Search

Background: Free flap reconstruction is the gold standard in complex head and neck reconstruction. The branches of the external carotid vessels (ECVs) are considered the most suitable recipients, but they may be unavailable in patients presenting "frozen necks" or "vessel-depleted necks" due to previous treatments. We report our experience using the transverse cervical vessels (TCV) in these situations., Methods: Retrospective chart review of microsurgical head and neck reconstructions from 2005 to 2017. We focused our analysis on secondary procedures and compared the complication rate according to whether the TCV or the ECVs were used., Results: A total of 97 free flaps were performed for secondary procedures in 89 patients, mainly due to oncological recurrence and fistulae. TCV were used in 14 procedures when external carotid vessel branches were unavailable. The overall complication rate (all grade III Dindo-Clavien) was of 21% versus 35%, respectively, in the TCV and ECVs group. Grade IIIb Dindo-Clavien complications, i.e., microsurgical complications (10%) and flap loss (1%), were only recorded in the ECVs group. Other complications recorded were seroma (7% versus 1%) and hematoma (17% versus 6%) in the TCV and ECVs groups, respectively, and corresponded to grade IIIa Dindo-Claviens., Conclusions: The use of TCV is a safe second-line recipient site for microsurgical head and neck reconstruction in vessel-depleted necks. Major advantages are their anatomical position outside the previous surgical and radiation zone, lower affinity for atherosclerotic damage, and similar diameter to the pedicles of the most used flaps., (© 2021 The Authors.)

Objective: In this study, we assess interdisciplinary surgical and medical parameters associated to recurrences of infected pressure ulcers., Background: There is a little in the published literature regarding factors associated with the outcome of treatment of infected pressure ulcers., Methods: We undertook a single-center review of spinal injured adults hospitalized for an infected pressure ulcer or implant-free osteomyelitis and reviewed the literature on this topic from 1990-2015., Results: We found 70 lesions in 31 patients (52 with osteomyelitis) who had a median follow-up of 2.7 years (range, 4 months to 19 years). The median duration of antibiotic therapy was 6 weeks, of which 1 week was parenteral. Clinical recurrence after treatment was noted in 44 infected ulcers (63%), after a median interval of 1 year. In 86% of these recurrences, cultures yielded a different organism than the preceding episode. By multivariate analyses, the following factors were not significantly related to recurrence: number of surgical interventions (hazard ratio 0.9, 95% confidence interval 0.5-1.5); osteomyelitis (hazard ratio 1.5; 0.7-3.1); immune suppression; prior sacral infections, and duration of total (or just parenteral) antibiotic sue. Patients with antibiotic treatment for <6 weeks had the same failure rate as those with as >12 weeks (χ test; P = 0.90)., Conclusions: In patients with infected pressure ulcers, clinical recurrence occurs in almost two-thirds of lesions, but in only 14% with the same pathogen(s). The number of surgical debridements, flap use, or duration of antibiotic therapy was not associated with recurrence, suggesting recurrences are caused by reinfections caused by other extrahospital factors.

Introduction: Hypertrophy of the calvarium has different aetiologies, among them the rare Proteus syndrome., Case Report: We report here the case of a young girl initially treated for relapsing right then left large chronic subdural haematoma, who progressively developed craniofacial hypertrophy consistent with the diagnosis of Proteus syndrome. Calvarium hypertrophy was shaved and remodelled combining midface advancement, essentially for cosmetic purposes. During the first calvarium remodelling, important bleeding of the bone required large volume of blood replacement. Haemostasis workup revealed platelets aggregation anomalies. Bleeding issues during subsequent surgeries were controlled with tranexamic acid and desmopressin acetate., Discussion: Other manifestations of Proteus syndrome, such as a right hypertrophy of the face with hypoplasia of its middle third, a pigmented epidermal nevus and asymmetric limbs and scoliosis, appeared progressively over time. Blood and fibroblast phosphatase and tensin homolog mutation was not found., Conclusion: Literature review of operated patients with Proteus syndrome did not reveal an association with platelets anomalies. A complete haemostasis workup following this unexpected haemorrhagic complication is recommended for this rare pathology.

Background: Noma is a poorly studied disease that leads to severe facial tissue destruction in children in developing countries, but the cause remains unknown. We aimed to identify the epidemiological and microbiological risk factors associated with noma disease., Methods: We did a prospective, matched, case-control study in Niger between Aug 1, 2001, and Oct 31, 2006, in children younger than 12 years to assess risk factors for acute noma. All acute noma cases were included and four controls for each case were matched by age and home village. Epidemiological and clinical data were obtained at study inclusion. We undertook matched-paired analyses with conditional logistic regression models., Findings: We included 82 cases and 327 controls. Independent risk factors associated with noma were: severe stunting (odds ratio [OR] 4·87, 95% CI 2·35-10·09) or wasting (2·45, 1·25-4·83); a high number of previous pregnancies in the mother (1·16, 1·04-1·31); the presence of respiratory disease, diarrhoea, or fever in the past 3 months (2·70, 1·35-5·40); and the absence of chickens at home (1·90, 0·93-3·88). After inclusion of microbiological data, a reduced proportion of Fusobacterium (4·63, 1·61-13·35), Capnocytophaga (3·69, 1·48-9·17), Neisseria (3·24, 1·10-9·55), and Spirochaeta in the mouth (7·77, 2·12-28·42), and an increased proportion of Prevotella (2·53, 1·07-5·98), were associated with noma. We identified no specific single bacterial or viral pathogen in cases., Interpretation: Noma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity., Funding: Gertrude Hirzel Foundation., (Copyright © 2013 Baratti-Mayer et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by .. All rights reserved.)

Angiomas are heterogenous vascular abnormalities, in terms of anatomy, biology and clinical course. Patients and families are often emotionally concerned. For all these reasons, a multidisciplinary approach is necessary in order to structure diagnostic and therapeutic work-up, and to ensure proper advice. The present paper summarizes contemporary classification of angiomas and presents some principles of multidisciplinary approach as it is applied for the past fifteen years at the University Hospitals of Geneva.

Unlabelled: For many years, adipose tissue has been mainly considered as an inert reservoir for storing triglycerides. Since the discovery that adipocytes may secrete a variety of bioactive molecules (hormones, chemokines, and cytokines), an endocrine and paracrine role for white adipose tissue (WAT) in the regulation of energy balance and other physiological processes has been established, particularly with regard to brain and muscle. In contrast, little is known about the interactions of WAT with liver. Hence, we examined the effect of the secretory products of WAT on hepatocytes. Conditioned medium of human WAT explants induced significant steatosis in hepatocyte cell lines. Factor(s) responsible for the conditioned medium-induced steatosis were screened by a battery of blocking antibodies against different cytokines/chemokines shown to be secreted by WAT. In contrast to interleukin-8 and interleukin-6, the monocyte chemoattractant protein-1 was capable of inducing steatosis in hepatocytes in a time-dependent manner at concentrations similar to those found in conditioned medium. Incubation of conditioned medium with antimonocyte chemoattractant protein-1 antibodies prevented triglyceride accumulation. Investigation of the mechanism leading to the triglyceride accumulation showed that both a diminution of apolipoprotein B secretion and an increase in phosphoenolpyruvate carboxykinase messenger RNA may be involved., Conclusion: The monocyte chemoattractant protein-1 secreted by adipose tissue may induce steatosis not only recruiting macrophages but also acting directly on hepatocytes.

Breast conserving surgery followed by radiation therapy is the treatment of choice for early breast cancer. For patients who choice or need a mastectomy, breast reconstruction provides an acceptable alternative. Breast cancer surgery has been evolving through minimally invasive approaches. Sentinel node biopsy has already remplaced axillary lymph node dissection in the evaluation of the axilla. Local ablation of the tumor may be a valuable alternative to surgery in the future.

The beneficial effects of the delay phenomenon have been evaluated extensively and are widely known. However, no study has quantified the vascular changes seen in an abdominal cutaneous island flap following a surgical delay by vascular pedicle ligation. We evaluated the effect of unilateral superficial inferior epigastric and deep inferior epigastric pedicle ligation on the vascularity of a rabbit abdominal cutaneous island flap. Thirty rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. A 19 x 15 cm abdominal cutaneous island flap was elevated at the time of sacrifice, based solely on the right superficial inferior epigastric pedicle. The flap vasculature was then evaluated by methylene blue injection and lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Methylene blue studies revealed perfusion of only the right (nonligated) side of the flap on day 0 and perfusion of the entire flap by day 15. This "capture" of the left (ligated) superficial inferior epigastric artery angiosome by day 15 could only have been achieved through enhanced cross-midline perfusion. Lead oxide microangiography revealed an increase in the number of vessels from day 0 to day 27 on both the ligated and nonligated sides in all the following: the number of large "choke" vessels (> 0.5 mm) crossing the flap midline, total number of vessels (all sizes) crossing the flap midline, and total number of vessels (all sizes) at the medial aspect of the right and left superficial inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the flap that were relatively more ischemic following left superficial inferior epigastric pedicle ligation (medial aspect of the caudad half of the left superficial inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (medial aspect of the cephalad half of the right superficial inferior epigastric artery angiosome).

The transverse rectus abdominis muscle (TRAM) flap has become the "gold standard" for autogenous breast tissue reconstruction. Complications are reported in 10 to 40 percent of patients undergoing this procedure, and many are related to soft-tissue necrosis secondary to ischemia. Various methods have been proposed to improve TRAM flap survival, including surgical delay of the flap. The beneficial effects of the delay phenomenon have been well established in laboratory studies and clinical evaluations. Many investigators agree that the delay phenomenon will enhance arterial inflow and venous outflow from the TRAM flap. No study has quantified the changes seen in the rectus abdominis muscle following a delay procedure. In this prospective, controlled, and blinded experiment, we evaluate the effect of a unilateral superficial inferior epigastric and deep inferior epigastric artery and vein ligation on the vascularity of the rectus abdominis muscles in rabbits. Thirty-eight rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. The rectus abdominis muscle vasculature was then evaluated by lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Magnification (x 2) was used to count the number of vessels at the periphery of the deep inferior epigastric artery angiosomes in the microangiograms. An increase in the number of vessels from day 0 to day 27 was seen on both the ligated and nonligated sides in all the following: the number of large (> 0.5 mm) "choke" vessels and total number of vessels (all sizes) crossing the abdominal wall midline and the total number of vessels (all sizes) at the medial, superior, and lateral aspects of the right and left deep inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the rectus abdominis muscles that were relatively more ischemic following left deep inferior epigastric pedicle ligation (medial aspect of the left deep inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (lateral aspect of the right deep inferior epigastric artery angiosome).

Background: We describe a familial lymphoproliferative syndrome associated with Epstein-Barr Virus (EBV) infection and the gamma delta phenotype., Methods: We reviewed clinical, pathologic, immunologic, and virologic findings in a nonconsanguineous French family, collected over a 13-year period. Specimens from the father (autopsy), son (liver, lymph nodes, and pericardial effusion), and daughter (skin, liver, and digestive tract) were studied with conventional histologic and immunohistochemical techniques. Anti-EBV latent membrane protein (LMP) antibody and T-cell receptor (TCR) gene rearrangements were also studied in the daughter., Results: The father and daughter had similar clinical and histologic features with maxilofacial, nasal, laryngeal, skin, lung, gastrointestinal, and liver involvement by a high grade large cell angiocentric T-cell lymphoma. The gamma delta phenotype and clonal rearrangement were identified in the daughter's tumor. At the time of his death from pericarditis, the son had a 5-year history of a recurrent hemophagocytic syndrome and lymphadenopathy. Chronic EBV infection was found in each case. EBV infection of the son was diagnosed by means of serologic tests and detection of the EBV genome in circulating lymphocytes, and in the father and daughter by use of an anti-LMP antibody. Its pathologic role is discussed., Conclusion: This familial T-cell lymphoma syndrome associated with the gamma delta phenotype and an unusual location is an original clinical entity. Chronic EBV infection was present in each case, but its precise role remains to be determined.

Several experimental studies have demonstrated that activated intestinal T cells can induce villous atrophy. This observation led us to examine the possible role of activated T cells in the pathogenesis of intestinal lesions in a group of 13 children with intractable diarrhea and villous atrophy of unknown origin. Immunohistochemical study showed signs of intestinal mononuclear cell activation in seven patients. These signs included a marked increase in the number of mucosal T cells, mainly TCR alpha beta+, the appearance of lamina propria interleukin-2-receptor-bearing cells, and an increased expression of HLA-DR antigens by enterocytes. No local cause of intestinal T-cell activation was found. However, four out of seven patients had extradigestive symptoms of autoimmunity, suggesting that the intestine might also be the site of an autoimmune reaction responsible for the epithelial lesions. In these patients, presence of crypt necrosis and colic extension of the lesions suggested poor prognosis. In contrast, in six other patients, no immunohistochemical evidence of mucosal T-cell activation was obtained. In the latter cases, analysis of clinical data favored the hypothesis of a primary inborn defect of enterocyte differentiation.