Comparison of two perioperative antibiotic schedules in patients undergoing surgical reconstruction with dermal matrix after excision of skin cancer

Perioperative antibiotic treatment duration in skin reconstruction with dermal substitutes is not well established. This study compares the incidence of infective complications after two different durations of perioperative antibiotic treatment in patients undergoing surgical reconstruction with skin dermal substitutes (SDS) after excision of skin cancer. Infective complications at the site of SDS were compared in subjects undergoing surgical reconstruction who received either a > 24‐hour (extended protocol) or a ≤ 24‐hour (short protocol) perioperative antibiotic treatment. Of 116 patients undergoing SDS surgical reconstruction, 62 (53.4%) received an extended schedule, and 54 (46.6%) received a short schedule. The two groups were similar for gender, age, comorbidities, American Society of Anesthesiologists score, and type of skin cancer. Overall incidence rate of infection was 20.7% (24/116). No differences in terms of risk of infection were observed between the two groups (OR: 1.04, 95% CI: 0.42‐2.55; P = .937). Patients undergoing SDS reconstruction in the limb/foot had a higher risk of infection in comparison with those undergoing SDS reconstruction in the chest/head (OR: 2.69, 95% CI: 1.06‐6.86; P = .038). The short protocol was demonstrated to be beneficial to patients undergoing surgical reconstruction with SDS. A ≤ 24‐hour perioperative antibiotic schedule did not increase the infection rate, potentially allowing a reduction of antibiotic exposure.     

早期小切口重建钉内固定治疗老年股骨粗隆间骨折

目的探讨股骨重建钉治疗老年股骨粗隆间骨折的疗效。方法2001年6月~2005年10月,采用闭合复位小切口股骨重建钉固定治疗老年股骨粗隆间骨折患者58例,均在伤后1周内施行手术,手术采用C型臂X线机透视下闭合复位,小切口将股骨重建钉置入,观察术后疗效并对该治疗方法进行评价。结果58例术后随访8~22个月,平均13.6个月。3例术后3个月股骨颈拉力钉脱出(行钉道充填骨水泥后重新固定),1例发生骨化性肌炎,2例发生髋内翻,无心、脑栓塞和坠积性肺炎发生;58例骨折均愈合,骨折愈合时间(15±5)周;按黄公怡评价标准,术后髋关节功能恢复优良率达91.6%。结论闭合复位小切口股骨重建钉固定治疗股骨粗隆间骨折,具有手术时间短、出血少且固定牢靠的优点,适用于老年股骨粗隆间骨折的治疗。     

Osteomyocutaneous peroneal artery perforator flap for reconstruction of composite maxillary defects

BACKGROUND: Composite maxillary defects often involve the maxilla, nasal mucosa, palate, and maxillary sinus. We presented the surgical techniques and outcome of the osteomyocutaneous peroneal artery perforator (PAP) flap for reconstruction of composite maxillary defects. METHODS: Six patients underwent an osteomyocutaneous PAP flap reconstruction of composite maxillary defects. The average age was 52 years. The defects were Cordeiro type II in three patients and type IV midfacial defects in another three patients. RESULTS: No total or partial flap failures occurred. At a mean 12-month follow-up, five patients had a normal speech and were able to eat a regular diet. One patient tolerated a soft diet and had intelligible speech. One patient had ectropion develop. Excellent cosmesis was found in five patients. CONCLUSIONS: The osteomyocutaneous PAP flap represents a further refinement of the fibula flap and increases its versatility, with multiple skin paddles, bone segments, and soleus muscle independently isolated. It is a comparable reconstruction option for composite maxillary defects.     

A three‐centre experience of orthotopic neobladder reconstruction after radical cystectomy: revisiting the initial experience,and results in 104 patients

OBJECTIVE

To assess, in a retrospective three‐centre series, a second analysis of the initial experience and results of patients undergoing radical cystectomy (RC) and orthotopic neobladder reconstruction (ONR) after an additional 4 years of follow‐up.

PATIENTS AND METHODS

The medical records of 104 suitable consecutive patients undergoing RC and ONR between June 1994 and April 2003 were reviewed retrospectively. The complications, mortality, continence and cancer control rates were all recorded.

RESULTS

The median (range) follow‐up was 88 (52–156) months; 90 patients had reconstruction with a ‘Studer’ neobladder, 12 with a Hautmann W pouch and 2 with a ‘T pouch’ ileal neobladder. There were 24 early complications, and one death after surgery. There were 32 late complications. The daytime continence rate was 98% and the nocturnal continence rate was 76%. Ten patients required intermittent self‐catheterization (ISC). In all, 30 patients had local and/or distant recurrences, all of whom died. Seven patients died from other causes.

CONCLUSIONS

ONR provides excellent long‐term continence rates and both acceptable complication and mortality rates. Suitable patients undergoing RC should be offered ONR.     

Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States

Introduction

Immediate breast reconstruction after mastectomy has increased in frequency during the past decade, but the socioeconomic and patient factors have yet to be fully identified.

Methods

Data were analyzed from the Nationwide Inpatient Sample from 1999 to 2003 using International Classification of Disease-9 codes to identify patients undergoing immediate breast reconstruction. Regression analyses were used to examine predictive variables for immediate breast reconstruction after mastectomy.

Results

Between 1999 and 2003, 469,832 patients underwent mastectomy. Immediate breast reconstruction occurred in 110,878 patients, yielding a 5-year average rate of 23.6% (range of 22.2% to 25.3%). Independent predictors of immediate breast reconstruction after mastectomy include private insurance, hospital in an urban location, teaching hospital, white race, hospital region in the south, age between the 3rd and 6th decades, and low number of comorbidities.

Conclusions

Immediate breast reconstruction after mastectomy is still not commonly performed in the United States. Socioeconomic and geographic factors play a significant role in whether patients undergo immediate reconstruction.     

Blood transfusion requirements in elective breast reconstruction surgery

IntroductionExcess-ordering of cross-matched blood in preparation for elective surgery is expensive with associated blood shortages and time-expired wastage. Although, the maximum surgical blood order schedule (MSBOS) for breast reconstruction recommends pre-operative cross-match of 2–6 units of red cell concentrate, there is no data confirming whether this guideline is observed in practice or whether compliance results in improved outcome. The aim of this study was to examine the utility of this MSBOS in clinical practice by assessing its performance in a validation set of patients.Materials and MethodsOver a three year period, 49 patients undergoing 50 consecutive elective breast reconstruction surgery were assessed for demographic data, surgical information and hematological/transfusion data to compare the number of units of blood cross-matched with those subsequently transfused for elective breast reconstruction surgery. This was in lieu of updating the current maximal surgical blood order schedule of cross-matching 2–6 units pre-operatively.ResultsFifty elective operations were undertaken during the study period with a zero peri-operative blood transfusion requirement and a 8% post-operative blood transfusion requirement. Pre-operative cross-match to transfusion ratio was unacceptably high with a time-expired blood wastage of 8.7%.DiscussionThese data thus indicate that adoption of a type and screen policy is satisfactory for haemorrhage risk management of elective breast reconstruction. The MSBOS is not designed to predict post-surgery blood needs and a requirement based blood ordering protocol will optimise blood utilisation efficiency.     

老年高血压病患者尿转铁蛋白/肌酐的相关因素研究

目的：通过筛选老年高血压病（EH）患者尿转铁蛋白/肌酐（TRF/Cr）的相关因素,来寻找减少老年EH患者尿转铁蛋白（TRF）排出的方法。方法：对1058例老年EH患者进行24h动态血压检测、实验室检查、尿TRF和肌酐（Cr）检测,运用Logistic回归分析方法筛选老年EH患者尿TRF/Cr的独立相关因素。结果：老年EH患者尿TRF/Cr的独立相关因素有24hSBP（β=0.029,P=0.007）、高血压病程（β=0.017,P=0.012）、低密度脂蛋白胆固醇（β=0.347,P=0.047）。结论：积极防治高血压病,并降低老年EH患者的低密度脂蛋白胆固醇水平,可能是减少老年EH患者TRF排出的重要方法。     

Free composite dorsalis pedis flap for the reconstruction of the hand

Summary One-stage reconstruction of traumatic loss of metacarpal bones, extensor tendons and skin is a challenging problem for the reconstructive surgeon. The anatomical and functional similarity between the structures of the dorsum of the foot and of the hand, makes the dorsalis pedis composite flap a consideration in reconstruction of compound defects of the hand.     

血管化游离腓骨肌皮瓣重建下颌骨缺损

目的：总结游离腓骨肌皮瓣修复下颌骨缺损的经验。方法：对25例应用游离腓骨肌皮瓣行下颌骨缺损修复的病例进行临床分析,探讨不同类型下颌骨缺损,所采用腓骨肌皮瓣的设计,复合组织瓣的成活情况及术后并发症的发生情况。结果：本组25例患者游离腓骨肌皮瓣成活率100%,最长的腓骨为16cm,分为三段者3例,两段者20例。结论：血管化的游离腓骨肌皮瓣修复下颌骨缺损血供丰富、抗感染力强、骨愈合快、塑形好、成活率高。     

2020 special issue: Twenty years of breast reconstruction: Past,present, and future

Breast reconstruction has evolved in the last 25 years to provide women with better autologous and implant‐based options. The general trends of breast reconstruction have shifted to skin and nipple‐areolar complex preservation, resulting in improved aesthetics and patient satisfaction. Autologous reconstruction has made a dramatic movement toward microsurgical reconstruction by free tissue transfer and has addressed lymphedema and breast sensation. Using the patient's own tissues, several aesthetic refinements have led to optimizing the cosmetic appearance of the reconstructed breast. Implant‐based reconstruction has improved with the invention of form‐stable silicone implants, acellular dermal matrix, and fat grafting. These positive trends will continue into the future. We hope that all women with a diagnosis of breast cancer will have the option of a consultation with a reconstructive plastic surgeon, ideally prior to undergoing resective surgery, to ensure they are aware of all reconstructive options to maximize their reconstructive result.     

Immediate nipple reconstruction in combination with implant reconstruction using dermal sling

The inferior de‐epithelialized dermal flap with implant is increasingly used for immediate breast reconstruction. We have adapted the technique to provide concurrent immediate nipple reconstruction by recruiting the triangle of skin above the excised nipple as a modified C‐V flap. The safety and efficacy of this technique has been assessed in 15 patients, of which eight were bilateral and seven were unilateral cases. We suggest that this is a safe, reliable, and original technique for immediate nipple reconstruction in patients undergoing immediate breast reconstruction with an inferior dermal sling and implant.     

Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes

The landscape of breast reconstruction has changed significantly. This study assesses trends in type of reconstruction performed after mastectomy and impact on immediate postoperative complications.MethodsData for 67,450 patients undergoing mastectomy for breast cancer were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2005-2014. Primary outcomes were wound, nonwound related infections, and bleeding complications. Data were analyzed by univariate and multivariate analysis.ResultsThe percentage of patients that underwent reconstruction after breast cancer increased from 26.94% in 2005 to 43.30% in 2014 (p < 0.01). There was increased wound (5.59%), bleeding (6.82%), and infection (1.80%) complications after flap-based reconstruction (p < 0.01). There was no difference in wound, infection, and bleeding complications between immediate implant reconstruction and tissue expander (TE) at 4.38 vs. 3.89% (p = 0.18), 0.82 vs. 0.7%, p = 0.46), and 0.76 vs. 0.64% (p = 0.45), respectively. Several independent factors were associated with increased wound complications in patients undergoing all or any forms of reconstruction after mastectomy such as being overweight (OR 1.38, CI 1.23–1.55), obese (OR 2.11, CI 1.89–2.35), morbidly obese (OR 3.84, CI 3.34-4.43), ASA Class III (OR 1.35, CI 1.08-1.69), ASA Class IV (OR 1.49, 1.06-2.10), diabetic (OR 1.28 , CI 1.14–1.43), and smokers (OR 1.76, CI 1.59–1.94). TRAM flap was associated with increased risk of wound complication (OR 1.87, CI 1.28–2.75).ConclusionMore women are undergoing reconstruction as utilization of TE increases drastically. Immediate implant placement has only seen moderate increase likely due to surgeon preference.     

A look at racial and socioeconomic disparities in post-mastectomy breast reconstruction at a midwestern academic hospital

Purpose of this study was to assess likelihood of undergoing breast reconstruction based on race, socioeconomic status, insurance, and distance from the hospital. Patients with public insurance were less likely to undergo reconstruction than patients with private insurance (OR = 2.99, p < 0.001). White patients were more likely to undergo reconstruction (OR = 0.62, p = 0.02). Patients who lived 10–20 miles and 20–40 miles from UCMC were more likely to undergo reconstruction (OR = 1.93, p = 0.01; OR = 3.06, p < 0.001). White patients and patients with private insurance are disproportionately undergoing breast reconstruction after mastectomy.     

Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction

Background:

There is no clear evidence in the literature regarding the incidence of deep vein thrombosis (DVT) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Literature also lacks on the recommendations on thromboprophylaxis in patients undergoing elective arthroscopic ACL reconstruction. We conducted a prospective analysis to assess incidence of DVT in patients undergoing arthroscopic ACL reconstruction.

Materials and Methods:

120 consecutive patients with MRI proven ACL injury who were operated for arthroscopic ACL reconstruction were enrolled in this prospective study. None of the patients had risk factors (on history) for DVT, and all were below the age of 45 years. All cases were operated upon by a single surgeon and a standard rehabilitation regime was followed. The patients underwent clinical examination and screening (Doppler ultrasonography/venous scan) for any DVT, on the day prior to surgery, day of discharge (Day 3) and at 4 weeks postsurgery. None of the patients received any form of thromboprophylaxis against DVT.

Results:

One hundred and twelve patients (61 males and 51 females) completed the study. The average age was 31.6 years (range 24-42 years). All patients underwent arthroscopic assisted ACL reconstruction surgery within 3 weeks of the injury. Two patients (males) in the series had Doppler venous scan proven DVT. One patient was asymptomatic but the screening Doppler picked up the DVT on the third postoperative day. The other patient was symptomatic at 12 weeks with pain and swelling in the leg and had ultrasound -proven DVT.

Conclusion:

In our study the incidence of deep vein thrombosis in patients undergoing arthroscopic ACL reconstruction is 1.78%. We do not recommend routine thromboprophylaxis in patients, who are not high risk candidates for thrombosis and are of less than 45 years, in patients undergoing arthroscopic ACL reconstruction, with early postoperative rehabilitation.     

A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: initial results

OBJECTIVE: To assess, in a retrospective three-centre series, the initial experience and results of patients undergoing radical cystectomy and orthotopic neobladder reconstruction. PATIENTS AND METHODS: The medical records were retrospectively reviewed for 104 suitable consecutive patients undergoing radical cystectomy and orthotopic neobladder reconstruction between June 1994 and April 2003. The initial histology, operating times, transfusion rates, complications, mortality rates, continence rates, potency rates, and cancer control rates were recorded. RESULTS: The median (range) follow-up was 48 (6-113) months; 90 patients had a reconstruction with a 'Studer' neobladder, 12 with a 'Hautmann W pouch' and two with a 'T pouch' ileal neobladder. There were 24 early complications, and in eight patients re-operation was required; there was one death after surgery. There were 14 late complications and 10 patients required re-operation. The daytime continence rate was 99% and the nocturnal continence rate 78%. Five patients required intermittent self-catheterization. Twenty-two patients died from local and/or distant recurrences, and four from other causes. CONCLUSIONS: Orthotopic neobladder reconstruction provides excellent continence rates, and both acceptable complication and mortality rates. Suitable patients undergoing radical cystectomy should be offered orthotopic neobladder reconstruction.     

Socioeconomic and Geographic Differences in Immediate Reconstruction after Mastectomy in the United States

Disparities are evident in breast cancer diagnosis, treatment, and outcomes. This study examines multiple socioeconomic and geographic regions across the US to determine if disparities exist in the type of reconstruction obtained after mastectomy. This is a retrospective study evaluating socioeconomic and geographic variables of 14,764 women who underwent mastectomy in 2008 using the Nationwide Inpatient Sample (NIS). Statistical analysis was performed on three groups of women: patients without reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients with autologous reconstruction such as free or pedicled flaps (FLAP). The majority of patients (63.9%) had NR, while 23.9% had TE and 12.2% underwent FLAP. Compared to patients with NR, women with TE or FLAP were younger (64.9 years versus 51.3 and 51.1 years, p < 0.001), had fewer chronic conditions (2.60 and 2.54 chronic conditions for TE and FLAP respectively versus 3.85 for NR, p < 0.001) and higher mean hospital charges ($42,850 TE and $48,680 FLAP versus $22,300 NR, p < 0.001). Both Medicare and Medicaid insurance carriers had a higher proportion of women that did not get reconstructed compared to other insurance types (p < 0.001). Compared to NR, reconstructed women more often lived in urban areas and zip codes with higher average incomes (p < 0.001). This is the first national study analyzing insurance type and geographic variations to show statistically significant disparities in rate and type of immediate reconstruction after mastectomy. These inequalities need to be addressed to extend immediate reconstruction options to all women undergoing mastectomy.     

The cardiac implications of breast reconstruction using the internal mammary artery as the recipient vessel

BACKGROUND:

Microsurgical breast reconstruction is a popular choice in breast reconstruction. Recipient vessel use for these autologous tissue reconstructions has shifted from the thoracodorsal to the internal mammary vessels. Coronary artery bypass (CAB) surgery remains the optimal revascularization strategy in patients with significant, diffuse coronary artery disease. The conduits of choice for coronary revascularization are the internal mammary arteries (IMA) because of their superior long-term graft patency rate and improved patient survival.

OBJECTIVE:

To review the cardiac risk factors in the breast reconstruction population, and to report the incidence of postoperative cardiac events at the London Health Sciences Centre, London, Ontario. The authors present the index cases illustrating cardiac complications following the use of internal mammary vessels.

METHOD:

A retrospective, single-centre, cumulative audit of breast reconstruction practice from 2005 to 2009 was conducted. A total of 81 patients undergoing autologous breast reconstruction were reviewed. Two women were noted to have experienced postoperative myocardial infarction requiring intervention. Both were noted to have triple-vessel disease, an indication for CAB; however, during the breast reconstruction, their IMAs had been utilized. As a result, both women subsequently underwent triple-vesssel percutaneous intervention, with one woman later requiring CAB without IMA because of recurrent ischemia.

CONCLUSION:

While there is limited overlap with the breast reconstruction and cardiac disease population, there can be significant cardiac health implications in the postoperative status (both short and long term) of women undergoing autologous breast reconstruction using the IMAs as recipient vessels.     

乳腺癌手术后即刻乳房重建患者的生活质量评价

目的对乳腺癌手术后即刻乳房重建患者的生活质量进行评价。 方法收集2017年11月—2019年11月在海南医学院第一附属医院乳腺胸部肿瘤外科接受乳房改良根治术的乳腺癌患者150例，根据手术方式分为根治术后即刻乳房重建组(根治＋重建组，n＝25)和根治术后未行即刻乳房重建组(单纯根治组，n＝125)。术后6个月时，应用欧洲癌症研究与治疗组织乳腺癌生活质量量表(EORTC QLQ-BR45)调查两组患者的生活质量，采用自制乳腺癌配偶问卷调查两组患者配偶的生活满意度，并进行组间比较。分析患者手术方式选择的影响因素。 结果生活质量调查分析发现：根治＋重建组患者在身体形象、性欲、未来预期方面的得分优于单纯根治组，差异有统计学意义(P<0.05)。自制问卷分析结果显示：根治＋重建组配偶在身体形象、自身性功能和感情家庭方面的得分优于单纯根治组配偶，差异有统计学意义(P<0.05)。Logistics回归分析结果显示：患者的年龄和经济水平与手术方式的选择有关(P<0.05)。 结论乳腺癌手术后即刻乳房重建患者的生活质量优于未行即刻乳房重建的患者。年龄和经济水平可能是乳腺癌患者手术方式选择的影响因素。     

腓骨近端肿瘤切除术后膝关节稳定性重建的临床研究

目的探讨腓骨近端肿瘤切除术后重建膝关节稳定性的方法及临床疗效。方法回顾分析2008年1月-2009年12月行近端腓骨切除并重建腓侧副韧带和股二头肌肌腱骨性止点的16例腓骨近端肿瘤患者(试验组)临床资料,与同期5例未行韧带骨性重建患者(对照组)进行比较。两组患者性别、年龄、病程、肿瘤发生部位等一般资料比较,差异无统计学意义(P>0.05),具有可比性。术后行膝外侧方应力试验;摄X线片测量关节间隙,与健侧比较间隙增大程度并分级;参照美国骨与软组织肿瘤协会(MSTS)功能评分标准对关节功能进行评分。结果术后两组切口均Ⅰ期愈合。两组采用MalawerⅡ型手术切除者均发生医源性完全腓神经功能丧失。患者术后均获随访,随访时间12～36个月,平均30个月。试验组中1例纤维母细胞性骨肉瘤患者发生局部复发,12个月后死于肺部及全身转移;其余患者肿瘤均无复发。末次随访时,试验组膝外侧方应力试验均为阴性,关节间隙增大分级为A级;对照组应力试验均为阳性,分级为D级。试验组MSTS评分为(97.5±3.5)分,对照组为(87.5±3.5)分,两组比较差异有统计学意义(t=2.85,P=0.01)。结论腓骨近端肿瘤切除术后重建腓骨近端腓侧副韧带及股二头肌肌腱的骨性附着点,恢复了膝关节稳定性,利于关节功能重建。