Quantifying postoperative recovery using wearable activity monitors following abdominal wall surgery: The AbTech trial

PURPOSE

This work aimed to investigate the validity of wearable activity monitors (WAMs) as an objective tool to measure the return toward normal functional mobility following abdominal wall surgery. This was achieved by quantifying and comparing pre- and postoperative physical activity (PA).

METHODS

A multicenter, prospective, observational cohort study was designed. Patients undergoing abdominal wall surgery were assessed for eligibility and consent for study participation was obtained. Participants were asked to wear a WAM (AX3, Axivity) on the wrist of their dominant hand at least 48 hours pre-operatively, for up to 2 weeks postop, and again after 6 months postop for 48 hours.

RESULTS

A cohort of 20 patients were recruited in this validation study with a mean age of 47.3 ± 13.0 years. Postoperation, the percentage median PA (±IQR) dropped to 32.6% (20.1), whereas on day 14, PA had reached 64.6% (22.7) of the preoperative value providing construct validity. Activity levels at >6 months postop increased by 16.4% on an average when compared to baseline preoperative PA (p = 0.046).

CONCLUSION

This study demonstrates that WAMs are valid markers of postoperative recovery following abdominal wall surgery. This was achieved by quantifying the reduction in PA postoperation, which has not been previously shown. In addition, this study suggests that abdominal wall surgery may improve the patient's quality of life via increased functional mobility at 6 months postop. In the future, this technology could be used to identify the patient and surgical factors that are predictors of outcome following abdominal wall surgery.

Identifying variation in the cost of abdominally based breast reconstruction in the UK

AIMS

To understand variation in the cost of autologous breast reconstruction in the UK, including identifying key areas of cost variability, differences between and within units and the impact of enhanced recovery protocols (ERAS).

METHODS

A micro-costing study was designed based on the responses to a national survey of clinical preferences completed by the majority of plastic surgeons and anaesthetists involved in the UK. Detailed costs were estimated from macro elements such as ward and theatre running costs, down to that of surgical meshes, anaesthetic drugs and flap monitoring devices.

RESULTS

The largest variation in cost arose from postoperative location and length of stay, preoperative imaging and flap monitoring strategies. Plastic surgeon costs varied from £1282 to £3141, whereas anaesthetic costs were between £32 and £151 (not including salary). Estimated cost variation within units was up to £893 per case. Units with ERAS had significantly lower total costs than those without (p < 0.05).

CONCLUSION

This study reveals significant cost variation in breast reconstruction in the UK based on clinician preferences. Many areas of practice driving this variation lack strong evidence of any clinical advantage. The total cost of a deep inferior epigastric perforator in the majority, if not all units, likely surpasses the national tariff for reimbursement, particularly when considering additional resource demand for immediate and bilateral breast reconstruction, as well as future symmetrisation procedures. Whilst units should look to streamline costs through ERAS, there should also be a realistic tariff that promotes excellent care.

Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer (PRADA): a multicentre, prospective, non-randomised, feasibility study

BACKGROUND

Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy.

METHODS

We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3-4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42·72 Gy in 16 fractions (over 3·2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2-6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment.

FINDINGS

Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12·1%, 95% CI 3·4-28·2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths.

INTERPRETATION

Preoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life.

FUNDING

Cancer Research UK, National Institute for Health Research.

The feasibility and safety of immediate breast reconstruction in the COVID-19 era

The coronavirus disease-2019 pandemic has had a significant impact on the delivery of surgical services, particularly reconstructive surgery. This article examines the current evidence to assess the feasibility of recommencing immediate breast reconstruction services during the pandemic and highlights considerations required to ensure patient safety.

Secondary free tissue transfer in head and neck reconstruction

BACKGROUND

The incidence of head and neck cancer (H&N) continues to increase together with the need for reconstructive surgery. Head and Neck microsurgeons are likely to encounter challenging secondary free flap surgery on the background of failed primary flaps, radiotherapy treatment or recurrence. The aim of this study was to review our experience of treating such cases in a tertiary referral centre in the United Kingdom.

METHODS

We performed a retrospective analysis of all patients undergoing sequential free flap surgery for head and neck defects in our unit during 2010-2017. Parameters recorded included indication for surgery, type and sequence of reconstruction, recipient vessel use and post-operative complications.

RESULTS

We identified 17 patients who underwent 39 free tissue transfers for the reconstruction of head and neck defects (five transfers were performed at other units). The radial forearm and anterolateral thigh flaps were most commonly used. Almost a quarter of patients underwent three or more free flap reconstructive procedures. In over a third, the same vein and artery were used for subsequent anastomoses, and we used five vein grafts over 68 anastomoses. There were no flap failures recorded.

CONCLUSIONS

Secondary free flaps in the head and neck are required for a variety of aetiologies and can have success rates similar to those for primary free tissue transfers with minimal morbidity and mortality. Free tissue transfer is the best reconstructive option in H&N patients and should still be considered the first choice option in salvage cases until the patient's donor sites have been depleted.

Preserving a patent DIEP pedicle to facilitate salvage breast reconstruction with a second free flap: A case report

Surgeons performing free flap breast reconstruction need to have a range of techniques in their armamentarium to successfully salvage cases of flap failure. We present a case of 47-year-old patient who suffered near-total right breast deep inferior epigastric perforator (DIEP) flap failure 3 days post-bilateral immediate breast reconstruction with DIEP flaps. At debridement, the DIEP pedicle was noted to be patent with preserved perfusion to a small segment of tissue around the origin of the pedicle. This tissue and the DIEP pedicle itself were therefore preserved to facilitate subsequent breast reconstruction using stacked transverse upper gracilis flaps anastomosed end-to-end to the original DIEP pedicle. Post-operatively, both flaps remained viable with no further complications and symmetrical aesthetic result maintained at 2 months follow-up post-salvage procedure. This case emphasizes the importance of exercising caution during initial debridement for free flap failure to preserve viable tissue in the flap and pedicle, particularly in circumstances where vascular flow in the pedicle is maintained, to facilitate successful salvage reconstruction.

In vivo optical microscopy of peripheral nerve myelination with polarization sensitive-optical coherence tomography

Assessing nerve integrity and myelination after injury is necessary to provide insight for treatment strategies aimed at restoring neuromuscular function. Currently, this is largely done with electrical analysis, which lacks direct quantitative information. In vivo optical imaging with sufficient imaging depth and resolution could be used to assess the nerve microarchitecture. In this study, we examine the use of polarization sensitive-optical coherence tomography (PS-OCT) to quantitatively assess the sciatic nerve microenvironment through measurements of birefringence after applying a nerve crush injury in a rat model. Initial loss of function and subsequent recovery were demonstrated by calculating the sciatic function index (SFI). We found that the PS-OCT phase retardation slope, which is proportional to birefringence, increased monotonically with the SFI. Additionally, histomorphometric analysis of the myelin thickness and g-ratio shows that the PS-OCT slope is a good indicator of myelin health and recovery after injury. These results demonstrate that PS-OCT is capable of providing nondestructive and quantitative assessment of nerve health after injury and shows promise for continued use both clinically and experimentally in neuroscience.

The perils of spinning class: an open ankle fracture following a spinning exercise session

Spinning is an increasingly popular form of cycle-based exercise. The workouts are often of high-intensity and participants are intermittently encouraged to achieve a high crank-set-cadence rate. We report a unique case of an open ankle fracture requiring free flap coverage, which highlights the potential perils of spinning class.

A comparison between complete immobilisation and protected active mobilisation in sensory nerve recovery following isolated digital nerve injury

Post-operative immobilisation following isolated digital nerve repair remains a controversial issue amongst the microsurgical community. Protocols differ from unit to unit and even, as evidenced in our unit, may differ from consultant to consultant. We undertook a retrospective review of 46 patients who underwent isolated digital nerve repair over a 6-month period. Follow-up ranged from 6 to 18 months. Twenty-four were managed with protected active mobilisation over a 4-week period while 22 were immobilised over the same period. Outcomes such as return to work, cold intolerance, two-point discrimination and temperature differentiation were used as indicators of clinical recovery. Our results showed that there was no significant difference noted in either clinical assessment of recovery or return to work following either post-operative protocol, suggesting that either regime may be adopted, tailored to the patient's needs and resources of the unit.

Extracting structural features of rat sciatic nerve using polarization-sensitive spectral domain optical coherence tomography

We present spectral domain polarization-sensitive optical coherence tomography (SD PS-OCT) imaging of peripheral nerves. Structural and polarization-sensitive OCT imaging of uninjured rat sciatic nerves was evaluated both qualitatively and quantitatively. OCT and its functional extension, PS-OCT, were used to image sciatic nerve structure with clear delineation of the nerve boundaries to muscle and adipose tissues. A long-known optical effect, bands of Fontana, was also observed. Postprocessing analysis of these images provided significant quantitative information, such as epineurium thickness, estimates of extinction coefficient and birefringence of nerve and muscle tissue, frequency of bands of Fontana at different stretch levels of nerve, and change in average birefringence of nerve under stretched condition. We demonstrate that PS-OCT combined with regular-intensity OCT (compared with OCT alone) allows for a clearer determination of the inner and outer boundaries of the epineurium and distinction of nerve and muscle based on their birefringence pattern. PS-OCT measurements on normal nerves show that the technique is promising for studies on peripheral nerve injury.

In vivo evaluation of demyelination and remyelination in a nerve crush injury model

Nerves of the peripheral nervous system have, to some extent, the ability to regenerate after injury, particularly in instances of crush or contusion injuries. After a controlled crush injury of the rat sciatic nerve, demyelination and remyelination are followed with functional assessments and imaged both ex vivo and in vivo over the course of 4 weeks with video-rate coherent anti-Stokes Raman scattering (CARS) microscopy. A new procedure compatible with live animal imaging is developed for performing histomorphometry of myelinated axons. This allows quantification of demyelination proximal and remyelination distal to the crush site ex vivo and in vivo respectively.

Validation of an incremental motor unit number estimation technique in rabbits

Motor unit number estimation (MUNE) allows for quantitative assessment of functional motor units in a nerve. Several techniques have been applied to human studies. Although MUNE has been performed in animals to study neurological disorders, reproducibility has not been addressed. We analyzed the test-retest reproducibility of an incremental MUNE technique in rabbits and performed histological correlation. A peroneal MUNE was performed in 9 rabbits on two occasions separated by 30 days. MUNE was then performed on 18 rabbits prior to euthanize. A count of total fibers and a second count of large myelinated fibers were performed on nerve cross-sections. Test-retest reproducibility revealed an intraclass correlation coefficient (ICC) of 0.75. The average test-retest relative difference was 26.6%. Comparison of MUNE and histomorphometrical counts revealed a correlation coefficient (r) of 0.21 (total fiber counts) and 0.27 (large fibers). Although incremental MUNE has a high degree of reproducibility in rabbits, there is poor correlation with histological fiber counts.

Epidermoid cyst post dermofasciectomy

We report the finding of an unusual presentation of an epidermoid cyst 3 years following dermofasciectomy for Dupuytren's disease. Epidermoid cysts remain a rare entity in the palmoplanter distribution but also a very unusual finding within the confines of a full thickness skin graft.

The human bite injury: a clinical audit and discussion regarding the management of this alcohol fuelled phenomenon

BACKGROUND

Human bite injuries are both deceptive and challenging in their presentation and management. They remain a frequent presentation to our unit, most often following late night alcohol fuelled aggression.

AIMS

To audit the management of these wounds, with particular focus on infective complications and outcomes.

METHODS

A three year retrospective chart review was undertaken on all patients referred to the plastic surgery unit from 1 January 2003 through to 31 December 2005.

RESULTS

A total of 92 patients with 96 human bite wounds were identified. The majority were male (92%). Alcohol consumption was documented in 86% of cases. The majority (70%) occurred over the weekend or on a public holiday. Facial injuries made up 70% of injuries with the remainder being to the upper limb. The ear was the most common target of all facial injuries (65%). Infection was documented in 18 cases (20%), with bite injuries to the upper limb and those presenting late (>12 h) having a higher incidence of infection.

CONCLUSIONS

Human bite wounds present a challenge to any emergency department, given the many issues involved in their management. Underestimation of the complexity and potential sequelae of these wounds will result in a suboptimal outcome for the patient.

Unicentric Castleman's disease: a surprising neck mass

BACKGROUND

We present the case of a 36-year-old female with a three-week history of a pulsatile, tender mass in the anterior triangle of the neck.

METHODS

Radiology demonstrated that this was a vascular tumour deep to the sternocleidomastoid muscle.

RESULTS

Pre-operative embolisation and complete surgical resection was performed. Histology revealed Castleman's disease.

CONCLUSION

Unicentric hyaline vascular Castleman's disease is an unusual cause of neck mass. Surgical resection remains the best chance for cure in unicentric disease. Long term follow-up is necessary as the risk of subsequent malignancy exists.

The Book-Worm

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