End-to-end versus end-to-side anastomoses in free flap reconstruction: single centre experiences

Background: The choice of microsurgical anastomotic technique, end-to-end (ETE) or end-to-side (ETS), is a relevant point in free tissue transfer. The decision-making process of choosing ETE or ETS technique depends on several clinical and perioperative factors. This study evaluates the outcomes of microvascular procedures in a large single centre patient series, focusing on ETE vs ETS arterial anastomoses.

Materials and methods: Between January 2009 and June 2015, 838 patients underwent free flap surgery for reconstruction after trauma, infection, or malignancies. The cases were divided according to the microsurgical technique of the arterial anastomosis into an ETE (n?=?693) and an ETS (n?=?145) group. The series was retrospectively analysed and the two groups compared regarding outcomes.

Results: Overall, there was no significant difference in rates of surgical complications, flap failures, and re-explorations between the patient groups during the 3-months follow-up period.

Conclusion: The presented analysis includes a large series of microsurgical reconstructions evaluating outcomes in respect to type of performed arterial anastomosis. While the decision of performing an ETE or ETS arterial anastomosis must be made according to recipient vessel quality and accessibility, given no change in outcomes, an ETS anastomosis should be performed whenever feasible in order to preserve distal perfusion.     

Necrotizing fasciitis caused by group A streptococcus

The first case of the confirmed necrotizing fasciitis caused by Group A Streptococcus in Yugoslavia was presented. Male patient, aged 28, in good health, suddenly developed symptoms and signs of severe infective syndrome and intensive pain in the axillary region. Parenteral antibiotic, substitutional and supportive therapy was conducted along with the radical surgical excision of the necrotizing tissue. The patient did not develop streptococcal toxic shock syndrome thanks to the early established diagnosis and timely applied aggressive treatment. He was released from the hospital as completely cured two months after the admission.     

Therapy of acute hepatitis C infection

BACKGROUND: Hepatitis C viral infection is a major cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. The progression of acute to chronic infection occurs in 50-90% of cases. There is no standard therapy for acute HCV infection. Comparative studies are required to verify the optimal doses, dosage schedules and the treatment duration, and to establish the optimal treatment for acute hepatitis C. Recent reports have demonstrated that early application of interferon alpha was a treatment of choice for acute HCV infection. The addition of ribavirinin in the treatment of acute HCV infection, and HCV genotype, did not improve the end-of-treatment responses. It is important to consider the treatment of acute HCV infection before it progresses to chronic state. CASE REPORT: Beneficial effect of interferon therapy in a patient with acute hepatitis C is presented. Early treatment with 3 MIU interferon alpha, three times a week, within six-months, resulted in the normal serum aminotransferases, and good virological response in our patient. CONCLUSION: Interferon therapy significantly increased the probability of obtaining normal serum aminotransferases and undetectable HCV RNA, following acute HCV infection.     

Successful use of biosorb osteofixation devices in 165 cranial and maxillofacial cases: a multicenter report

Bioabsorbable osteofixation devices were developed to avoid problems associated with metals. Bioabsorbable devices are mostly made of the polymers polylactide, polyglycolide, and their copolymers [polyglycolide-co-polylactide and P(L/DL)LA]. Using the technique of self-reinforcement of bioabsorbable materials, it is possible to manufacture osteofixation devices with ultra high strength. Self-reinforced polyglycolide-co-polylactide 80/20 was selected to make devices (Biosorb PDX) for this study because of its favorable degradation characteristics. The aim of this study was to evaluate the efficacy of using self-reinforced polyglycolide-co-polylactide 80/20 (Biosorb) plates and screws in the fixation of osteotomies in craniomaxillofacial surgery. In a prospective study, 165 patients (161 children and 4 adults) were operated on in four European Union centers (Paris, Innsbruck, London, and Oulu) from May 1, 1998 to January 31, 2002. Indications included correction of dyssynostotic deformities (n = 159), reconstruction of bone defects after trauma (n = 2), tumor removal (n= 2), and treatment of encephalocele (n = 2). Plates used were 0.8, 1, or 1.2 mm thick, and screws had an outer (thread) diameter of 1.5 or 2 mm and a length of 4, 6, or 8 mm. Tacks had an outer diameter of 1.5 or 2 mm and a length of 4 or 6 mm. During surgery, the devices were easy to handle and apply and provided stable fixation apart from 2 cases. Postoperative complications occurred in 12 cases (7.3%), comprising infection (n = 6), bone resorption (n = 4), diabetes insipidus (n = 1), delayed skin wound healing/skin slough (n = 2), and liquorrhea (n = 1). Accordingly, self-reinforced polyglycolide-co-polylactide 80/20 (Biosorb) plates and screws can be used safely and with a favorable outcome in corrective cranioplasties, especially in infants and young children.     

Microsurgical management of the diabetic foot

Allthough there has been dramatic progress in limb salvage in recent decades, management of nonhealing wounds in diabetic patients continues to present a dilemma for the reconstructive surgeon. However, the acceptance of free-flap resurfacing of diabetic foot ulcers has increased in recent years. This study reviews 10 microvascular free muscle flaps in nine patients over a mean follow-up period of 44 months. Five patients had evidence of peripheral vascular disease. There was one flap loss, and nine flaps were transferred successfully. No perioperative mortality was encountered. The operations required a long, costly hospitalization (average hospital stay was 40 days). Seven of eight patients whose flaps survived had complications related to the free-flap recipient site. These seven patients underwent 20 secondary surgical procedures due to arterial and venous thrombosis, partial necrosis of the skin grafts, minor local infections, and gangrene or necrosis of the remaining toes. In three patients, progressive ischemic necrosis of the remaining toes, with total survival of the flap, was attributed to a microvascular steal phenomenon. However, all eight patients whose flaps survived subsequently ambulated on their flaps. The study demonstrates that microvascular surgery may result in functional lower-extremity salvage in diabetic patients with foot wounds that are not treatable by local flaps or skin grafts, and are destined for amputation.     

Image quality and dose in mammography in 17 countries in Africa, Asia and Eastern Europe: results from IAEA projects

Purpose

The objective is to study mammography practice from an optimisation point of view by assessing the impact of simple and immediately implementable corrective actions on image quality.

Materials and methods

This prospective multinational study included 54 mammography units in 17 countries. More than 21,000 mammography images were evaluated using a three-level image quality scoring system. Following initial assessment, appropriate corrective actions were implemented and image quality was re-assessed in 24 units.

Results

The fraction of images that were considered acceptable without any remark in the first phase (before the implementation of corrective actions) was 70% and 75% for cranio-caudal and medio-lateral oblique projections, respectively. The main causes for poor image quality before corrective actions were related to film processing, damaged or scratched image receptors, or film-screen combinations that are not spectrally matched, inappropriate radiographic techniques and lack of training. Average glandular dose to a standard breast was 1.5 mGy (mean and range 0.59–3.2 mGy). After optimisation the frequency of poor quality images decreased, but the relative contributions of the various causes remained similar. Image quality improvements following appropriate corrective actions were up to 50 percentage points in some facilities.

Conclusions

Poor image quality is a major source of unnecessary radiation dose to the breast. An increased awareness of good quality mammograms is of particular importance for countries that are moving towards introduction of population-based screening programmes. The study demonstrated how simple and low-cost measures can be a valuable tool in improving of image quality in mammography.     

Impact of stem cell source on allogeneic stem cell transplantation outcome in hematological malignancies

BACKGROUND/AIM: Peripheral blood (PB) is used more frequently as a source of stem cells (SCs) for allogeneic transplantation. However, the influence of cell source on the clinical outcome of SC transplantation is not yet well established. The aim of this study was to compare the results of PBSC transplantation (PBSCT) with bone marrow transplantation (BMT) on the basis of engraftment, frequency and severity of immediate (mucositis, acute Graft versus Host Disease--aGvHD) and delayed (chronic GvHD--cGvHD) complications, as well as transplant-related mortality (TRM), transfusion needs, relapses and overall survival (OS). METHODS: We analyzed 158 patients, women/men ratio 64/94 median age 29 (range 9-57), who underwent allogeneic SC transplantation between 1989 and 2009. All included patients had diseases as follows: acute myeloid leukemia (AML)--39, acute lymphoblastic leukemia (ALL) 47, chronic myeloid leukemia (CML)--32, myelodysplastic syndrome (MDS)--10, Hodgkin's lymphoma (HL)- 2, multiple myeloma (MM) 3, granulocytic sarcoma (GrSa) 3, severe aplastic anemia (sAA)--22. The patients underwent transplantations were divided into two groups: BMT group (74 patients) and PBSCT group (84 patients). Each recipient had HLA identical sibling donor. SCs from bone marrow were collected by multiple aspirations of iliac bone and from PB by one "Large Volume Leukapheresis" (after recombinant human granulocyte colony stimulating factor, rHuG-CSF) application (5-12 microg/kgbm, 5 days). Conditioning regimens were applied according to primary disease, GvHD prophylaxis consisted of combination of a cyclosporine A and methotrexate. Results. Engraftment, according to the count of polymorphonuclear and platelets, were significantly (p < 0.001) faster in the PBSCT vs BMT group. The needs for transfusion support were significantly (P < 0.01) higher in the BMT group. Those patients had more frequently oropharingeal mucositis grade 3/4 (33.3% vs 10.0%, p < 0.05). There were no significant differences in the incidence of aGvHD and cGvHD between the two groups. The patients who underwent PBSCT had more frequently extensive cGvHD in comparison with the BMT group (29.1% vs 11.29%, p < 0.05). SC source (SCS) had no significant influence on the TRM (21.62% vs 23.8%, p = 0.64) and the incidence of relapses (21.6% vs 29.7%, p = 0.32). Finally, the patients treated by BMT hd a significantly better OS (logrank 2.33, p < 0.05). Conclusion. SCs harvesting from PB resulted in improved cell yield, faster engraftment, as well as in a decrease of immediate transplantation related complications with a reduced treatment cost. Allogeneic PBSCT were associated with more frequent extensive cGvHD, while the influence of SCS in TRM and relapses was not observed. Finally, the long-term OS was better in the patients treated by BMT. To verify impact of SC source on transplantation (PBSCT vs BMT) overall efficacy, more larger randomized clinical studies are needed.