Post-radiation tracheoesophageal fistula following salvage laryngectomy: microsurgical repair using a “bi-laminar” lateral arm flap

Post-radiotherapy tracheoesophageal fistula (TOF) is a serious complication following salvage laryngectomy, associated with severe morbidity and high mortality. In the absence of recurrent disease, they commonly follow creation of a tracheoesophageal puncture for speech rehabilitation after total laryngectomy. Frequently, direct closure, local and regional flaps repairs are unsuccessful, further making the bed hostile or challenging for definitive treatment. We report using a free fasciocutaneous lateral arm flap, folded to create a bi-laminar (epithelial) reconstruction for salvage repair of large, high output persistent TOF initiated by tracheoesophageal puncture following total laryngectomy, two previous courses of radiotherapy and two unsuccessful repairs using small local flap and a pedicled pectoralis major. The folded lateral arm free flap provided resolution of the fistula, interposition of well-vascularised soft tissue, in addition to oesophageal lining and external tension-free cutaneous coverage, while maintaining a patent endotracheostomy. Chronic high output fistulas present extremely high risk and post-operative complications and necessitate complex reconstruction. Careful surgical planning, multidisciplinary approach and conservative measures to optimise the patient are paramount to achieve success. Microsurgical reconstruction provides an alternate and important adjunct in salvage repair of persistent and large TOFs. Level of Evidence: Level V, therapeutic study.     

Fishing-related foreign body in hand: not hook! A case report

An unusual case of a fishing-related accident is presented. A piece of the float that hit the patient’s hand as a rebound when the caught fish broke free with the hook was undiagnosed for a period of 7 weeks. A 30-mm-long piece of rubber embedded in granulation tissue was recovered on exploration.     

Cryptogenic stroke following abdominal free flap breast reconstruction surgery

INTRODUCTION

Abdominal free flap breast reconstruction is regarded as the gold standard method of post-mastectomy breast reconstruction by many. It is a major surgery which can be associated with varied systemic complications. To date, there have been no reports of cerebrovascular complications in the literature which examine the possible relation between thromboembolism and patent foramen ovale (PFO) in patients undergoing microvascular breast reconstruction.

PRESENTATION OF CASE

A 54-year old female with a pre-existing PFO developed a stroke following bilateral mastectomies and immediate free flap breast reconstruction on postoperative day 5. This was attributed to an air embolus caused by central venous pressure line removal. After uneventful intra and early postoperative periods, the patient had collapsed suddenly on day 5 and become unresponsive immediately following the removal of a central venous line. Brain magnetic resonance imaging confirmed a cerebrovascular accident. This resolved within 48 h following therapeutic heparinisation. A clinical diagnosis of paradoxical embolism was made and she was subsequently referred to the cardiologists for angiographic closure of the PFO.

DISCUSSION

The case study herein reported gives an account that PFO can have considerable health implications in the early postoperative period and conceivably intraoperatively in patients undergoing major reconstructive surgeries.

CONCLUSION

Surgeons and cardiologists should be aware of this cerebrovascular complication secondary to PFO following major reconstructive surgery such as microvascular breast reconstruction. It also serves to challenge microvascular surgeons to reconsider routine use of central venous pressure lines in free flap patients who might otherwise have good peripheral vessels for postoperative fluid and antibiotic administration.     

考虑血液灌注温度依赖特性的相变生物传热分析

目的 基于温度依赖型血液灌注率,分析生物组织在体表冷刀作用下的降温冻结及相应的复温过程。方法 依据经典Pennes生物传热方程。用变时间步长的隐式有限差分法,通过循环迭代逼近来求解。结果 数值计算得到体表冷刀温度固定（-196℃及-30℃）和体表冷刀降温速度恒定（8.95℃/min)两种情况下不同血液灌注率（血液灌注率为常数,零、随温度变化及平均血液灌注率）对生物组织降温及相变过程的温度影响,瞬态降温速度分布及复温的温度响应。结论 血液灌注率的温度依赖模型较传统平均血液灌注率模型更接近活体组织的实际血液灌注率,而基于两者的相变分析差别显著。因此低温外科手术中精确温度预示应采用前者,本文结果对其有积极的参考价值。