Morbidity Associated With Distal Tibial Autograft Harvest

Distal tibial autograft harvesting has been studied in the past, but morbidity at the level of the donor site is unclear. The purpose of this retrospective review is to assess morbidity in distal tibial autograft harvesting associated with foot and ankle arthrodesis procedures. A retrospective analysis was performed utilizing patients treated in the last 13 years at a large, multicenter, academic, tertiary referral, research institution. Included patients were between the ages of 18 and 80 years old. One-hundred and seven patients (39 male; 68 female) underwent ipsilateral distal tibial bone graft (n = 110) harvesting to augment the index procedure. Patients were followed for an average of 11.2 months after surgery (Range: 1-73 months). The incidence rate of distal tibial stress fractures was 4.5%, with an overall postoperative complication rate of 8.2%. Overall, low complication rates associated with distal tibial autograft harvesting were found, supporting the use of the distal tibia as an appropriate site for autograft harvesting in foot and ankle surgery.

Ultrasonographic analysis of palatal donor site healing accelerated with platelet-rich fibrin following subepithelial connective tissue harvesting

OBJECTIVE

Platelet-rich fibrin (PRF) contains a variety of growth factors and bioactive molecules that play crucial roles in wound healing and angiogenesis. We aimed to evaluate the effects of PRF on tissue thickness and vascularization of the palatal donor site by ultrasound (USG) following subepithelial connective tissue harvesting.

METHODOLOGY

A subepithelial connective tissue graft was harvested from the palatal region with a single incision for root coverage in 20 systemically healthy patients. In the test group (n = 10), the PRF membrane was placed at the donor site, whereas no material was applied in the control group (n=10). Palatal tissue thickness (PTT) and pulsatility index (PI) were evaluated by USG at baseline and on the 3rd, 7th, 14th, 30th, and 90th days after surgery. The early healing index (EHI) was used to evaluate donor site healing for 30 days.

RESULTS

PTT was significantly higher in the PRF group on the 3rd and 14th days after surgery when compared to the controls. In the PRF-treated group, PI levels were significantly higher than in the controls, especially on the 14th day. PTT increased significantly 90 days after surgery compared to the test group baseline, but controls showed a significant decrease. The PRF group showed statistically significant improvements in EHI scores compared to controls on days 3, 7, and 14. This study found a negative correlation between PI values and EHI scores on postoperative days three and seven in the test group.

CONCLUSION

USG is a non-invasive, objective method to radiographically evaluate the regenerative effects of PRF on palatal wound healing after soft tissue harvesting. To overcome graft inadequacy in reharvesting procedures, PRF application may enhance clinical success and reduce possible complications by increasing tissue thickness and revascularization in the donor area.

[Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]

BACKGROUND

Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest.

MATERIAL & METHODS

This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches.

RESULTS

In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort.

CONCLUSION

The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

[Robotic-assisted harvesting of a latissimus dorsi muscle flap: a case report]

Having established itself in various other areas of surgery as well as in urology, robotics is increasingly gaining importance in plastic surgery. The case presented in this manuscript describes the first published robotic-assisted harvesting of a latissimus dorsi muscle free flap in the German-speaking world. The aim is to increase the knowledge of robotics in plastic surgery and to support the introduction of robotic-assisted plastic surgery in Germany.

Outcomes and Cost Comparison of 3 Different Laparoscopic Approach for Living Donor Nephrectomy: A Retrospective, Single-Center, Inverse Probability of Treatment Weighting Analysis of 551 Cases

BACKGROUND

At our institution, we switched from hand-assisted retroperitoneal laparoscopic donor nephrectomy (HRN) to hand-assisted transperitoneal laparoscopic donor nephrectomy (HTN); we later switched to standard retroperitoneal laparoscopic donor nephrectomy (SRN). This study was performed to evaluate outcomes and hospital costs among the 3 techniques.

METHODS

This retrospective, observational, single-center, inverse probability of treatment weighting analysis study compared the outcomes among 551 cases of living donor kidney transplantation between 2014 and 2022.

RESULTS

After the inverse probability of treatment weighting analysis, there were 114 cases in the HRN group, 204 cases in the HTN group, and 213 cases in the SRN group. Donor complication rates were lowest in the SRN group but did not differ between the HRN and HTN groups (1.1 vs 4.4 and 5.9%, P = .021). Donors in the SRN group had the lowest serum C-reactive protein concentrations on postoperative day 1 (4.3 vs 10.5 and 7.8 mg/dL, P < .001) and the shortest postoperative stay (4.3 vs 7.4 and 8.4 days, P < .001). Donors in the SRN group had the lowest total cost among the 3 groups (8868 vs 9709 and 10,592 USD, P < .0001). Donors in the SRN group also had the lowest costs in terms of "basic medical fees," "medication and injection fees," "Intraoperative drug and material costs," and "testing fees." Furthermore, the presence of complications was significantly correlated with higher total hospital costs (P < .001).

CONCLUSION

SRN appeared to have the least invasive and complication, and a potential cost savings compared with the HRN and HTN.

Cytokines Removal During Ex-Vivo Lung Perfusion: Initial Clinical Experience

Ex Vivo Lung Perfusion (EVLP) can be potentially used to manipulate organs and to achieve a proper reconditioning process. During EVLP pro-inflammatory cytokines have been shown to accumulate in perfusate over time and their production is correlated with poor outcomes of the graft. Aim of the present study is to investigate the feasibility and safety of cytokine adsorption during EVLP. From July 2011 to March 2020, 54 EVLP procedures have been carried out, 21 grafts treated with an adsorption system and 33 without. Comparing the grafts perfused during EVLP with or without cytokine adsorption, the use of a filter significantly decreased the levels of IL10 and GCSFat the end of the procedure. Among the 38 transplanted patients, the adsorption group experienced a significant decreased IL6, IL10, MCP1 and GCSF concentrations and deltas compared to the no-adsorption group, with a lower in-hospital mortality (p = 0.03) and 1-year death rate (p = 0.01). This interventional study is the first human experience suggesting the safety and efficacy of a porous polymer beads adsorption device in reducing the level of inflammatory mediators during EVLP. Clinical impact of cytokines reduction during EVLP must be evaluated in further studies.

Tolerable degree of muscle sacrifice when harvesting a vastus lateralis or myocutaneous anterolateral thigh flap

The myocutaneous anterolateral thigh (ALT) and vastus lateralis (VL) flaps include a large muscle mass and a sufficient vascular pedicle, and they have been used for decades to reconstruct traumatic and acquired defects of the head and neck and extremities. In spite of these benefits, musculoskeletal dysfunction was reported in nearly 1 out of 20 patients at follow-up. It is unclear whether the recently proposed muscle-sparing flap-raising approach could preserve VL muscle function and whether patients at increased risk could benefit from such an approach. Therefore, we performed a predictive dynamic gait simulation based on a biological motion model with gradual weakening of the VL during a self-selected and fast walking speed to determine the compensable degree of VL muscle reduction. Muscle force, joint angle, and joint moment were measured. Our study showed that VL muscle reduction could be compensated up to a certain degree, which could explain the observed incidence of musculoskeletal dysfunction. In elderly or fragile patients, the VL muscle should not be reduced by 50% or more, which could be achieved by muscle-sparing flap-raising of the superficial partition only. In young or athletic patients, a VL muscle reduction of 10%, which corresponds to a muscle cuff, has no relevant effect. Yet, a reduction of more than 30% leads to relevant weakening of the quadriceps. Therefore, in this patient population with the need for a large portion of muscle, alternative flaps should be considered. This study can serve as the first basis for further investigations of human locomotion after flap-raising.

Validation of a Cleanroom Compliant Sonication-Based Decellularization Technique: A New Concept in Nerve Allograft Production

Defects of the peripheral nervous system are extremely frequent in trauma and surgeries and have high socioeconomic costs. If the direct suture of a lesion is not possible, i.e., nerve gap > 2 cm, it is necessary to use grafts. While the gold standard is the autograft, it has disadvantages related to its harvesting, with an inevitable functional deficit and further morbidity. An alternative to autografting is represented by the acellular nerve allograft (ANA), which avoids disadvantages of autograft harvesting and fresh allograft rejection. In this research, the authors intend to transfer to human nerves a novel technique, previously implemented in animal models, to decellularize nerves. The new method is based on soaking the nerve tissues in decellularizing solutions while associating ultrasounds and freeze-thaw cycles. It is performed without interrupting the sterility chain, so that the new graft may not require post-production γ-ray irradiation, which is suspected to affect the structural and functional quality of tissues. The new method is rapid, safe, and inexpensive if compared with available commercial ANAs. Histology and immunohistochemistry have been adopted to evaluate the new decellularized nerves. The study shows that the new method can be applied to human nerve samples, obtaining similar, and, sometimes better, results compared with the chosen control method, the Hudson technique.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times

INTRODUCTION

We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety.

METHODS

150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated.

RESULTS

Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04).

CONCLUSIONS

Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.

3D virtual reality vs. 2D desktop registration user interface comparison

Working with organs and extracted tissue blocks is an essential task in many medical surgery and anatomy environments. In order to prepare specimens from human donors for further analysis, wet-bench workers must properly dissect human tissue and collect metadata for downstream analysis, including information about the spatial origin of tissue. The Registration User Interface (RUI) was developed to allow stakeholders in the Human Biomolecular Atlas Program (HuBMAP) to register tissue blocks-i.e., to record the size, position, and orientation of human tissue data with regard to reference organs. The RUI has been used by tissue mapping centers across the HuBMAP consortium to register a total of 45 kidney, spleen, and colon tissue blocks, with planned support for 17 organs in the near future. In this paper, we compare three setups for registering one 3D tissue block object to another 3D reference organ (target) object. The first setup is a 2D Desktop implementation featuring a traditional screen, mouse, and keyboard interface. The remaining setups are both virtual reality (VR) versions of the RUI: VR Tabletop, where users sit at a physical desk which is replicated in virtual space; VR Standup, where users stand upright while performing their tasks. All three setups were implemented using the Unity game engine. We then ran a user study for these three setups involving 42 human subjects completing 14 increasingly difficult and then 30 identical tasks in sequence and reporting position accuracy, rotation accuracy, completion time, and satisfaction. All study materials were made available in support of future study replication, alongside videos documenting our setups. We found that while VR Tabletop and VR Standup users are about three times as fast and about a third more accurate in terms of rotation than 2D Desktop users (for the sequence of 30 identical tasks), there are no significant differences between the three setups for position accuracy when normalized by the height of the virtual kidney across setups. When extrapolating from the 2D Desktop setup with a 113-mm-tall kidney, the absolute performance values for the 2D Desktop version (22.6 seconds per task, 5.88 degrees rotation, and 1.32 mm position accuracy after 8.3 tasks in the series of 30 identical tasks) confirm that the 2D Desktop interface is well-suited for allowing users in HuBMAP to register tissue blocks at a speed and accuracy that meets the needs of experts performing tissue dissection. In addition, the 2D Desktop setup is cheaper, easier to learn, and more practical for wet-bench environments than the VR setups.

Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis

Laparoscopic donor hepatectomy (LDH), accepted as a minimally invasive approach, has become increasingly popular for living donor liver transplant. However, the outcomes of LDH remain to be fully clarified when compared with open living donor hepatectomy. Thus, our meta-analysis was designed to assess the efficacy of laparoscopic in comparison with conventional open donor hepatectomy.The PubMed, Cochrane, and Embase electronic databases were searched to identify the articles concerning the comparison of the efficacy of laparoscopic versus open surgery in treatment of living donor liver transplantation updated to March, 2020. The main search terms and medical Subject Heading terms were: "living donor," "liver donor," "minimally invasive," "laparoscopic surgery," and "open surgery." After rigorous evaluation on quality, the data was extracted from eligible publications. The outcomes of interest included intraoperative and postoperative results.The inclusion criteria were met by a total of 20 studies. In all, 2001 subjects involving 633 patients who received laparoscopic surgery and 1368 patients who received open surgery were included. According to the pooled result of surgery duration, the laparoscopic surgery was associated with shorter duration of hospital stay (MD = -1.07, 95% CI -1.85 to -0.29; P = .007), less blood loss (MD = -57.57, 95% CI -65.07 to -50.07; P < .00001), and less postoperative complications (OR = 0.61, 95% CI 0.44-0.85; P = .003). And the open donor hepatectomy achieved a trend of shorter operation time (MD = 30.31, 95% CI 13.93-46.69; P = .0003) than laparoscopic group. Similar results were found in terms of ALT (P = .52) as well as the AST (P = .47) peak level between the 2 groups.LDH showed the better perioperative outcomes as compared with open donor hepatectomy. The findings revealed that LDH may be a feasible and safe procedure for the living donor liver transplantation.

Ink Retention and Endothelial Cell Viability After the Application of an Orientation Stamp Over an Air Bubble During Descemet Membrane Endothelial Keratoplasty Graft Preparation

PURPOSE

To investigate stamp visibility and endothelial cell loss (ECL) after the application of an orientation mark to Descemet membrane endothelial keratoplasty (DMEK) grafts supported by an air bubble.

METHODS

Eighteen DMEK grafts were prepared at an eye bank using a technique where an orientation mark was applied to the stromal surface of a DMEK graft that was supported by a small air bubble placed at the edge of the 2 endothelial surfaces of the graft. Grafts were evaluated at 2 and 5 days for stamp visibility and at 5 days with calcein-AM staining for ECL. Nine grafts underwent cross-country shipping, and the ECL of shipped and nonshipped grafts was compared using unpaired t test.

RESULTS

All 18 DMEK grafts exhibited a single, solid, readily visible orientation mark 2 and 5 days after preparation with a mean ECL of 13.5% ± 4.9%. Shipping conditions had no effect on stain retention or ECL.

CONCLUSIONS

The application of an orientation stamp to a DMEK graft over an air bubble in an eye bank setting results in a single, solid orientation mark that is readily visible within the period in which most eye bank-prepared tissue is used. This technique produces no further ECL compared with the methods where the orientation stamp is applied through a stromal window. Eye bank technicians and surgeons can be confident that this modified preparation technique results in transplant-quality DMEK grafts with the additional benefit of conserving the stromal cap for use in other anterior lamellar procedures, thereby making efficient use of donor tissue.

Isolation, Culture, Cryopreservation, and Preparation of Skin-Derived Fibroblasts as a Final Cellular Product Under Good Manufacturing Practice-Compliant Conditions

Cell-based therapies have become a popular approach in the field of regenerative medicine. Human fibroblast cells, one of the cell types widely used in clinical applications, have been used for skin regeneration and wound healing procedures. Furthermore, they are utilized for aesthetic purposes since fibroblasts lose their abilities such as collagen synthesis with age. Here, we describe detailed procedures for isolation, culture, cryopreservation, and preparation of fibroblasts derived from adult human skin as a final product under good manufacturing practice-compliant conditions.

First Organ Donation after Circulatory Death Following Withdrawal of Life-sustaining Treatment in Korea: a Case Report

In February 2018, the Withdrawal of the Life-sustaining Treatment (WLST) Decision Act was legalized in Korea. Donation after circulatory death (DCD) after WLST was classified as DCD category III. We report the first case of successful organ donation after WLST in Korea. A 52-year-old male who experienced cerebral hemorrhage was a potential brain-dead donor with donation consent. During the first brain death examination, Babinski reflex was present, which disappeared two days later. Then, electroencephalography was performed five times at intervals of 2 to 3 days, according to the recommendation of a neurologist. The patient was transferred to the OR at 19:30 July 3, 2020. At 20:00, an intensive care unit specialist performed extubation and discontinued vasopressors. Oxygen saturation fell to < 70% in 1 minute, which signaled the beginning of functional warm ischemia. At 20:15, asystole was confirmed; after 5 minutes of "no-touch time," circulatory death was declared. Organ procurement surgery was initiated, with surgeons performing the recipient surgery ready in the adjacent OR. Through the first successful DCD case, we expected that DCD will be actively implemented in Korea, saving the lives of patient waiting for transplantation and resolving the imbalance between organ receipt and donation.

Tissue Loss, Processing Time, and Primary Graft Failure in Eye Bank-Prepared Descemet Membrane Endothelial Keratoplasty Grafts Before and After Prestripped to Preloaded Graft Transition

PURPOSE

To examine tissue loss rates, processing time, and primary graft failure (PGF) of "prestripped-only" Descemet membrane endothelial keratoplasty (DMEK) grafts at a single eye bank and how these parameters changed after the introduction of steps to preload tissue among experienced processors.

METHODS

Tissue loss and processing time during DMEK graft preparation as well as PGF were analyzed retrospectively at a single eye bank between 2012 and 2018. Outcomes were assessed in consecutive grafts before and after the introduction of preloading to the eye bank's standard operating procedure.

RESULTS

A total of 1326 grafts were analyzed, composed of the first 663 preloaded DMEK grafts and, for comparison, the 663 DMEK grafts processed immediately before starting the preloaded service. Mean processing time increased from 17.0 ± 3.9 minutes to 26.0 ± 5.4 minutes with the advent of preloading (P < 0.01). Initially, average processing time increased dramatically, with a maximum processing time of 51 minutes, before regressing to the average. No significant difference in the rate of tissue wastage was observed before versus after the implementation of preloaded DMEK (1.2% vs. 1.7%, P = 0.48). PGF occurred in 7 grafts before the preloaded service and 10 grafts after starting the service (1.6% vs. 2.3%, P = 0.47).

CONCLUSIONS

Preloading does not affect tissue wastage for experienced technicians or the PGF rate but increases processing time. Eye banks that are considering adding preloading to their standard operating procedure may need to account for longer processing times in their daily operations.

Adipose Tissue-Derived Stem Cell Yield Depends on Isolation Protocol and Cell Counting Method

In plastic surgery, lipofilling is a frequent procedure. Unsatisfactory vascularization and impaired cell vitality can lead to unpredictable take rates in the fat graft. The proliferation and neovascularization inducing properties of adipose tissue-derived stem cells may contribute to solve this problem. Therefore, the enrichment of fat grafts with stem cells is studied intensively. However, it is difficult to compare these studies because many factors—often not precisely described—are influencing the results. Our study summarizes some factors which influence the cell yield like harvesting, isolation procedure and quantification. Stem cells were isolated after liposuction. Quantification was done using a cell chamber, colony counting, or flow cytometry with changes to one parameter, only, for each comparison. Quantification of cells isolated after liposuction at the same harvesting site from the same patient can vary greatly depending on the details of the isolation protocol and the method of quantification. Cell yield can be influenced strongly by many factors. Therefore, a comparison of different studies should be handled with care.

Midline Rotation of the Right Renal Hilum During Hand-Assisted Laparoscopic Living Donor Nephrectomy

BACKGROUND/OBJECTIVES

Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney.

METHODS

Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 - 36. Graft vein and arterial anastomosis data were also reported.

RESULTS

Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 - 60) and 53 (3 - 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications.

CONCLUSIONS

The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial

This randomized clinical trial examines intermediate-term outcomes of endoscopic vs open vein harvesting for coronary artery bypass grafting as part of the Randomized Endo-Vein Graft Perspective (REGROUP) trial.

Live Liver Donors: Is Right Still Right?

BACKGROUND

Conventional wisdom dictates that a larger hepatectomy is more prone to complications. Consequently, with the donor safety as paramount, the transplant community has intuitively been proponents of left lobe donation in live donor liver transplantation (LDLT), thereby satisfying the tenet of double equipoise. More recently some data suggest that this may not always be the case, especially in established centres. Our aim was to compare right and left lobe donor outcomes in LDLT from a centre with cumulative experience.

METHODS

Review of a prospectively collected database of right and left lobe liver donors operated between August 2009 and July 2017 was performed. Their preoperative demographics, operative and post-operative outcomes were compared.

RESULTS

Of 904 liver transplantations, 458 were right lobe donors [379 without middle hepatic vein (MHV), 79 with MHV] and 58 left lobe donors. There was a significant difference in GRWR and functional liver remnant between the right and left lobe donors (1.27 ± 0.45 vs. 1.03 ± 0.28 p = 0.004, and 63.2 ± 7.9 vs. 37.7 ± 16.3, respectively, p value). The end portal pressure (7 vs. 8 mmHg p = <0.001), peak bilirubin (1.6 ± 0.8 vs. 2.9 ± 1.5 p = <0.001) and day 5 bilirubin (0.8 ± 0.3 vs. 1.4 ± 0.9 p = <0.001) were significantly higher in right lobe donors. There was no difference in blood loss, duration of surgery or peak lactate between the groups. Complications (20.7% vs. 25.9% p = 0.48), including serious complications (Clavien-Dindo > III) (6.9% vs. 8.1% p = 0.95), duration of ICU and hospital stay, were comparable between the groups. Subgroup analysis between left lobe and right lobe with and without MHV donor was also comparable.

CONCLUSION

Though biochemical differences exist between the groups, no difference in outcomes was noted. Despite larger liver mass loss in right lobe donors, a strict protocol-based approach to donor selection leads to comparable outcomes between left lobe and right lobe donations.

Evidence of Air Trapping During Ex Vivo Lung Perfusion: A Swine Experimental Lung Imaging and Mechanics Study

Ex vivo lung perfusion (EVLP) allows the ventilation and perfusion of lungs to evaluate their viability for transplantation. The aim of this study is to compare the mechanical, morphologic and functional properties of lungs during EVLP with values obtained in vivo to guide a safe mechanical ventilation strategy. Lungs from 5 healthy pigs were studied in vivo and during 4 hours of EVLP. Lung compliance, airway resistance, gas exchange, and hemodynamic parameters were collected at positive end-expiratory pressure (PEEP) of 5 cm H₂O. Computed tomography was performed at PEEP 0, PEEP 5, and total lung capacity (TLC). Lung pressure-volume (PV) curves were performed from PEEP 0 to TLC. Lung compliance decreased during EVLP (53 ± 5 mL/cm H₂O vs 29 ± 7 mL/cm H₂O, P < .05), and the PV curve showed a lower inflection point. Gas content (528 ± 118 mL vs 892 ± 402 mL at PEEP 0) and airway resistance (25 ± 5 vs 44 ± 9 cmH₂O/L∗s^-1, P < .05) were higher during EVLP. Alveolar dead space (5% ± 2% vs 17% ± 6%, P < .05) and intrapulmonary shunt (9% ± 2% vs 28% ± 13%, P < .05) increased ex vivo compared to in vivo, while the partial pressure of oxygen to inspired oxygen fraction ratio (PO₂/FiO₂) did not differ (468 ± 52 mm Hg vs 536 ± 14 mm Hg). In conclusion, during EVLP lungs show signs of air trapping and bronchoconstriction, resulting in low compliance and increased alveolar dead space. Intrapulmonary shunt is high despite oxygenation levels acceptable for transplantation.

Internal pudendal perforator artery flap harvesting without pre-operative imaging: Reliability and approach

Since its initial description in 1996 by Yii and Niranjan, the internal pudendal perforator flap (also known as the Singapore flap, the gluteal fold flap, and the lotus petal flap) has become a workhorse in perineal soft tissue reconstruction. In 2001, Hashimoto described the presence of three to five perforators in the perineal anogenital triangle. The ischial tuberosity has thus become a useful anatomic landmark for the safe boundary of medial dissection during flap elevation, in order to avoid damaging the perforator vessels. The objective of the present study was to evaluate the perforators' positions within the anogenital triangle by using color Doppler ultrasound. In a study of 15 subjects in the lithotomy position, we identified a total of 24 perforator vessels with a diameter greater than 5 mm. We noted the vessels' positions using orthonormal measurements, according to the distance from the midline and the distance on a straight line between the two ischial tuberosities (i.e. consistent bony anatomic landmarks that are independent of the patient's height and body mass index). The mean distance between the ischial tuberosity and the internal pudendal perforator was 27.3 mm. Based on our present results, we consider that routine ultrasound identification and dissection of the perforators is not always required before pudendal flap harvesting. This decreases the operating time and simplifies the flap harvesting procedure.

Management of Chylous Ascites After Laparoscopic Nephrectomy for Living Kidney Donor: A Case Report and Literature Review

Kidney transplant is currently the elective treatment of choice for end-stage renal disease. Laparoscopic living donor nephrectomy (LLDN) has substantial advantages over open nephrectomy. Chylous ascites (CA) is a rare surgical complication after the LLDN; there are few reports in the literature. We present a case report of a 58-year-old woman who started CA on the 21st day post operation. The recommended initial therapeutic approach to suspend the fat in the diet and place percutaneous drainage was not enough. It was decided to jointly introduce fasting and total parenteral nutrition with the administration of octreotide, resolving the complication completely in 15 days with no need for the patient to undergo surgery. The conservative management, during the first 4 to 8 weeks after the diagnosis is the best option. Surgery is generally recommended if conservative management fails. The prevalence of CA varied between 0% and 6.2% of LLDNs. In our experience of 87 LLDNs, we only presented 1.15% for this complication. There are 62 cases reported in the international literature. The mean presentation was 14 days after LLDN. All patients underwent conservative treatment, and only 15 patients (24%) went to surgery after the failure of conservative management. It would be highly useful, considering the disparity of the prevalence, if the bibliographic reports detail what hemostatic and sealing techniques are used in an LLDN. In this way it would be possible to identify which factor affects a complication like this one.

Mechanical Vibration-Extracted Stromal Vascular Fraction Improves Volume Retention after Autologous Fat Grafting

BACKGROUND

The stromal vascular fraction can improve volume retention after fat grafting, but the optimal stromal vascular fraction extraction method remains controversial. This study investigated the effect of mechanical vibration on stromal vascular fraction activity and explored the efficacy of vibration as a new extraction method compared to centrifugation, enzyme digestion, and nanoemulsion methods.

METHODS

Twenty-four rabbits were divided into three groups, and adipose tissue was harvested from the scapular region of each rabbit. In the first group, stromal vascular fraction was extracted from adipose tissue by vibration with different frequencies and durations. Cell counts and colony formation were assessed to determine the optimal vibration parameters. In the second group, stromal vascular fraction was extracted by the four methods, and the cell counts, proliferation, and adipogenic capabilities were observed in vitro. In the third group, adipose tissue mixed with stromal vascular fraction extracted by means of the four methods was grafted into rabbit ears. Volume retention and histologic changes were evaluated over 24 weeks.

RESULTS

Stromal vascular fraction activity was not influenced by low-frequency (≤45 Hz) and short-duration (≤20 minutes) vibrations. Vibration at 30 Hz for 15 minutes was most efficient for stromal vascular fraction extraction. In vitro, stromal vascular fraction extracted by vibration showed advantages for cell viability. In vivo, the vibration group showed a more normal tissue morphology and a higher retention rate (60.68 ± 7.07 percent) than the enzyme digestion (31.88 ± 4.99 percent), centrifugation (43.76 ± 4.32 percent), and nanoemulsion groups (21.79 ± 3.57 percent) (p < 0.05).

CONCLUSION

Vibration at 30 Hz for 15 minutes is recommended as a novel nonenzymatic method to extract stromal vascular fraction with high activity.

Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction

BACKGROUND

Robotically assisted latissimus dorsi harvest permits harvest of the latissimus dorsi muscle without a back incision, as compared to the traditional open technique. The authors hypothesized that robotic harvest has lower donor-site complication rates, decreased opioid requirements, and a shorter length of stay than the traditional open technique.

METHODS

A retrospective review was performed of all consecutive pedicled latissimus dorsi flaps for breast reconstruction between 2011 and 2015. All procedures were conducted by two surgeons who performed both robotic and open cases.

RESULTS

Fifty-two patients were identified; 25 underwent robotically assisted latissimus dorsi harvest and 27 underwent the open technique. Demographic data between the two groups were similar. Median length of stay for robotic harvest was shorter than that for the traditional technique (2 days versus 3 days; p = 0.031). Postoperative morphine requirement was less in the robotic compared to the traditional technique, but the difference was not significant (158 mg versus 184 mg; p = 0.826). Seroma rate was higher in the robotic group (16 percent versus 0 percent; p = 0.034). The mean duration of surgery was longer in the robotic cohort (388 minutes versus 311 minutes; p = 0.002).

CONCLUSIONS

This study demonstrates robotically assisted latissimus dorsi harvest as an effective alternative to the traditional open technique in select patients. Advantages of robotic harvest include no back scar, a shorter length of stay, and lower opioid requirements, although the difference was not significant; disadvantages include longer operative time and a higher seroma rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Human Stromal Cell Aggregates Concentrate Adipose Tissue Constitutive Cell Population by In Vitro DNA Quantification Analysis

BACKGROUND

Regenerative cell strategies rely on stromal cell implants to attain an observable clinical outcome. However, the effective cell dose to ensure a therapeutic response remains unknown. To achieve a higher cell dose, the authors hypothesized that reducing the volume occupied by mature adipocytes in lipoaspirate will concentrate the stromal vascular fraction present in the original tissue.

METHODS

Human standardized lipoaspirate (n = 6) was centrifuged (1200 g for 3 minutes) and the water phase was discarded. Mechanical disaggregation was achieved by shearing tissue through 2.4- and 1.2-mm Luer-to-Luer transfers. After a second centrifugation (800 g for 10 minutes), stromal cell aggregates were separated from the supernatant oil phase. Lipoaspirate percentage composition was determined by its constituent weights. Cell content was measured by total DNA quantification, and partial cell viability was determined by image cytometry. Tissue sections were evaluated histologically (hematoxylin and eosin and Masson trichrome stains).

RESULTS

Stromal cell aggregates reduced the standardized lipoaspirate mass to 28.6 ± 4.2 percent. Accordingly, the cell density increased by 222.6 ± 63.3 percent (from 9.9 ± 1.4 million cells/g to 31.3 ± 6.6 million cells/g; p < 0.05). Cell viability was unaffected in stromal cell aggregates (71.3 ± 2.5 percent) compared to standardized lipoaspirate (72.2 ± 2.3 percent), and histologic analysis revealed high-density areas enriched with stromal cells (622.9 ± 145.6 percent) and extracellular matrix (871.2 ± 80.3 percent).

CONCLUSION

Stromal cell aggregates represent a biological agent that triplicates the cell density versus unprocessed lipoaspirate, low on oil and water fluids, and enriched extracellular matrix components.

A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity

BACKGROUND

For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site.

METHODS

Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat.

RESULTS

All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection.

CONCLUSIONS

The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.

Transplantation of a heart donated after circulatory death via thoraco-abdominal normothermic regional perfusion and results from the first Spanish case

BACKGROUND

Controlled donation after circulatory death (cDCD) has emerged as one of the main strategies for increasing the organ donor pool. Because of the ischemic injury that follows the withdrawal of life-sustaining therapies, hearts from cDCD donors have not been considered for transplantation until recently. The ex-situ perfusion of hearts directly procured from cDCD donors has been used to allow the continuous perfusion of the organ and the assessment of myocardial viability prior to transplantation. Based on our experience with abdominal normothermic regional perfusion in cDCD, we designed a protocol to recover and validate hearts from cDCD donors using thoraco-abdominal normothermic regional perfusion without the utilization of an ex-situ device.

CASE PRESENTATION

We describe the first case of a cDCD heart transplant performed with this approach in Spain. The donor was a 43-year-old asthmatic female diagnosed with severe hypoxic encephalopathy. She was considered a potential cDCD donor and a suitable candidate for multiorgan procurement including the heart via thoraco-abdominal normothermic regional perfusion. The heart recipient was a 60-year-old male diagnosed with amyloid cardiomyopathy. Cold ischemia time was 55 min. The surgery was uneventful.

CONCLUSIONS

This case report, the first of its kind in Spain, supports the feasibility of evaluating and successfully transplanting cDCD hearts without the need for ex-situ perfusion based on the use of thoraco-abdominal normothermic regional perfusion opening the way for multiorgan donation in cDCD.

Trephine biopsy versus conventional open surgical technique for bone graft harvesting from the olecranon: A retrospective comparison of perioperative outcomes

OBJECTIVE

This study aimed to compare the perioperative clinical outcomes of trephine biopsy (TB) with the conventional open surgical method (COSM) in bone graft harvesting from the olecranon.

METHODS

In this retrospective study, 130 patients who underwent bone graft harvesting from the olecranon using either TB or COSM were included. Patients were then divided into two groups: the COSM group (48 patients; 36 men and 12 women; mean age=32 years; age range=18-52) and the TB group (82 patients; 61 men and 21 women; mean age=34 years; age range=20-62). The mean follow-up was 30 months (range=17-57) in the COSM group and 26.8 months (range=6-48 months) in the TB groups. The two groups were compared in terms of pain intensity, operating time, complication rate, elbow range of motion, and the scar sensitivity of the graft donor site. Pain intensity was measured using the visual analogous scale (VAS) on postoperative days 1 and 15. Other outcome measures were evaluated at the final follow-up.

RESULTS

In the TB group, the mean VAS score was 4±1.62 on postoperative day 1 and 1.6±0.76 on postoperative day 15. In the COSM group, the mean VAS score was 7.2±1.38 on postoperative day 1 and 3.1±1.34 on postoperative day 15. The early VAS scores were significantly higher in the COSM group than in the TB group (p<0.05). The mean operating time was 7±1.99 minutes in the TB group and 20±4.51 minutes in the COSM group. Hematoma occurred in one patient from each group, with an incidence of 2.1% in the COSM group and 1.2% in the TB group. There was no significant difference between the two groups regarding elbow range of motion at final follow-up p>0.05). No patient in the TB group showed sensitivity of the scar region, while scar sensitivity occurred in 3 of 48 patients (0.6%) in the COSM group.

CONCLUSION

Compared with COSM, TB seems to be a safe technique with similar complication rates. TB can provide shorter operating time, less postoperative pain, and smaller and less sensitive scar compared with COSM.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Current perceptions of 'Brazilian butt lift' (BBL) surgery in the UK: A BAAPS-led survey of BAAPS members

BACKGROUND

The BAAPS advice against Brazilian butt lift (BBL) surgery in the UK was set in October 2018. A Delphi study conducted by BAAPS highlighted the importance of defining current practice and perceptions amongst UK surgeons, as this is currently unknown.

OBJECTIVES

To evaluate BAAPS members' current practice and perceptions around BBL surgery to ensure patient safety and propose better recommendations.

METHODS

A BAAPS-commissioned survey was emailed to all BAAPS members through an on-line link. The survey collected quantitative and qualitative information in several domains.

RESULTS

This survey received a 44% response rate. Of 102 respondents, 32 surgeons undertook BBL surgery before the BAAPS advice to halt it. There was a wide variation in actual fat volumes injected, and in perceptions of what constituted a small or large volume. Virtually all respondents (96.9%) performed only subcutaneous fat injections. There were differences in fat harvest techniques. The majority (66.7%) felt that BAAPS should maintain its recommendation against undertaking BBL surgery until further data became available. Nearly a quarter of 102 respondents (20.6%) had been treated for BBL complications, the majority as a result of surgical tourism.

CONCLUSIONS

The survey provides member-reported perception and experience with regard to BBL surgery in the UK. The demand for BBL surgery and its provision should be reassessed in the UK. This information will be analysed with further national and international data to better define and shape the scope of the safety of BBL surgery in the UK. BAAPS will use such data towards the production of future guidance and support for surgeons and patients.

Single Stapler Technique for Vascular Control in Laparoscopic Donor Nephrectomy

BACKGROUND

Recent advancements in surgical instruments, energy sources, vascular staplers, and increased experience altogether led to several modifications in the laparoscopic donor nephrectomy (LDN) technique. In the conventional approach, the renal artery and vein are divided separately by vascular stapling. This study aimed to evaluate the safety and feasibility of using single vascular stapling technique for dividing the renal artery and vein simultaneously.

MATERIALS AND METHODS

Patients who underwent LDN performed by the same surgeon between January 2018 and January 2020 were included. Demographic data, body mass index, number of arteries and veins, vascular division technique, estimated blood loss, surgical time, warm ischemia time, surgical complications, and length of hospital stay were recorded. Descriptive statistics were used to describe the characteristics of the dataset.

RESULTS

A total of 196 donors were included in the cohort. The mean age was 44.5 years (19-80 years, standard deviation: 13.2). A total of 132 donors (82.65%) underwent left-sided LDN, and 34 (17.35%) underwent right-sided LDN. The mean surgical time and warm ischemia time were 68.4 ± 24.7 (32-116) and 2.8 ± 1.2 (1.6-4.0) minutes, respectively. Two cases were converted to open donor nephrectomy (1.02%). The single stapling technique was successfully performed in 168 (85.7%) donors with a single renal artery and vein.

CONCLUSION

Single stapling for the concurrent division of the renal artery and vein in the setting of LDN seems to be a safe and feasible approach. It also has the potential to shorten warm ischemia time and reduce the cost of LDN.

Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction

BACKGROUND

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction.

METHODS

The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction.

RESULTS

Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis.

CONCLUSION

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Feasibility of bilateral internal thoracic artery harvesting using the da Vinci SP system

PURPOSE

We conducted this study to investigate the feasibility of mobilizing the bilateral internal thoracic arteries (ITAs) using the da Vinci SP through a single intercostal incision and to compare the amount of rib spreading with that required for mini-thoracotomy procedures. We also evaluated the construction of an intrathoracic T-graft anastomosis using existing instrumentation of the SP system.

METHODS

We harvested bilateral ITAs from two male cadavers via a single incision made in the fifth intercostal space using the da Vinci SP. A T-graft end-to-side anastomosis was created in one cadaver.

RESULTS

The bilateral ITAs were harvested in less than 60 min and a T-graft was completed. No additional rib spreading was required. Intraoperative adjustments of the da Vinci SP were necessary to maintain alignment with the surgical targets.

CONCLUSIONS

Bilateral ITA harvest using the da Vinci SP through a single intercostal incision was feasible, with less rib spreading than in mini-thoracotomy procedures. Thus, creating an intrathoracic T-graft with the existing da Vinci SP instruments is possible.

Radial artery harvesting for total arterial revascularization

There is growing evidence to support total arterial revascularization in coronary artery bypass grafting and the radial artery is being used with increasing frequency as the second conduit of choice. Open radial artery harvesting enables safe dissection and the procedure is both effective and easy to teach. In this video tutorial, we present our technique for open radial artery harvesting using the LigaSure™ Exact Dissector. Key advantages include safety, time efficiency, ease of teaching, ease of use, and minimal blood loss.

The clinical application of microincision vein harvesting of the great saphenous vein in coronary artery bypass grafting

BACKGROUND

The present study aimed to summarize the clinical application of microincision vein harvesting (MVH) of the great saphenous vein in coronary artery bypass grafting (CABG).

METHODS

From July 2014 to October 2017, 160 patients underwent coronary artery bypass grafting. Among them, 80 patients received MVH of the great saphenous vein, and 80 received open venous harvesting (OVH). The results of the sampling operation, complications during hospitalization, and the long-term patency of the great saphenous vein were compared between the two groups.

RESULTS

All the patients in both groups received successful operations. The difference in the length of the veins obtained and the injury of the veins was not statistically significant (P > 0.05). The difference in the long-term patency rate of the graft vessels between the two groups was not statistically significant. The in-hospital mortality rate was the same in both groups. The MVH group had noticeable advantages over the OVH group in terms of the vein collection times, the incision length, and the complications experienced when performing the leg incisions (P < 0.01). The time relating to the patients' observed early out-of-bed activity was significantly longer in the MVH group. Furthermore, the patients' hospitalization length was significantly shorter in the MVH group compared to the OVH group (P < 0.05). The MVH group had significant advantages in pain score and patient satisfaction, and this difference was also statistically significant (P < 0.05).

CONCLUSIONS

The MVH procedure met the requirements of CABG in vein grafting. When compared with OVH, MVH can significantly reduce leg incision complications and improve patients' overall satisfaction with their hospital experience.

Predictors of surgical sperm retrieval in non-obstructive azoospermia: summary of current literature

Intracytoplasmic sperm injection (ICSI), combined with surgical sperm retrieval (SR) techniques, is the sole option for patients with non-obstructive azoospermia to achieve fertility; however, with suboptimal results. Given the variability in clinical presentation, the potential role of factors that can predict the likelihood of successful testicular SR needs to be clarified. This article summarizes the current evidence concerning the variables predicting SR success in non-obstructive azoospermic patients with spermatogenic failure. For this, we used 60 articles, including 46 original papers and six meta-analyses. Clinical and laboratory factors, as well as adjuvant therapies and surgical retrieval methods, were the factors most commonly investigated. We found that Klinefelter syndrome, Y chromosome microdeletions in regions AZFa/b, and Sertoli cell-only histopathology were associated with reduced SR success. By contrast, testis volume > 12.5 ml, history of cryptorchidism, use of micro-TESE as the sperm retrieval method, and adjuvant therapy were associated with improved SR success. None of the predictors, alone or combined, provide definitive information about the chances of harvesting sperm in men with non-obstructive azoospermia, except for Y chromosome microdeletions in regions AZFa/b. In the latter, SR success is virtually nil. We conclude that SR outcomes in men with non-obstructive azoospermia are difficult to predict based on the existing variables. Although several predictors can be used for patient counseling, their clinical value is limited to either ensure SR success or discourage reproductive urologists from recommending SR to men with non-obstructive azoospermia seeking fertility. A notable exception includes the deletions involving the regions AZFa and/or AZFb of the Y chromosome; the affected patients should be counseled against undergoing SR.

Comparison of two methods for obtaining and transporting corneal samples in suspected infectious keratitis

BACKGROUND AND PURPOSE

The purpose of this study is to compare two alternative methods of collecting and transporting media for the diagnosis of corneal ulcers, as not all clinical settings have conventional culture materials and transport media available.

METHODS

In this open-label, prospective, comparative, and randomized study, patients with clinical suspicion of infectious keratitis with high risk of loss of vision had corneal specimens collected using two methods and transport media: Eswab scraping with Amies transport medium and 23-gauge needle scraping in BACTEC Peds broth. The order of each collection method was randomized. The samples were processed by standard methods, comparing the positivity frequencies for both by parametric and nonparametric tests, according to normality criteria.

RESULTS

Corneal infiltrates from 40 eyes of 40 patients were analyzed. Culture positivity rate was 50% for Eswab and 35% for 23-gauge needle (P=0.258). The overall growth rate of the two methods combined was not higher than with the swab alone. The results obtained with a swab were not influenced by the collection sequence (P=0.112); however, the positivity rate was significantly higher when the sample taken with the needle was performed first (P=0.046).

CONCLUSIONS

The single sample Eswab method of collection and transportation for the diagnosis of high risk corneal ulcers is a valid alternative and can be used in cases in which, for various reasons, there is no access to the full set of traditional culture materials.

Optimizing pre-Descemet endothelial keratoplasty technique

Pre-Descemet endothelial keratoplasty (PDEK) is an alternative technique to Descemet membrane endothelial keratoplasty (DMEK). The preparation of PDEK tissue by pneumatic dissection is simple and reproducible. The PDEK clamp helps to consistently obtain a type 1 big bubble. The mean size of type 1 big bubble is 7.255 ± 0.535 × 6.745 ± 0.668 mm. The volume of air required to obtain type 1 big bubble is 0.14 to 0.37 mL. Dissection of PDEK tissue can be achieved by trephination or manual excision. Insertion of tissue into the recipient eye can be by injection or pulling. Unfolding techniques used for PDEK are similar to those used in DMEK. Unlike DMEK, PDEK tissue is easier to handle and unscroll and allows use of younger donors. It could help surgeons converting to endothelial keratoplasty, with significant advantages in preparation, handling, and unscrolling in the eye.

Prospective Comparison of Donor-Site Morbidity following Radial Forearm and Ulnar Artery Perforator Flap Harvest

BACKGROUND

The forearm is a common donor site, providing thin, pliable workhorse flaps for head and neck reconstruction. There are no prospective studies comparing the donor-site morbidity of the radial forearm flap to the ulnar artery perforator flap.

METHODS

All patients undergoing forearm free flaps were included for analysis and followed for a minimum of 1 year. Grip strength, sensation to light touch, temperature sensation, and wound healing were assessed.

RESULTS

A total of 98 patients were enrolled (radial forearm flap, n = 50; ulnar artery perforator flap, n = 48). There were three osteocutaneous radial forearm flaps performed. The donor site was closed primarily in one radial forearm flap patient and four ulnar artery perforator flap patients. The majority of donor sites were resurfaced with full-thickness skin grafts (radial forearm flap, n = 40; ulnar artery perforator flap, n = 44), and the remaining were closed with split-thickness skin grafts. Average grip strength compared to baseline measured at 1, 3, 6, and 12 months after surgery demonstrated no significant differences. All patients returned to baseline sensation to light touch with no long-term sensory deficits at 1 year. No patients suffered significant changes in temperature sensation or cold intolerance. Seven patients suffered partial skin graft loss (radial forearm flap, n = 5; ulnar artery perforator flap, n = 2); all of them healed secondarily with local wound care. There were no flap losses in the study.

CONCLUSIONS

The radial forearm and ulnar artery perforator flaps are equivalent in terms of success and donor-site morbidity. Selection of flap should be based on need for pedicle length, flap bulk, concerns with radial or ulnar dominance, and surgeon comfort.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Preoperative assessment system for hand-assisted laparoscopic donor nephrectomy by discriminant analysis

We developed a preoperative assessment system to predict surgical workload in hand-assisted laparoscopic donor nephrectomy (HALDNx) using the normal-based linear discriminant rule (NLDR). A total of 128 cases of left HALDNx performed by a single operator were used as training data. Surgical workload was measured by operative time. The optimized model had 9 explanatory variables: age, total protein, total cholesterol, number of renal arteries (numberRA), 4 variables of perinephric fat (PNF), and thickness of subcutaneous fat. This model was validated using cross-validation and the .632 estimator to estimate discrimination rates with future test data. PNF and numberRA were the predominant factors affecting workload followed by the computed tomography value of PNF, body weight, and male sex. The estimated accuracy of the prediction system was 94.6%. The complication rate was 9.38% and did not correlate with surgical workload. We also made our program available online for constructing assessment functions from other cohort data. In conclusion, the surgical workload of HALDNx could be predicted with PNF and numberRA as the dominant risk factors.

Mobile Extracorporeal Membrane Oxygenation Teams for Organ Donation After Circulatory Death

The shortage of available organ donors is a significant problem worldwide, and various efforts have been carried out to avoid the loss of potential organ donors. Among them, organ donation from cardiocirculatory deceased donors (DCD), in which withdrawal of life-sustaining therapies is ongoing (Maastricht type III donors), is one emerging strategy. Thanks to the latest advances in transplantation and organ preservation, such as normothermic regional perfusion (NRP), ex vivo perfusion techniques, and good organization and communication among prehospital care providers, emergency departments, intensive care units, and transplantation units, DCD is rapidly increasing; it's estimated that it will increase the number of donations of lungs and splanchnic organs by more than 40%. Although Maastricht type II DCD requires a 24/7 available experienced extra corporeal membrane oxygenation (ECMO) team in the institution, Maastricht DCD type III could be organized in secondary care and spoke hospitals without in loco ECMO facilities for NRP. This article analyses a potential mobile team organization based on the hub-and-spoke model, which already exists and functions in Italy, by estimating the dimension of the controlled DCD phenomenon in Italy, coordination requirements, costs, personnel training, and education, and reporting a single center experience in Milan, Italy.

Possible effect of morphological variations of plantaris muscle tendon on harvesting at reconstruction surgery-case report

Purpose

Seemingly a well-known, weak, and vestigial plantaris muscle should not be a revelation. However, recent studies have shown that this structure is incredibly underestimated and perceived only as an infirm flexor of the talocrural joint, the knee joint or a great source of graft tissue. Usually, the origin of this inconspicuous muscle begins at the lateral supracondylar line of the femur and the knee joint capsule. It continues distally, forming a long and slender tendon. In most cases, it inserts onto the calcaneal tuberosity on the medial side of the Achilles tendon. However, many morphological variations have been discovered during anatomical dissections and surgical procedures. Nevertheless, according to the present literature, no other studies presented such a complex insertion variant, with indisputable clinical value and significant proof of development of this forgotten muscle.

Methods

The dissection of the right thigh, knee, crural and talocrural region was performed using standard techniques according to a strictly specified protocol.

Results

Four different insertion points were observed. The first band (A) inserted near to the tarsal canal flexor retinaculum. The second band (B) bifurcates into two branches—B1 and B2. B1 is located on the medial side and B2 is located on the lateral side of the calcaneal tuberosity. The third band (C) is inserted into the superior nonarticular calcaneal surface of the calcaneus anteriorly to the Achilles tendon.

Conclusion

A differently shaped plantaris tendon could be considered a cause of harvesting procedure failure. In the light of new case reports perhaps what we are now witnessing is remodeling and transformation of the Plantaris muscle. If so, the awareness of the influence on the onset of Achilles midportion tendinopathy or a potential role in tibialis posterior conflict can be crucial for every clinician.

Neurotized Free Platysma Flap for Functional Eyelid Reconstruction: A Cadaveric Study of Anatomical Feasibility

BACKGROUND

Conventional reconstructive options for large full-thickness eyelid defects are limited to static local flaps without replacing the missing orbicularis. The authors' aim is to delineate the platysma neurovascular anatomy for innervated functional eyelid reconstruction.

METHODS

Fourteen fresh latex-injected heminecks were dissected. The locations where neurovascular structures entered the platysma muscles were expressed as the percentage distance ± SD from the sternocleidomastoid muscle mastoid insertion to manubrium origin.

RESULTS

The superior thyroid, facial, and lingual vessels were the major pedicles in eight of 14 (57.1 percent), four of 14 (28.6 percent), and one of 14 specimens (7.1 percent), respectively. In one specimen (7.1 percent), both the superior thyroid and facial vessels supplied a major pedicle. Venous drainage generally mirrored arterial inflow but was redundant, with 43 percent and 14 percent of flaps also with major contributions from the external jugular and anterior jugular veins, respectively. Neurovascular pedicles entered the platysma 28 to 57 percent caudal to the sternocleidomastoid muscle mastoid insertion, between 0.5 and 4.8 cm anterior to the medial sternocleidomastoid muscle border.

CONCLUSION

Although variability exists, platysma neurovascular pedicles enter at predictable locations between 28 and 57 percent of the distance from the mastoid insertion of the sternocleidomastoid muscle, therefore making free platysma transfer a feasible option for eyelid reconstruction.

An Update on Cryopreservation of Adipose Tissue

Currently, fat transplantation occurs immediately after harvesting procedures. Because low rates of fat graft take are well reported in the literature, many patients require multiple surgical procedures for fat graft harvest. These subsequent procedures lead to increased cost, donor-site morbidity, and patient discomfort in the long term. The ability to preserve our patients' own adipose aspirate would allow us to counteract these shortcomings and ultimately improve the clinical outcome after fat grafting. Unfortunately, there is no optimal and practical adipose tissue cryopreservation protocol for use by the plastic surgeon at the present time. Because of this dilemma, the senior author (L.L.Q.P.) has investigated this concept in an effort to create a protocol that is both technically sound and clinically achievable to allow for the long-term preservation of adipose tissue. In this article, the authors aim to outline this effort, review current clinical applications that have been reported in the literature, and detail exciting future perspectives in the use of preserved lipoaspirates for repeated fat grafting procedures or in the form of cell-based therapy engineered for reconstructive endeavors for their patients.

Novel heat shock protein 90 inhibitor improves cardiac recovery in a rodent model of donation after circulatory death

OBJECTIVE

Organ donation after circulatory death (DCD) is a potential solution for the shortage of suitable organs for transplant. Heart transplantation using DCD donors is not frequently performed due to the potential myocardial damage following warm ischemia. Heat shock protein (HSP) 90 has recently been investigated as a novel target to reduce ischemia/reperfusion injury. The objective of this study is to evaluate an innovative HSP90 inhibitor (HSP90i) as a cardioprotective agent in a model of DCD heart.

METHODS

A DCD protocol was initiated in anesthetized Lewis rats by discontinuation of ventilation and confirmation of circulatory death by invasive monitoring. Following 15 minutes of warm ischemia, cardioplegia was perfused for 5 minutes at physiological pressure. DCD hearts were mounted on a Langendorff ex vivo heart perfusion system for reconditioning and functional assessment (60 minutes). HSP90i (0.01 μmol/L) or vehicle was perfused in the cardioplegia and during the first 10 minutes of ex vivo heart perfusion reperfusion. Following assessment, pro-survival pathway signaling was evaluated by western blot or polymerase chain reaction.

RESULTS

Treatment with HSP90i preserved left ventricular contractility (maximum + dP/dt, 2385 ± 249 vs 1745 ± 150 mm Hg/s), relaxation (minimum -dP/dt, -1437 ± 97 vs 1125 ± 85 mm Hg/s), and developed pressure (60.7 ± 5.6 vs 43.9 ± 4.0 mm Hg), when compared with control DCD hearts (All P = .001). Treatment abrogates ischemic injury as demonstrated by a significant reduction of infarct size (2,3,5-triphenyl-tetrazolium chloride staining) of 7 ± 3% versus 19 ± 4% (P = .03), troponin T release, and mRNA expression of Bax/Bcl-2 (P < .05).

CONCLUSIONS

The cardioprotective effects of HSP90i when used following circulatory death might improve transplant organ availability by expanding the use of DCD hearts.

Laparoscopic myomectomy using self-made retrieval bag to contain tissue extraction

OBJECTIVE

To introduce an effective approach using a self-made retrieval bag during laparoscopic myomectomy to contain tissue extraction.

DESIGN

Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique, approved by the Shengjing Hospital of China Medical University.

SETTING

University hospital.

PATIENT(S)

A 32-year-old woman diagnosed with a uterine myoma (diameter, 6 cm). She had endured 5 years of intermittent lower abdominal pain and 2 years of infertility.

INTERVENTION(S)

A self-made retrieval bag during laparoscopic myomectomy was used (consists of four steps) to contain tissue extraction. 1. Self-made retrieval bag using a sterile medical bag. 2. Inspect the pelvic cavity, evaluate and determine the location and number of myomas. 3. Resect the myoma. 4. Morcellate the myoma into pieces inside the retrieval bag using laparoscopic power morcellation.

MAIN OUTCOME MEASURE(S)

Value and feasibility of using a self-made retrieval bag in laparoscopic myomectomy.

RESULT(S)

The myoma was successfully and completely resected by laparoscopy using a self-made retrieval bag to contain tissue extraction. Operative time was 93 minutes. In the follow-up period, the patient did not report any symptom of iatrogenic parasitic myoma. The woman had a pregnancy at month 26 after operation and underwent a cesarean section. This resulted in a full-term baby.

CONCLUSION(S)

Our surgical approach demonstrated a number of noteworthy advantages. The use of retrieval bag to contain tissue extraction during laparoscopic morcellation can avoid the risk of iatrogenic parasitic myoma. The retrieval bag is self-made using a sterile packing bag, which is cost free and also reduces operative expenses.

Effects of SCCO2, Gamma Irradiation, and Sodium Dodecyl Sulfate Treatments on the Initial Properties of Tendon Allografts

Sterile and decellularized allograft tendons are viable biomaterials used in reconstructive surgeries for dense connective tissue injuries. Established allograft processing techniques including gamma irradiation and sodium dodecyl sulfate (SDS) can affect tissue integrity. Supercritical carbon dioxide (SCCO₂) represents a novel alternative that has the potential to decellularize and sterilize tendons with minimized exposure to denaturants, shortened treatment time, lack of toxic residues, and superior tissue penetration, and thus efficacy. This study attempted to develop a single-step hybrid decellularization and sterilization protocol for tendons that involved SCCO₂ treatment with various chemical additives. The processed tendons were evaluated with mechanical testing, histology, scanning electron microscopy (SEM), and Fourier-transform infrared (FTIR) spectroscopy. Uniaxial mechanical testing showed that tendons treated with SCCO₂ and additive NovaKill^TM Gen2 and 0.1% SDS had significantly higher (p < 0.05) ultimate tensile stress (UTS) and Young's modulus compared to gamma-irradiated and standard-SDS-treated tendons. This was corroborated by the ultrastructural intactness of SCCO₂-treated tendons as examined by SEM and FTIR spectroscopy, which was not preserved in gamma-irradiated and standard SDS-treated tendons. However, complete decellularization was not achieved by the experimented SCCO₂-SDS protocols used in this study. The present study therefore serves as a concrete starting point for development of an SCCO₂-based combined sterilization and decellularization protocol for allograft tendons, where additive choice is to be optimized.

Attitude of Older People Toward Living Donation

BACKGROUND

Living donation is a potential source of organs that could help to reduce the organ transplant deficit. Given that we have a worldwide aging population, it is important to assess the opinion of older people toward this type of donation.

OBJECTIVES

To analyze the attitude of people aged > 65 years toward living kidney donation (LKD) and living liver donation (LLD) and to investigate the variables affecting their attitudes.

METHODS

A multicentric study was carried out using a representative sample of people > 65 years stratified by sex and geographic location in southeastern Spain (n = 420). The measurement instrument was a validated questionnaire about LKD and LLD. Statistics were analyzed using SPSS version 21.0 (IBM Corp, Armonk, NY, United States) software. Descriptive analysis was carried out using Student t test, χ² test, and a multivariate analysis.

RESULTS

The questionnaire completion rate was 84% (n = 351) with 88% (n = 310) in favor of LKD, and 89% (n = 311) in favor of LLD. Favorable attitude decreased to 3% when the donation under consideration was unrelated. Attitudes toward LKD and LLD were associated with having received information from the television (P = .016 and P = .045) and from friends (P = .017 and P = .03); accepting an autopsy after death (P = .001 and P = .002); and not being worried about scars (P = .015 and P = .044). In the multivariate analysis, the following variables continued to be significant: having received information from the television (odds ratio [OR], 2) and from friends (OR, 10.3); and the acceptance of an autopsy (OR, 2).

CONCLUSIONS

Older people are in favor of both LKD and LLD, assuming it is a related donation. In addition, the information the elderly population receives regarding organ donation and transplantation affects their attitudes.

[Minimally Invasive Cancellous Bone Graft Harvesting in Trauma Indication - Clinical Part of the Study]

PURPOSE OF THE STUDY The clinical prospective study presents the results of minimally invasive harvesting of cancellous bone tissue in trauma indications. We focused on evaluating the clinical outcomes of this technique, particularly on the amount of cancellous bone harvested, the effectiveness of its use and complications. The pain in the bone graft harvest site is evaluated and compared with the pain after a standard harvest from the iliac crest. MATERIAL AND METHODS All the patients aged 18-90 years, in whom cancellous bone was harvested by minimally invasive technique using a bone cutter were included prospectively in the study. It was used to fill the defect in treating a fracture or in surgical treatment of non-union. The patients, in whom the grafts harvested in this manner were combined with another substitute, were not included in the study. Thus, 57 adult patients (40 men, 17 women) were included in the group in the period from March 2012 to March 2016. 37 patients, i.e. 65% of the total number of 57 patients, arrived for the evaluation of the clinical outcome. The minimally invasive graft harvesting was performed using the Aesculap® cutters. The graft was harvested either from the skeleton directly in the area of surgical wound or by a mini incision above the harvest site in the area under surgical drapes. The diameter of the cutter was selected based on the planned necessary number of grafts and with account taken of the harvest site. There were 6 harvest sites selected - proximal humerus, proximal ulna, iliac crest, greater trochanter of femur, distal femur and proximal tibia. The age and gender of patients, harvest site, type of the used cutter and the total number of harvested grafts were recorded in the study. The patients underwent a clinical follow-up at 6 weeks, 3 months, 6 months and 1 year postoperatively. The healing of the fracture or non-union was assessed on radiographs and in case of any doubt a CT scan was indicated. The pain at the graft harvest site was quantified with the use of the VAS score. A possible correlation between the age and the harvest site pain was explored by means of the Pearson s correlation coefficient. RESULTS In surgical management of fractures, 10.98 cm³ of bone marrow (σ 5.32) was harvested on average, in non-unions it was 10.85 cm³ (σ 5.52). With the above described technique, the mean healing time of lower extremity fractures was 26 weeks, in upper extremity it was 22 weeks. The non-unions of lower extremity and upper extremity healed after 28 weeks and 19 weeks, respectively. The average pain at the harvest site was 4.08 (σ 2.21, p ˂ 0.001). By calculating the Pearson's correlation coefficient it was confirmed that there is no correlation between the age and pain VAS score at the harvest site (r = -0.05). No early complications at the graft harvest site were observed in our group of patients. DISCUSSION On average, 10.98 cm³ of bone marrow was harvested in treated fractures, which in comparison to standard harvests from the iliac crest offers sufficient amount of tissue to treat complicated fractures and non-unions. Technically, the standard harvest site of cancellous bone tissue from the iliac crest is replaceable. The harvesting technique offers an interesting alternative also in terms of the duration of surgery and material. CONCLUSIONS Our study confirmed that by the minimally invasive technique of bone graft harvesting adequate amount of tissue to treat defect fractures and non-unions can be harvested. Spongioplasty using grafts harvested in this manner is effective, with a minimum percentage of non-unions. The advantage of this technique is the proximity of the harvest site and the operative field and low level of pain. The minimally invasive graft harvesting represents a technique with a low risk of postoperative and late complications. Key words: bone graft, autografts, minimally invasive surgery, ilium, pain.