Superiorly Based Posterior Pharyngeal Flaps: Using A Care Pathway to Optimize Speech and Airway Outcomes

BACKGROUND

Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency, but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) preoperative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient-specific surgical approach via appropriately sized PFs can result in excellent speech outcomes while limiting occurrence of OSA.

METHODS

This was a retrospective chart review of all patients with velopharyngeal insufficiency (VPI) (aged 2-20 years) seen at the University of Rochester from 2015 to 2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine PF width. Patients underwent polysomnography and speech evaluation before and at least 6 months after PF surgery.

RESULTS

Forty-one children aged 8.5 ± 4.1 years (range, 4 to 18 years) who underwent posterior PF surgery for VPI were identified. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin sequence. Thirty-nine patients had both pre- and postoperative speech data and underwent both a pre- and postoperative sleep study. Polysomnography showed no significant difference in obstructive apnea-hypopnea index after posterior PF surgery (obstructive apnea-hypopnea index preop, 1.3 ± 1.2 events per hour; postop, 1.7 ± 2.1 events per hour; P = 0.111). Significant improvements in speech outcome were seen in patients who underwent PF (modified Pittsburgh score preop, 11.52 ± 1.37; postop, 1.09 ± 2.35; P < 0.05).

CONCLUSIONS

Use of preoperative staged adenotonsillectomy as well as patient-specific PF dimensions results in effective resolution of VPI and a low risk of OSA.

Plastic Surgery Involvement With Surgical Management of Infected Ventricular Assist Devices Decreased Lifetime Return to Operating Room and 90-Day Infectious Complications

BACKGROUND

The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Retrospective review has previously shown a decrease in lifetime return to operating room (RTOR) with no change in 90-day complications when a muscle or omental flap is used for coverage after washout for infection. We wished to determine if early plastic surgery intervention led to a decreased length of stay for these patients.

METHODS

Patients with LVAD readmitted for LVAD infection at a single institution from 2008 to 2021 were identified using a preexisting database. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with χ2 and analysis of variance testing was used to analyze outcomes.

RESULTS

Of 568 patients admitted with an LVAD infection, 104 underwent operative debridement and closure by plastic and reconstructive surgery (PRS) or cardiothoracic surgery (CTS). Fifty-three underwent PRS closure, and 51 underwent CTS closure. There was an increased incidence of diabetes among the PRS group (P < 0.001); otherwise, there was no difference in baseline characteristics. There was increased RTOR over a lifetime with CTS closure compared with PRS (P = 0.03) and increased 90-day risk of infection (P = 0.007). Patients with PRS closure had an increased risk of postoperative hematoma (P = 046). Plastic and reconstructive surgery was typically consulted on hospital day 10. Both PRS and CTS closure patients were discharged on postoperative day 7, on average (P = 0.542).

CONCLUSIONS

Plastic surgery involvement with surgical decision making and closure of infected LVAD devices has a decrease in lifetime RTOR and decreased 90-day complications related to infections. There may be a benefit to earlier PRS consultation for coverage assessment.

Hernia Recurrence and Complications After Abdominal Reconstruction With Reinforced Versus Nonreinforced Biologic Mesh

INTRODUCTION

Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence.

METHODS

A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2.

RESULTS

Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028).

CONCLUSIONS

Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy

OBJECTIVE

To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes.

DESIGN

A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI.

SETTING

A single academic center between January 2015 and January 2022.

PARTICIPANTS

Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI.

INTERVENTIONS

Simultaneous conversion Furlow palatoplasty and tonsillectomy.

MAIN OUTCOME MEASURE(S)

Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications.

RESULTS

Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p  =  0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p  =  0.16).

CONCLUSIONS

Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

Outcomes Following Use of Negative-Pressure Wound Therapy Over Autologous Meshed and Non-Meshed Skin Grafts

Negative-pressure wound therapy (NPWT) over split thickness skin grafts can control exudate, decrease infection rates, and improve revascularization. However, no study specifically addresses differences in outcomes between meshed/perforated and non-meshed autologous skin grafts dressed with NPWT. Through retrospective chart review, patients undergoing autologous split thickness skin grafting with a NPWT dressing for any burn injury over a 10-month period were identified. Data on etiology, graft take, meshed/perforated or non-meshed graft, graft size, and seroma/hematoma incidence were collected. Our study included 123 patients who had STSG with NPWT and consisted of 57% males, 57% Caucasian, and an average age of 41. Burn injury etiologies consisted of scald (55%), chemical (25%), flame (15%), and contact (5%). Average 2nd degree TBSA in our cohort was 2.34%, 3rd degree TBSA 4.50%, and total TBSA 5.35%. 66.7% of patients received non-meshed grafts, and these patients had an average graft area of 76.5 cm2. 33.3% of patients received meshed grafts, with an average graft area of 163.5 cm2. Non-meshed burn grafts were significantly smaller than meshed grafts (P = .04). There was 100% graft take and 0% seroma/hematoma formation in all patients. Data was analyzed using an unpaired student's T test and ANOVA testing. There were no statistically significant differences in patient demographics, or burn etiology. There exist many options for dressings after repair of burn injuries, each with its own unique advantages. There were, however, no differences in graft take or incidence of seroma/hematoma formation using a NPWT dressing over autologous meshed grafts vs non-meshed grafts. Our data shows that NPWT use as a bolster dressing is safe and efficacious overlying meshed skin grafts and non-meshed grafts.

Current Management of Trigger Digit in Rheumatoid Arthritis Patients: A Survey of ASSH Members

BACKGROUND

Traditional dogma regarding management of rheumatoid arthritis (RA) patients with trigger digit symptoms holds that A1 pulley release should be avoided. Surgical release was thought to further destabilize the metacarpophalangeal joint. Biologic disease modifying anti-rheumatic drugs (DMARDs) have limited the development of hand deformities. Despite advances in RA treatment, many textbooks continue to discourage release of the A1 pulley in RA patients. The aim of this study was to determine if this belief is consistent with current trends in surgical management of trigger digits in patients with RA.

METHODS

Active Members of the American Society for Surgery of the Hand (ASSH) were surveyed on their training and current practices as related to RA patients with trigger digits.

RESULTS

Five hundred three surveys were completed (16% response rate). During training, 55% of ASSH Members were taught to avoid releasing the A1 pulley in RA patients. Seventy-one percent of respondents currently release the A1 pulley in RA patients with no preexisting deformities, no tenosynovial thickening, or if tenosynovectomy and flexor digitorum superficialis slip excision fail to relieve triggering. Forty percent reported that their practice has evolved toward more frequent release of the A1 pulley in RA patients.

CONCLUSION

The majority of ASSH Active Members were taught during training to avoid surgical release of the A1 pulley in RA patients to prevent acceleration of finger deformities. Indications and contraindications for A1 pulley release are evolving along with the improved natural history of RA associated with the use of biologic DMARDs.

Urinary 11β-PGF2α and N-methyl histamine correlate with bone marrow biopsy findings in mast cell disorders

BACKGROUND

The utility of measuring histamine and prostaglandin metabolites in the urine of patients with mastocytosis has not been critically examined in a large series of patients. This study examined the relationship between the extent of increase in urinary excretion of 11β-prostaglandinF2α and N-methyl histamine, with serum tryptase, whole blood serotonin, and bone marrow findings including morphology, percentage involvement, and abnormal mast cell phenotype.

METHODS

This was a retrospective analysis of 90 patients who were continuously enrolled in the study for a period of 6 years (2008-2014). We recorded serum tryptase, whole blood serotonin, levels of urinary mast cell metabolites 11β-prostaglandinF2α and N-methyl histamine (NMH), and bone marrow findings.

RESULTS

Urinary mast cell metabolites 11β-prostaglandinF2α and N-methyl histamine correlated with levels of serum tryptase, mast cell burden in the bone marrow, the presence of mast cell aggregates, and atypical mast cells on bone marrow biopsy. Whole blood serotonin did not have a significant correlation with the serum tryptase or mast cell burden in the bone marrow. Urinary NMH was significantly different between c-kit D816V-positive and c-kit D816V-negative patients, while 11β-prostaglandinF2α was not. Urinary 11β-prostaglandinF2α 24-h excretion >3500 ng and NMH levels >400 μg/gm Cr corresponded with the high degree of bone marrow biopsies positive for atypical mast cells, the presence of aggregates, and c-kit mutation.

CONCLUSIONS

Easily obtained and quantified urinary metabolites of histamine (greater than twice the upper limit of normal) and prostaglandin D2 (>3.4 times the upper limit of normal) correlate well with bone marrow findings of mastocytosis.

'Idiopathic' eosinophilia with an Occult T-cell clone: prevalence and clinical course

In a study of 99 consecutive patients with "idiopathic" eosinophilia, clonal T-cells were demonstrated in blood, bone marrow, or other tissue samples of 14 patients including 6 who had an overt T-cell malignancy. The remaining eight patients (approximately 8%) with an "Occult" T-cell clone had predominantly cutaneous disease and FIP1L1-PDGFRA was absent in all six evaluable patients. Two patients were effectively treated with low-dose oral cyclophosphamide or methotrexate whereas Gleevec treatment was ineffective in another two patients. Two patients (25%) transformed into cutaneous T-cell lymphoma after 3-8 years of eosinophilic prodrome.

Changes in neutrophil surface phenotype during hemodialysis

The initiation of hemodialysis using cuprophane membranes is followed by a rapid fall in the circulating neutrophil count. This neutropenia is caused by a transient sequestration of neutrophils in the lung due to homotypic aggregation, largely in response to generation of C5a by contact of plasma with the dialyzer. The transient nature of hemodialysis neutropenia is due to desensitization of neutrophils to stimulation by C5a, thus demonstrating desensitization in vivo. To examine the in vivo effects on surface phenotype of continuous exposure of neutrophils to C5a over 3 h, the surface expression of 22 antigens was examined by flow cytometry in patients undergoing dialysis. Neutropenia was prominent at 15 min and absent at 60 and 180 min of dialysis. CD10, CD11b, CD11c, CD13, CD18, CD35, CD45, CD66acde, and CD66b were upregulated at 15 min and remained upregulated at 180 min. CD61 and CD63 increased slightly at 15 min and returned to baseline by 180 min. CD16 and CD62L were down regulated at 15 min and normalized by 180 min. CD15s, CDw17, CD32, and CD44 were slightly down regulated at 15 min and then returned to baseline by 180 min. CD11a, CD15, CD24, CD31, and CDw65 did not change during dialysis. This study demonstrates the changes in surface phenotype of neutrophils during prolonged in vivo exposure to C5a over 3 h, during which time neutrophils become desensitized to subsequent stimulation by similar concentrations of C5a but maintain responsiveness to other chemotactic stimuli.

The circulation in diabetes, from HL523 to the NO era

In 1955, F R Barany, a Swedish research physician interested in diabetes, summarised his dissertation (Acta Med Scand 1955; suppl 1304: 127) with the words "The ultimate cause of the various abnormal vascular reactions in diabetes might be assumed to be the cause of diabetic neuropathy in which autonomic pathways are the first to be destroyed...". That diabetes might involve a microcirculatory disease affecting the autonomic nervous system may be more relevant to the following reminiscence about the agent HL523 than I realised.

Polyunsaturated fatty acids stimulate superoxide formation in tumor cells: a mechanism for specific cytotoxicity and a model for tumor necrosis factor?

Some neoplastic cell lines are readily killed when incubated in the presence of polyunsaturated fatty acids (PUFA). In an attempt to elucidate this phenomenon, we studied PUFA-driven superoxide (O2-) production by cultured NS-1 cells (murine lymphoid tumor cells). We find: (1) Even in the absence of added PUFA, NS-1 cells generate O2- (i.e., reduce nitroblue tetrazolium). (2) addition of PUFA increases O2- by greater than 50%. (3) Artificial loading of NS-1 cells with liposome encapsulated superoxide dismutase prevents the majority of spontaneous and PUFA-driven NBT reduction. We conclude that PUFA drives O2- generation by tumor cells, that this generation is largely intracellular, and that this phenomenon may help explain toxicity of PUFA for tumor cells.

Phosphorylation of tyrosine enhances its electron transfer capability: a model of redox modulation as oncogene expression?

The influence of tyrosine and o-phosphotyrosine on the transfer of electrons to nitrobluetetrazolium (NBT) was studied. Tyrosine phosphate was found to strongly promote the transfer of electrons from ferrous iron to NBT, while tyrosine was inhibitory. The enhancement of NBT reduction by tyrosine phosphate was blocked by superoxide dismutase (SOD). The results suggest a role for phosphorylated tyrosine residues to promote intracellular redox reactions. We suggest that the role of tyrosine protein kinases in cell proliferation and transformation may be to regulate electron transport in as yet undefined cellular systems. Consistent with a unique role for phosphotyrosine, the other commonly occurring phosphoamino acids, o-phosphoserine and o-phosphothreonine were not effective electron transfer agents.

The dopaminergic D receptor: another example of reductive activation?

We have previously suggested that several intercellular messengers activate their receptors via reductive activation. Adenylate cyclase activation involves exposure of a sulfhydryl group. The dopamine D1 receptor activates this enzyme. Because sulfhydryl exposure could be secondary to reduction of a disulfide group we evaluated dopaminergic D1 agonists and antagonists as reducing agents. The agonists were found to be reducing agents and the antagonists were inactive. These results are consistent with the concept that dopaminergic D1 agonists activate adenylate cyclase via reductive activation.

Fear of hypoglycemia: quantification, validation, and utilization

Hypoglycemia can lead to various aversive symptomatic, affective, cognitive, physiological, and social consequences, which in turn can lead to the development of possible phobic avoidance behaviors associated with hypoglycemia. On the other hand, some patients may inappropriately deny or disregard warning signs of hypoglycemia. This study presents preliminary reliability and validity data on a psychometric instrument designed to quantify this fear: the hypoglycemic fear survey. The instrument was found to have internal consistency and test-retest stability, to covary with elevated glycosylated hemoglobin, and to be sensitive to a behavioral treatment program designed to increase awareness of hypoglycemia.

The herring gull Larus argentatus as a carrier of salmonella

The proportion of salmonella carriers among town-nesting herring gulls increased significantly from 2.1% in 1975-6 to 8.4% in 1979. The range of serotypes carried by herring gulls was similar to that causing infection in man, and it is likely that the gulls ingest these serotypes when feeding at untreated sewage outfalls on the coast. This is supported by the proportion of salmonella carriers being higher among first-year birds (9.7%) than among older birds (2.0%), as it is known that higher proportions of immature herring gulls feed on the coast. Herring gulls carrying salmonellas appeared healthy at the time of capture and at a later date it was assumed that they were not themselves infected. However, their habit of congregating in large numbers on reservoirs and rubbish tips and also at resting sites on farmland often far from feeding and roosting areas, multiplies the pollution problem and increases the potential health hazard for both man and farm stock. Herring gulls feed at a variety of sites and fly many miles from food source to food source and from feeding areas to the roost. Thus, even within the same day, there is the possibility of the transfer of salmonellas over a much wider area than previously considered.

The herring gull Larus argentatus as a likely transmitting agent of Salmonella montevideo to sheep and cattle

This paper presents evidence for the involvement of herring gulls (Larus argentatus) as vectors in the recent outbreaks of Salmonella montevideo in sheep and cattle in Scotland and suggests that the transfer can take place over considerable distances. The breeding area in Scotland of herring gulls which overwinter in N.E. England is remarkably similar to the geographical distribution of the outbreaks. This pattern, together with the feeding behaviour of herring gulls on farmland, the presence of S. montevideo in herring gulls just before their departure from the wintering area and the timing of the return just before the peak of outbreaks are all circumstantial evidence implicating this gull in the outbreaks. The rapid return of these gulls to their breeding areas means that S. montevideo can be transported long distances in one day and raises the possibility that the original source of S. montevideo could have been in N.E. England rather than in Scotland.

Tail-cuff blood pressure measurement without external preheating in awake rats

A new photoelectric sensor capable of detecting tail pulses even in unheated rats was tested for accuracy in indirect measurements of blood pressure. This sensor proved more sensitive than a Doppler ultrasonic flowmeter because it allowed detection not only of tail pulsations without preheating but also of peak oscillations usable for estimating mean arterial pressure. After blood pressures in anesthetized rats were elevated with norepinephrine or lowered with sodium nitroprusside, systolic pressures determined with the photoelectric sensor were almost identical with those recorded concurrently from femoral catheters (r = 0.939). Cuff pressure at peak oscillations in the tail correlated better with femoral mean pressure than with femoral diastolic pressure. However, similar comparisons in awake rats with chronically implanted carotid catheters showed that, although correlation between tail-cuff and carotid systolic pressures remained significant (r = 0.962), the correlation between peak tail oscillations and either mean or diastolic pressure was not. When systolic pressures were measured indirectly once a week for 7 weeks in unheated awake rats, normotensive rats could be easily distinguished from streptozotocin-diabetic and DOCA-salt hypertensive rats.

Surgical repair of coarctation of the aorta in infants less than six months of age: including the question of pulmonary artery banding

High mortality rates (20% to 60%) have been reported in the repair of coarctation of the aorta in infancy. During a 4 year period, 34 infants less than 6 months of age had coarctation repair (two prior to 1976). Eleven were less than 2 weeks of age, nine were 2 weeks to 1 month, eight were 1 to 2 months, and six were 2 to 6 months. Associated lesions were patent ductus arteriosus (PDA) (82%), ventricular septal defect (VSD) (53%), and other intracardiac lesions (35%). Twenty-three patients (67%) had emergency operations; the other procedures were semielective. The indications for operation included congestive cardiac failure (91%), acidosis (32%), hypertension (29%), cardiogenic shock (26%), and cardiac arrest (18%). There was one operative death (2.9%) in a patient with severe pulmonary valve insufficiency and multiple VSDs. There was one late death a 4 months (Taussig-Bing complex). Primary repair was used in 15, patch-graft angioplasty in 19 (left subclavian artery in nine, left common carotid in one, and Dacron or pericardial patch in nine). Two (6%) required reoperation for recurrent coarctation (follow-up 3 to 36 months with a mean of 25.8). Of 15 patients with a large VSD, six had pulmonary artery banding with two deaths (one operative and one late), two had debanding plus VSD repair, and two are awaiting operation. The remaining nine patients did not have banding (no operative or late deaths), four patients required late VSD closure, two VSDs closed spontaneously, two VSDs became smaller, and one patient is awaiting VSD closure. The infrequent need for pulmonary artery banding may be partly due to "physiological banding" seen at Denver's high altitude. The VSD spontaneously closed or became smaller in 44% of nonbanded patients. The low operative mortality can be ascribed to (1) aggressive medical therapy, (2) emergency catheterization and repair, (3) avoidance of hypothermia, and (4) adequate relief of the coarctation.