral reconstructions. The primary indication was previous mastectomy in 785 cases, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Postoperative surgical revision for abdominal wall hernia was required in 0.2% of cases. The group with a higher BMI and the group of smokers had significantly higher complication rates. Elderly patients (> 65 years), patients who had undergone chemo-/radiotherapy and patients with diabetes did not have higher complication rates. Conclusion DIEP flap surgery is an excellent option for autologous breast reconstruction, with a low rate of donor site morbidity and low complication rates. DIEP flap surgery carried out in a specialised interdisciplinary breast centre in a standardised clinical setting after prior careful patient selection to take account of risk factors such as high BMI and smoking is a reliable method with a low complication rate and satisfactory long-term reconstruction results.

Background Electrical stimulation immediately following nerve lesion helps regenerating axons cross the subsequently grafted nerve repair site. However, the results and the mechanisms remain open to debate. Some findings show that stimulation after crush injury increases axonal crossing of the repair site without affecting regeneration speed. Others show that stimulation after transection and fibrin glue repair doubles regeneration distance. Methods Using a sciatic-nerve-transection-graft in vivo model, we investigated the morphological behavior of regenerating axons around the repair site after unilateral nerve stimulation (20 Hz, 1 hour). With mice expressing axonal fluorescent proteins (thy1-YFP), we were able to calculate the following at 5 and 7 days: percentage of regenerating axons and arborizing axons, branches per axon, and regeneration distance and speed. Results Brief stimulation significantly increases the percentage of regenerating axons (5 days: 35.5 vs. 27.3% nonstimulated, p 0.05; 7 days: 43.3 vs. 33.9% nonstimulated, p 0.05), mainly by increasing arborizing axons (5 days: 49.3 [4.4] vs. 33.9 [4.1]% [p 0.001]; 7 days: 42.2 [5.6] vs. 33.2 [3.1]% [p 0.001]). Neither branches per arborizing axon nor regeneration speed were affected. Conclusion Our morphological data analysis revealed that electrical stimulation in this model increases axonal crossing of the repair site and promotes homogeneous perilesional branching, but does not affect regeneration speed.

Background Systemic alteration of interleukin-6 (IL-6) influences peripheral nerve regeneration. We investigated the potential influences of in situ (at the coaptation site) IL-6 modulation in a peripheral-nerve-transection/sciatic-nerve-graft in vivo model. Methods We quantified the elongation of regenerating axons, the number of arborizing axons, and the number of branches per arborizing axon 7 days after the injury in mice expressing axonal fluorescent proteins (thy-1-YFP mice). Sciatic nerves from nonexpressing mice (C57Bl6 or IL-6 −/− mice) were grafted into those expressing yellow fluorescent protein. We altered the in situ IL-6 concentration by loading a topical gelatin sponge with an inhibiting IL-6 receptor antibody or IL-6 combined with a soluble IL-6 receptor. Sciatic nerves from IL-6 −/− mice were grafted into an additional group. The contralateral sham-operated side served as control in all the groups. Results Axonal elongation increased significantly with the in situ application of the IL-6 receptor antibody, while topical IL-6 significantly reduced the regeneration distance. The number of arborizing axons increased significantly in nerves grafted from IL-6 −/− mice, whereas branches per arborizing axons remained stable. Conclusion In situ IL-6 receptor inhibition and IL-6 −/− nerve grafting enhance early peripheral nerve regeneration in an acute murine injury model.

Background Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. Methods 1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Dusseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. Results Overall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). Conclusion The DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result.

Currently, autologous breast reconstruction with a free tissue transfer from the lower abdomen is considered to be a safe method that provides a stable long-term solution. The DIEP-flap and the ms-2-TRAM-flap reconstructions have helped reduce donor site morbidity. In order to assess the potential differences between these techniques, we carried out myosonographic evaluations that assessed the muscle dynamics pre- and post-operatively. In addition to investigating the properties of the rectus abdominis muscle post-operatively, this prospective study also allowed us to analyse the muscle preoperatively and to investigate the prospects for harvesting a DIEP-flap as opposed to a TRAM-flap.Sixty patients underwent breast reconstruction with 71 (11 bilateral) free abdominal wall flaps (DIEP-: n = 48; ms-2-TRAM-flap: n = 23). Myosonographic examinations were performed preoperatively and at 3 and 6 months post-operatively. The thickness of the muscle at relaxation and maximum contraction and the difference between the muscle thickness measured at the two states were measured. A general-linear-model (GLM) was used for statistical analysis. The main variable was the surgical method, and the co-variables included BMI and patient age. The decision on whether to harvest a DIEP- or ms-2-TRAM-flap was made intra-operatively and based on the dominant perforator.It shows that the patients who underwent breast reconstruction with a DIEP-flap had significantly better muscle function (p 0.05) in the follow-up. In addition, the analysis revealed that better muscle function before surgery made it more likely that a patient would undergo a DIEP-flap-reconstruction successfully. Patient age also had a highly significant effect on muscle recovery (p 0.0005).This prospective study used a dynamic ultrasound evaluation of the abdominal wall and showed that the DIEP-flap significantly reduces donor site morbidity compared to the ms-2-TRAM-flap. The study also showed that good preoperative muscle function might increase the probability of surgeons performing a DIEP-flap reconstruction.

Summary Sternal wound infections after sternotomy are associated with high morbidity, high mortality and escalating treatment costs. Repeated radical debridement – with the removal of any hardware – and wound conditioning are the prerequisites for reconstruction. Muscle and, less frequently, omentum flaps are usually used for reconstruction. However, these flaps are associated with considerable donor-site morbidity, long operation times and aesthetic impairment. Fasciocutaneous flaps seem to be an alternative. This study presents our experience of using the second intercostal mammary artery fasciocutaneous perforator flap for defect closure in nine patients (mean age: 70.2 years). Following a retrospective chart review, we assessed data on patient demographics, the type of cardiac surgery, the prevalence of deep sternal wound infection (DSWI) risk factors, identified pathogens, surgery duration, hospitalization tim patients had undergone coronary artery bypass surgery, and two had valve replacements. The mean duration of surgery (121.4 ± 39 min) was short. The patients had a mean body mass index (BMI) of 32.8 ± 4.9 kg/m 2 . An average flap size of 124 ± 22 cm 2 sufficiently covered and obliterated each defect. One mediastinal haematoma required revision surgery. One wound dehiscence at the flap and two at the donor site were managed conservatively. Our experience reveals that a fasciocutaneous flap based on the second intercostal perforator of the internal mammary artery can be an alternative, quick-to-prepare flap for covering sternal defects. In adipose patients, it has sufficient bulk, and it is large enough to cover common sternal wounds. It also has low complication and morbidity rates, and it achieves an aesthetically pleasing result.

Microsurgical suturing is the gold standard of nerve coaptation. Although literature on the usefulness of fibrin glue as an alternative is becoming increasingly available, it remains contradictory. Furthermore, no data exist on how both repair methods might influence the morphological aspects (arborization; branching) of early peripheral nerve regeneration. We used the sciatic nerve transplantation model in thy-1 yellow fluorescent protein mice (YFP; n = 10). Pieces of nerve (1cm) were grafted from YFP-negative mice (n = 10) into those expressing YFP. We performed microsuture coaptations on one side and used fibrin glue for repair on the contralateral side. Seven days after grafting, the regeneration distance, the percentage of regenerating and arborizing axons, the number of branches per axon, the coaptation failure rate, the gap size at the repair site and the time needed for surgical repair were all investigated. Fibrin glue repair resulted in regenerating axons travelling further into the distal nerve. It also increased the percentage of arborizing axons. No coaptation failure was detected. Gap sizes were comparable in both groups. Fibrin glue significantly reduced surgical repair time. The increase in regeneration distance, even after the short period of time, is in line with the results of others that showed faster axonal regeneration after fibrin glue repair. The increase in arborizing axons could be another explanation for better functional and electrophysiological results after fibrin glue repair. Fibrin glue nerve coaptation seems to be a promising alternative to microsuture repair.

Motoneurons reinnervate the distal stump at variable rates after peripheral nerve transection and suture. In the rat femoral nerve model, reinnervation is already substantial 3 weeks after repair, but is not completed for an additional 7 weeks. However, this “staggered regeneration” can be temporally compressed by application of 20 Hz electrical stimulation to the nerve for 1 hr. The present experiments explore two possible mechanisms for this stimulation effect: (1) synchronization of distal stump reinnervation and (2) enhancement of regeneration speed. The first possibility was investigated by labeling all motoneurons that have crossed the repair at intervals from 4 d to 4 weeks after rat femoral nerve transection and suture. Although many axons did not cross until 3–4 weeks after routine repair, stimulation significantly increased the number crossing at 4 and 7 d, with only a few crossing after 2 weeks. Regeneration speed was studied by radioisotope labeling of transported proteins and by anterograde labeling of regenerating axons, and was not altered by stimulation. Attempts to condition the neuron by stimulating the femoral nerve 1 week before injury were also without effect. Electrical stimulation thus promotes the onset of motor axon regeneration without increasing its speed. This finding suggests a combined approach to improving the outcome of nerve repair, beginning with stimulation to recruit all motoneurons across the repair, followed by other treatments to speed and prolong axonal elongation.

Myocardial contrast echocardiography (MCE) is a promising diagnostic tool for detecting microvascular integrity. The aim of the study was to investigate the comparative specificity and sensitivity of intravenous MCE, technetium-99m Sestamibi single-photon emission computed tomography (SPECT) and dipyridamole–dobutamine (DIDO) stress echocardiography for predicting functional recovery after coronary revascularization in patients with acute myocardial infarction (AMI). Methods: In a prospective, observational study, 17 consecutive patients short after AMI who received successful treatment with primary percutaneous coronary angioplasty (PTCA) plus stent-implantation were examined with DIDO (dipyridamole with 0.28 mg/kg over 4 min plus dobutamine up to 10 mcg/kg/min), MCE (10 ml 4 g, 400 mg/ml Levovist® intravenously; second harmonic power imaging) within 12–24 h and resting perfusion SPECT within 48–72 h after PTCA. Functional recovery of regional contractile function after 6-month follow-up was the gold standard to assess viability. Results: The rate of agreement between SPECT and MCE was 69% and between SPECT and a positive response to stress echo was 76% for combined DIDO. MCE showed a higher sensitivity (96%) in the identification of viability than SPECT (77%) and combined DIDO alone (79%). Specificity was lower for viability recognition with MCE (58%) compared with SPECT (93%) and DIDO (87%). Conclusions: The wall motion response during DIDO echocardiography is useful in the prediction of recovery of regional and global ventricular function after revascularization in patients after AMI. Combined intravenous MCE and DIDO is more accurate in the diagnosis of stunned myocardium than Tc-99m-MIBI SPECT alone.

Summary Background Currently about 70% of women who suffer from breast cancer undergo breast-conserving therapy (BCT) without removing the entire breast. Thus, this surgical approach is the standard therapy for primary breast cancer. If corrections are necessary, the breast surgeon is faced with irritated skin and higher risks of complications in wound healing. After radiation, an implant-based reconstruction is only recommended in selected cases. Correction of a poor BCT outcome is often only solved with an additional extended operation using autologous reconstruction. Material/Methods In our plastic surgery unit, which focuses on breast reconstruction, we offer a skin-sparing or subcutaneous mastectomy, followed by primary breast reconstruction based on free autologous tissue transfer to correct poor BCT outcomes. Between July 2004 and May 2011 we performed 1068 deep inferior epigastric artery perforator (DIEP) flaps for breast reconstruction, including 64 skin-sparing or subcutaneous mastectomies, followed by primary DIEP breast reconstruction procedures after BCT procedures. Results In all free flap-based breast reconstruction procedures, we had a total flap loss in 0.8% (9 cases). Within the group of patients after BCT, we performed 41 DIEP flaps and 23 ms-2 TRAM flaps after skin-sparing or subcutaneous mastectomies to reconstruct the breast. Among this group we had of a total flap loss in 1.6% (1 case). Conclusions In cases of large tumour sizes and/or difficult tumour locations, the initial oncologic breast surgeon should inform the patients of a possibly poor cosmetic result after BCT and radiation. In our opinion a skin-sparing mastectomy with primary breast reconstruction should be discussed as a valid alternative.

To investigate the specificity and sensitivity of the combination of dipyridamole and dobutamine echocardiography for predicting functional recovery in patients with reduced ventricular function after coronary angioplasty.Twenty-five patients, mean (SD) age 60.8 (10) years, with previous myocardial infarction (3 months), angiographically assessed coronary artery disease, and resting regional dysfunction (left ventricular ejection fraction35%) were studied. They underwent rest-redistribution thallium Tl-201 single photon emission computed tomography, and low-dose pharmacologic stress echocardiography with dobutamine (up to 10 microg/kg per minute), ultra low-dose dipyridamole (0.28 mg/kg over 4 minutes), and combined dipyridamole-dobutamine administration.The rate of agreement between Tl-201 and stress echo was 59% for dipyridamole, 62% for dobutamine, and 71% for combined dipyridamole-dobutamine (P.05 vs dipyridamole and vs dobutamine). Combined dipyridamole-dobutamine showed a higher sensitivity (89%) than Tl-201, dobutamine, or dipyridamole (84%, 78%, and 80%). Specificity was lower for functional recovery prediction with Tl-201 (60%) compared with dobutamine (89%), dipyridamole (90%), and combined dipyridamole-dobutamine (91%).Thallium is more sensitive than dipyridamole or dobutamine; the sensitivity gap is filled with combined dipyridamole-dobutamine. Pharmacologic stress echocardiography is more specific than Tl-201 scintigraphy.