Patient reported outcomes after multivisceral resection for advanced rectal cancers in female patients

INTRODUCTION

Multivisceral resections for rectal cancer can lead to long-term functional disturbances. This study aims to evaluate the quality-of-life outcomes in female patients who underwent multivisceral resection for rectal cancer, specifically focusing on urinary and sexual functions.

METHODS

A cross-sectional study was conducted on female patients who underwent multivisceral rectal resections. Quality of life was assessed using the EORTC QLQ-CR29.

RESULTS

Out of 198 female patients that underwent multivisceral resections, 69 were assessable for functional outcomes. The uterus was removed in 42 patients (61%), and the posterior vaginal wall in 34 (49%). A vaginal reconstructive procedure was carried out in 30% (21 patients). Patients reported the most troubles with urinary frequency (mean: 69.6; SD: 9.9), hair loss (mean: 64.7; SD: 13.9), pain during intercourse (mean: 44; SD: 40.7), and bowel frequency (mean: 36.9; SD: -10.7) in this order. Amongst the functional scales, anxiety about future health (mean: 42.5; SD: -018.9) and interest in sex (mean: 57.2; SD: 33.2) scored the lowest.

CONCLUSION

Multivisceral rectal resections in female patients are associated with physical and psychosocial changes resulting in urinary and bowel complaints, anxiety about future health, poor sexual health, and pain.

Gastric salvage after venous congestion during major pancreatic resections: A series of three cases

Pancreatic resections, depending on the location of the tumor, usually require division of the vasculature of either the distal or proximal part of the stomach. In certain situations, such as total pancreatectomy and/or with splenic vein occlusion, viability of the stomach may be threatened due to inadequate venous drainage. We discuss three cases of complex pancreatic surgeries performed for carcinoma of the pancreas at a tertiary care center in India, wherein the stomach was salvaged by reimplanting the veins in two patients and preserving the only draining collateral in one case after the gastric venous drainage was compromised. The perioperative and postoperative course in these patients and the complications were analyzed. None of these 3 patients developed any complication related to gastric venous congestion, and additional gastrectomy was avoided in all these patients. Re-establishment of the Gastric venous outflow after extensive pancreatic resections helps to avoid additional gastric resection secondary to venous congestive changes.

DIEP Flap for Head and Neck Reconstruction: An Underutilized Option!

Background  The deep inferior epigastric artery perforator (DIEP) flap is a workhorse flap for breast reconstruction. Its use for head and neck (HN) reconstruction is rare. Abdomen provides a donor site abundant in skin and subcutaneous tissue, amenable to primary closure; sizeable, robust, and consistent perforators and a long, sizeable pedicle for comfortable microvascular anastomosis. Its offers all the donor variables needed for HN reconstruction in abundance. Methods  It is a quasiexperimental design study. DIEP flap use for HN reconstruction in our series was opportunistic, that is, when donor site matched the defect. Cases that had very thick thighs and lesser bulk in abdomen and cases that had very thin thighs but much more bulk in abdomen were considered for reconstruction using DIEP flap. Results  The DIEP flap was done in 11 cases for HN reconstruction. There were two re-explorations during postoperative period: one flap loss and another had partial necrosis. Conclusion  Abdomen is an excellent donor site option for HN reconstruction in selected cases, especially when harvested as a perforator flap.

Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap

BACKGROUND

 Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect.

METHODS

 A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups.

RESULTS

 A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129).

CONCLUSION

 The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

Tata Memorial Centre Evidence Based Management of Breast cancer

ABSTRACT

The incidence of breast cancer is increasing rapidly in urban India due to the changing lifestyle and exposure to risk factors. Diagnosis at an advanced stage and in younger women are the most concerning issues of breast cancer in India. Lack of awareness and social taboos related to cancer diagnosis make women feel hesitant to seek timely medical advice. As almost half of women develop breast cancer at an age younger than 50 years, breast cancer diagnosis poses a huge financial burden on the household and impacts the entire family. Moreover, inaccessibility, unaffordability, and high out-of-pocket expenditure make this situation grimmer. Women find it difficult to get quality cancer care closer to their homes and end up traveling long distances for seeking treatment. Significant differences in the cancer epidemiology compared to the west make the adoption of western breast cancer management guidelines challenging for Indian women. In this article, we intend to provide a comprehensive review of the management of breast cancer from diagnosis to treatment for both early and advanced stages from the perspective of low-middle-income countries. Starting with a brief introduction to epidemiology and guidelines for diagnostic modalities (imaging and pathology), treatment has been discussed for early breast cancer (EBC), locally advanced, and MBC. In-depth information on loco-regional and systemic therapy has been provided focusing on standard treatment protocols as well as scenarios where treatment can be de-escalated or escalated.

Delayed Partial Venous Insufficiency of Free Flap: To Intervene or Not?

Delayed venous congestion of a free flap poses a dilemma for clinicians, as the optimal management strategy is often uncertain. This case report presents a successful outcome achieved through a strategy of watchful waiting for a delayed presentation of a partially congested free flap. This approach enabled the avoidance of unnecessary surgical interventions and minimized potential complications associated with flap exploration. By adopting a watchful waiting strategy, clinicians can navigate the challenging decision-making process in cases of partial venous congestion of free flaps, optimizing patient outcomes.

Free Thoracodorsal Artery Perforator Flap for Head and Neck Reconstruction: An Indian Experience

Background  We describe our experience with use of free thoracodorsal artery perforator (TDAP) flap for head and neck (H&N) cancer reconstruction, with respect to the patient and disease profile, suitable defect characteristics, the reconstructive technique, and complications. Methods  Consecutive patients ( N  = 26) undergoing free TDAP flap for H&N onco-reconstruction, in a single center, were included from January 2015 to December 2018 and the data were analyzed. Results  Perforator(s) were reliably predicted preoperatively, using handheld Doppler. Lateral position was comfortable for the harvest. Twenty flaps were harvested on a single perforator, more commonly musculocutaneous ( n  = 16). The thoracodorsal nerve and latissimus dorsi muscle could be preserved, completely in almost all cases. The skin paddle was horizontally ( n  = 5) or vertically ( n  = 21) oriented, both giving a satisfactory scar. The flap was used as a single island or two islands by de-epithelializing intervening skin. Pedicle length was sufficient in all cases. Four cases were explored for suspected venous insufficiency. Two had thrombosis, of which one was salvaged, while the other necrosed. One flap had minimal partial necrosis, which was managed with secondary suturing. The 5-year follow-up showed good oral competence, mouth opening, and cosmetic satisfaction among patients. Conclusion  TDAP flap provides all the advantages of a perforator-based free flap and of back as a donor site with close color match to the face, relatively hairless, and thickness in between the thigh and the forearm. It can be a useful tool to provide an ideal functional and aesthetic outcome, with a hidden donor site and minimal donor site morbidity in selected cases.

Safety of free fibula flap harvest in IIIA and IIIB tibio-peroneal trunk variations

INTRODUCTION

In head and neck cancer malignancies, free fibula flap is the gold standard for reconstruction of segmental bone defects owing to its predictable anatomy, long bone length, and feasibility for multiple osteotomies. However, sometimes because of variations in anatomy of tibio-peroneal trunk, it is a dilemma for the surgeons to use free fibula flap for reconstruction. This case series aimed to evaluate the safety of harvest of fibula in such cases in terms of acute and chronic donor-site complications.

MATERIAL AND METHODS

A retrospective study was conducted from January 2018 to May 2021. All the patients with tibio-peroneal trunk anomaly, diagnosed during surgery, who underwent successful harvest of the free fibula were included in the study and analyzed for the early major and minor donor wound complications, long-term donor complications, and late functional deficit using the Foot and Ankle Disability Index (FADI).

RESULTS

Out of 714 free fibulae operated, 26 patients (3.6%) had such tibio-peroneal trunk variations: 22 (2.9%) cases of type III A and B anomalies and 4 (0.56%) cases of type III C anomalies. The average FADI score was 95.3%. No one had any difficulty in personal care and activity of daily living.

CONCLUSIONS

The free fibula flap can be safely harvested in patients with type III A and B anomalies if vascularity of foot after clamping of peroneal vessels is good and anterior tibial vessels are normal.

Comparison of Functional Outcomes of Intestinal Flaps Vs Tubed Fasciocutaneous Flaps for Circumferential Pharyngoesophageal Defects-an Indian Perspective

Pharyngolaryngoesophageal (PLO) reconstruction is a complex and technically demanding procedure. The reconstructive surgeon's concerns include avoiding fistula and stricture formation, as well as restoring normal speech and swallowing. A retrospective observational study with circumferential pharyngo-laryngo-oesophagal defects with aims and objectives of evaluation and comparison of the long-term functional outcomes like speech and swallowing along with the complications of fistula and stricture in two groups of JFF and FC flaps from the data is collected from electronic medical records of Tata Memorial Hospital, Mumbai, from January 2011 to May 2020. A total of 67 patients (52 JFF and 15 fasciocutaneous flaps) were operated on in last 9 years in our institute. The difference in fistula rates and stricture rates between the two groups was not significant (p= 0.98 and 0.947). The difference in 100% oral diet between the two groups was significant (p= 0.019). The difference in speech rehabilitation between the two groups was significant (p= 0.024). The intestinal tubes and fasciocutaneous tubes have comparable outcomes with regard to fistula and stricture formation. Speech outcomes in the form of the ability to have functional speech and voice quality were significantly better with skin-lined tubes. Swallowing outcomes were much better with intestinal tubes, along with early oral alimentation.

In-Situ ‘Divide’ and ‘Deliver’: A Simple Technique to Preserve Nerves in Chimeric Anterolateral Thigh Flap Harvest

Anterolateral thigh (ALT) flap is the workhorse for reconstruction in head and neck post cancer excision. Chimeric multi-paddle flaps are useful for composite defects involving skin, mucosa, and soft tissue. The nerve to vastus lateralis (VL) runs along the pedicle, frequently interdigitating with it or the perforators. Sometimes, the nerve may be preserved during harvest but needs to be sacrificed frequently, leading to increased donor site morbidity.

We recommend a simple technique to preserve the nerve, wherein the skin paddles or chimeric components are divided in-situ and manipulated around it without causing injury.

This technique was used in 27 cases over 5 years. All involved nerves, perforators and pedicles were preserved.

The technique can be extended to any flap harvest with multiple perforators with nerves in proximity, when multiple skin islands are desired.

Opportunistic use of naturally expanded neck skin for a buccal mucosa defect

A 77-year-old female presented with an ulceroproliferative lesion of the left buccal mucosa extending to the commissure, diagnosed with squamous cell carcinoma on biopsy. She also had a large thyroid swelling, with expanded skin, diagnosed with a multinodular goiter. The patient underwent buccal mucosa wide local excision with left-sided selective neck dissection and total thyroidectomy. The naturally expanded skin over the anterior neck overlying the goiter was used for the reconstruction of the buccal mucosa defect based on the perforator unexpectedly arising directly from the external carotid artery instead of superior thyroid artery. The venous drainage was to an internal jugular vein tributary, multiple dilated veins on the flap were draining into this vein. We describe the innovative use of locally expanded skin for buccal mucosa reconstruction and thereby avoiding the morbidity of a free flap transfer and associated donor site morbidity.

Utilizing the Retrograde Flow of Internal Mammary Vessels as a Donor Pedicle

Introduction  The aim of this study is to assess the results of retrograde flow of internal mammary artery and vein (IMA/V) as a donor vessel for free flap microvascular anastomosis (MVA). This need arises with bipedicle deep inferior epigastric perforator (DIEP) flaps, when all four zones with extra fat need to be harvested for unilateral breast reconstruction coupled with poor midline crossover of circulation naturally or because of midline scar. Large anterolateral thigh flaps for chest wall cover, with multiple perforators from separate pedicles, also need supercharging. This needs an additional source of donor vessels, antegrade IMA/V being the first one.

Materials and Methods  Retrospective study of microvascular breast reconstruction using retrograde internal mammary donor vessels.

Results  Out of 35 cases, 20 cases had distal IMA/V, with retrograde flow, as donor vessel for second set of arterial and venous anastomosis. In two cases, retrograde IMA/V was used for the solitary set of MVA. In remaining 13 cases, either retrograde IMA or V was utilized either as a principal or accessory donor. No flap was lost. Venous and arterial insufficiency happened in one case each, both were salvaged. Two cases developed partial necrosis, needing debridement and suturing. One case developed marginal necrosis. Only one case developed fat necrosis with superadded infection on follow-up.

Conclusion  Distal end of IMA and IMV on retrograde flow is safe for MVA as an additional or sole pedicle. It is convenient to use being in the same field. It enables preservation of other including thoracodorsal pedicle and latissimus dorsi flap for use in case of a complication or recurrence.

Microvascular Flap Reconstruction for Head and Neck Cancers in Previously Operated and/or Radiated Neck: Is It Safe?

BACKGROUND

Microvascular reconstruction after oncologic resection with curative intent in recurrent or second primary cancer cases is challenging not only because of the complexity of the defect but also due to difficulty in finding suitable donor vessels in the neck that has already been subjected to surgery and subsequent adjuvant treatment. In our present study, we evaluated the success of free flaps, reexplorations, and factors associated with reexploration and with flap failures in previously operated and/or radiated neck.

METHODS

In this retrospective study, we analyzed patients who underwent microvascular reconstruction from January 2016 to December 2018 in patients with previous surgery and/or radiation, considered as "already treated neck" (ATN). These cases were reviewed to analyze variables that included age, sex, indication for surgery (recurrence, second primary, osteoradionecrosis, and secondary reconstruction), duration since previous surgery or radiation, free flap done, donor vessels used, the need to go to the contralateral neck or outside the neck, need for vein grafts, flap reexploration rate, flap survival rate, and hospital stay of the patients. We also tried to identify factors that predisposed for a reexploration after performing reconstruction with a free flap in ATN.

RESULTS

Of 1522 free flaps done, 371 patients were included in the study. Flap success rate was 90.8% in ATN, which was comparable to naive neck (94%; P = 0.108). The reexploration rate in ATN (16.2%) was significantly higher (P = 0.0003) than in naive neck (9.8%). The previous treatment (neck dissection) received [P = 0.001; odds ratio, 13.7 (1.87-101.6)] was the most significant predisposing factor, and patients undergoing osteocutaneous flaps were more prone to undergo reexplorations (P = 0.05). Side of anastomosis, vessel used for anastomosis, comorbidities, and time since previous treatment did not affect the reexploration rate significantly.

CONCLUSIONS

Microvascular reconstruction can be safely performed in ATN with good success rates, and it should not be a deterrent in whom free flap is required to achieve best functional outcome. However, it may be associated with increase in reexploration rates in the postoperative period. Patients having undergone a previous neck dissection are at more risk of undergoing this reexploration in comparison with radiotherapy (RT)/chemotherapy and radiotherapy (CTRT) alone.

Reduction Mammoplasty Approach to Oncoplasty-Zone-Wise Planning in Indian Patients

Introduction This article is an attempt to formulate certain guidelines for planning of zone-wise reconstruction after breast conservation surgery. The planning involves applying reduction mammoplasty principles with certain modifications to address the defect.

Patients and Methods This is a retrospective study of 61 patients with breast cancer who underwent breast conservation surgery and reconstruction of partial breast defects with oncoplastic techniques between January 2014 to March 2019. Patients having low tumor to breast ratio and thus good candidates for volume displacement techniques were included in the study.

Results A total of 61 breast cancer cases were included; 22 cases were located in zone 1, nine in zone 2, seven in zone 3, three in zone 4, four in zone 5, one in zone 6, 12 in zone 7, two in zone 8, and three in zone 9. The most common pedicle design used was superomedial in 38 cases, followed by inferior in 19 and medial in 6 cases. Vertical short scar technique was used in 33 cases and Wise pattern skin incision in 30 cases. Follow-up period ranged from 4 months to 65 months, with a mean of 31 months. Four patients had partial skin necrosis, three had suture line dehiscence, two had wound infection, one had seroma, and eight patients had fat necrosis. All patients were satisfied with the cosmetic outcome.

Conclusion Breast oncoplastic techniques are effective, reliable, oncologically safe, and conducted with minimal complications in patients with moderately large ptotic breasts, thereby making planning easier and more reproducible by following the reconstruction procedures described in the article. We believe that these techniques should be incorporated in the armamentarium of every plastic surgeon to manage the defects created after breast conservation surgery, in order to achieve the best cosmetic outcomes.

Awareness and Acceptability of Breast Reconstruction Among Women With Breast Cancer: A Prospective Survey

PURPOSE

Quality of life has become an integral aspect of the management of breast cancer. Many women still need to undergo a modified radical mastectomy (MRM). Factors affecting the choice a woman makes to undergo breast reconstruction (BR) are unclear and are hypothesized to be influenced by socioeconomic factors. We conducted a survey to evaluate the awareness and acceptability of BR among women with breast cancer at our institution.

METHODS

A novel questionnaire was designed and served to 3 groups of women: planned for MRM, follow up (FU) post-MRM, and FU post breast-conserving surgery.

RESULTS

Responses were analyzed from 492 women. Of these, 280 (56.91%) were planned for MRM and 212 (43.08%) women were on FU. Almost 45% women were older than 50 years of age, and literacy rate was 87.6%. More than 70% were homemakers and 15 women (3%) were unmarried. The aspects evaluating awareness of BR suggested that 251 (51.01%) women had knowledge about BR. Major source of information was the surgeon (45.81%) and media (32.87%). About 80% women on FU post-MRM did not want reconstruction, and 55% did not opt for BR as they had coped with the mastectomy and did not feel the need for BR. Only 6% cited family or financial reasons and 10% cited recurrence concerns. Among women planned for surgery, 65.71% had not considered BR. When questioned, 25 (12.88%) felt influenced by cost, 102 (52.58%) felt they did not need it, and 20 (10.31%) were worried it would affect treatment.

CONCLUSION

Our study shows high awareness regarding BR, but only 27.89% women opt for BR independent of economic issues. We recommend all patients should be counseled about the reconstructive options when their MRM is planned.

Chimeric ALT Plus TFL Perforator Flap for Breast Reconstruction Post Radical Mastectomy with Large Skin Defect

A 17-year-old girl with large malignant phyllodes tumor of left breast underwent a radical mastectomy with large skin excision resulting in defect of 20 cm × 18 cm. Postoperative radiation therapy necessitated robust cover with flap. The challenge was compounded by her body habitus. Both abdomen and back were deficient as donor sites and a single-island anterolateral thigh (ALT) flap would need skin grafts, volume deficit withstanding. We harvested chimeric ALT plus tensor fascia lata (TFL) perforator free flap sparing all muscles and nerves. Microvascular anastomoses were done to the second internal mammary artery (IMA) perforator artery and vein. The donor site was closed primarily. The TFL flap territory recruited almost three times the volume of ALT territory and allowed us to create a matching breast mound in addition to covering the defect. She tolerated 40 Gy radiation well and doesn’t desire further augmentation. Consistency of ALT and TFL perforators makes this a replicable procedure.

Transposition flap for the oncoplastic reconstruction of outer quadrant breast defects

Plastic surgical principles are incorporated with breast conservation surgery (BCS) for cancer to improve aesthetic outcomes. In developing countries, average tumour size is larger at presentation resulting in larger resections often, including overlying skin. LD flap has been the workhorse of partial breast reconstruction. We present an easy and effective alternative to LD flap for carefully selected cases of outer quadrant breast tumours. We report 41 cases of local transposition flap from the lateral chest wall for oncoplastic restoration post BCS, performed between January 2016 and February 2020, at our institution. The median age was 49 years (28-63). Twenty-six patients underwent upfront surgery and 15 after neoadjuvant chemotherapy (NACT). The average pathological tumour size was 2.9 cm (median 2.7 and range 1.1-6) and 1.5 cm (median 1.8 and range 0-3.5) for upfront and post-NACT groups, respectively. The median volume of the resected specimen was 277.8 ml and 253.2 ml for upfront and post-NACT groups, respectively. Three patients (7.5%) had a microscopic positive margin requiring margin revision. Three (7.5%) patients had post-operative minor wound complications and were managed conservatively. At a median follow-up of 14 months (1-36), only 2/19 (10.5%) patients had clinical fat necrosis. Local transposition flap from the lateral chest wall based on dermal and subdermal plexus, carefully designed in selected patients, can be used effectively for the reconstruction of outer quadrant breast defects. It is easy to learn, offers good cosmetic outcome, avoids the morbidity and time of LD flap and saves LD flap for future use.

Thoracodorsal Artery Perforator and Superior Epigastric Artery Perforator Flaps for Volume Replacement Oncoplastic Breast Surgery

Introduction  Breast conservation therapy (BCT) and oncoplastic breast surgery (OBS) are now established modalities of treatment for breast cancer, with proven oncological safety. Traditionally, latissimus dorsi (LD) flaps have been the one-stop solution workhorse when volume replacement is needed. We present our experience with thoracodorsal artery perforator (TDAP) and superior epigastric artery perforator (SEAP) flaps. These flaps allow the preservation of muscle structure and function.

Material and Methods  Data were collected prospectively of patients in whom pedicled perforator flaps after BCT were used. A handheld 8-MHz audio Doppler was used to locate the perforators. TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients. Skin paddle sizes ranged from 10 × 3 cm to 21 × 7 cm.

Results  TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients All flaps survived. No flap had partial necrosis or fat necrosis. All donor sites were closed primarily and healed uneventfully, and none had a seroma requiring aspiration.

Conclusion  TDAP flaps can be selectively employed when the LD muscle function needs to be preserved. SEAP flaps can also be employed as a rare option in case of lower inner quadrant defects. Pedicled perforator flaps are a useful and reliable option for volume replacement OBS in select patients for reconstructing partial mastectomy defects.

Free anteromedial thigh perforator flap: Complementing and completing the anterolateral thigh flap

OBJECTIVE

Theobjective of this study was to determine the indications, utility, advantages and surgical approach for the anteromedial thigh (AMT) flap.

MATERIALS AND METHODS

We reviewed the records of the patients in whom the AMT flap was used for head and neck reconstruction. We use an anterior approach to harvest the anterolateral thigh (ALT) flap with a non-committal straight line incision. This preserves both ALT and AMT flap territories intact, and further decision is based on the intraoperative anatomy of perforator and pedicle. The ALT flap was usually used as the first choice when available and suitable.

RESULTS

Free AMT skin flaps were harvested in 24 patients. All flaps were used for the head and neck reconstruction. Two flaps had marginal flap necrosis. One flap was lost due to venous thrombosis.

DISCUSSION

The thigh is an excellent donor site as it has large available skin territory, expendable lateral circumflex femoral artery system and low donorsite morbidity. The ALT flap is the most commonly used flap for reconstruction of soft-tissue defects. However, it is characterised by variable vascular pedicle and perforator anatomy. The AMT flap is an excellent alternative when the ALT flap is not available due to variable perforator anatomy, injury to perforator, when an intermediate thickness is needed between distal and proximal thigh or a chimeric flap is needed.

CONCLUSION

The AMT flap offers all the advantages of the ALT flap without increasing donor-site morbidity. The anterior non-committal approach keeps both the ALT and the AMT flap options viable.

Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap

Introduction:

Tracheoesophageal voice prosthesis is highly effective in providing speech after total laryngectomy. Although it is a safe method, in certain cases dilatation or leakage occurs around the prosthesis that needs closure of tracheoesophageal fistula. Both non-surgical and surgical methods for closure have been described. Surgical methods are used when non-surgical methods fail. We present the use of the sternocleidomastoid musculocutaneous (SCMMC) transposition flap for the closure of tracheoesophageal fistula.

Materials and Methods:

An incision is made at the mucocutaneous junction circumferentially around the tracheostoma. Tracheoesophageal space is dissected down to and beyond the fistula. The tracheoesophageal tract is divided. The oesophageal mucosa is closed with simple sutures. Then SCMMC transposition flap is raised and transposed to cover sutured oesophagus and the defect between the oesophagus and the trachea.

Results:

This study was done prospectively over a period of 1 year from June 2012 to May 2013. This technique was used in patients with pliable neck skin. In nine patients, this procedure was done (inferior based flap in nine cases) and it was successful in eight patients. In one case, there was dehiscence at the leading edge of flap with oesophageal dehiscence, which required a second procedure. In two cases, there was marginal necrosis of flap, which healed without any intervention. Nine patients in this series were post-radiation.

Conclusion:

This method of closure is simple and effective for patients with pliable neck skin, who require permanent closure of the tracheoesophageal fistula.

Clinical evaluation of a new art material: Nanoparticulated resin-modified glass ionomer cement

Context:

The success of atraumatic restorative treatment (ART) technique depends on the restorative material; hence, clinical studies with various materials are necessary.

Aim:

The aim of the present study was to clinically evaluate and compare the nanoionomer and high-viscosity glass ionomer using United States Public Health Services (USPHS) Modified Cvar/Ryge Criteria with ART approach.

Materials and Methods:

Two primary molars in 50 healthy children aged between 5 and 8 years were selected for the study. The teeth were treated with ART and divided into two groups. The group 1 teeth were restored with nanoionomer (Ketac Nano 100 3M ESPE) and group 2 with high-viscosity glass ionomer cement (HVGIC), (Fuji IX GC). Each restoration was evaluated using the USPHS Modified Cvar/Ryge Criteria at baseline and 6 months’ and 12 months’ time interval.

Statistical analysis used:

Chi-squared (χ²) test.

Results:

Nanoionomer was significantly better than HVGIC with respect to color match at baseline, 6 months, and 12 months (P<0.001). Nanoionomers were also significantly better than HVGIC in case of cavosurface marginal discoloration and marginal adaptation (P<0.001) at 6 months and 12 months. There was no significant difference between the two materials with respect to secondary caries at 6 months (P>0.05), but at 12 months, nanoionomer was statistically better than HVGIC (P<0.05). There was no statistical significant difference with respect to anatomical form and postoperative sensitivity (P>0.05).

Conclusion:

The results indicate that nanoionomer can be a successful alternative restorative material for use with ART technique.

Association of the gonadotrophin-regulated testicular RNA helicase gene polymorphism with human male infertility

Gonadotrophin-regulated testicular RNA helicase (GRTH) plays an important role in RNA functions including nuclear transcription, pre-mRNA splicing and it regulates the translation of specific genes required for the progression of spermatogenesis. In this study, we analysed the association of GRTH gene IVS6+55G/T and c.852C/T polymorphisms with human male infertility. The study showed c.852 T allele was associated with an increased risk of male infertility (OR: 3.16, P = 0.008), whereas IVS6+55G/T allele conferred no risk. In Indian population, this is the first report on association of GRTH gene SNP polymorphism and male infertility and it underscores the significance of GRTH genotypes in modulating the risk of male infertility.

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap - An alternative to free flap for suprastructure maxillectomy with external skin defect

Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.

Prevalence of systemic and local disturbances in infants during primary teeth eruption: a clinical study

AIM

The purpose of this study was to find the correlations between local and systemic manifestations during primary teeth eruption and the eruption of various groups of teeth.

MATERIALS AND METHODS

The infants selected for the study purpose were between 6 months to 3 years of age who had at least one erupting tooth. The study group consisted of 894 infants and other 550 infants served as a control group. Questionnaires were distributed to all parents and the data was collected. Chi square test was performed to analyse the information obtained between the two groups. There were 378 girls (42.2%) and 516 boys (57.7%) in the study group. The control group consisted of 195 girls (35.4%) and 355 boys (64.5%).

RESULTS

The most common finding was gingival irritation 821 (95.9%) and the least common symptom observed in the study was running nose 234 (27.3%). The presence of fever diarrhea was seen in 101 (11.7%) infants. In the control group, 92.1% of the infants did not show any clinical manifestations.

CONCLUSION

An association was found between primary teeth eruption and local and systemic manifestations. Most manifestations were found during eruption of the primary incisors.

Long-term phosphorus fertility in wastewater-irrigated cropland

Land treatment of municipal wastewater effluent is a proven method for augmenting freshwater resources and avoiding direct nutrient discharges to surface waters. We assessed changes in soil test phosphorus (P) of the Ap horizon of cropped fields continuously irrigated for 26 yr with secondary effluent from the Penn State University wastewater treatment plant. For annual P additions averaging 97 kg P ha(-1), Mehlich-3 P (M3P) response in the 0- to 20-cm surface soil (initially < 20 mg kg(-1)) was represented by two lines. For the first 12 yr of irrigation, soil test P increased, with 14.5 kg P ha(-1) needed to increase M3P by 1 mg P kg(-1). After the initial buildup, M3P maintained a quasi-steady-state value of approximately 110 mg kg(-1). Over time, the surface soil equilibrium P concentration at zero sorption increased markedly (from < 1 to 5.5 mg P L(-1)), and extractable aluminum (Al) decreased significantly (P < 0.001). Speciation modeling using Visual MINTEQ suggests complexation of Al by dissolved organic carbon at site pH conditions. Loss of Al from the surface layer lowered its P-sorbing capacity, causing added effluent-P to move into the subsoil. Results suggest that current management practices can continue for many years without exceeding the surface soil M3P environmental threshold (200 mg kg(-1)) used in state P-based nutrient policies.

Effect of Curcuma longa freeze dried rhizome powder with milk in STZ induced diabetic rats

This study deals with the effects of freeze dried rhizome powder of Curcuma longa (C. longa) dissolved in milk on normal as well as diabetic models. Diabetes of type II and type I was within 3 days of a single administration of doses of 45 and 65 mg kg(-1) of streptozotocin respectively. Various parameters such as blood glucose levels, triglycerides, total cholesterol, high density lipoprotein, very low density lipoprotein, low density lipoprotein, serum glutamic oxaloacetic transaminase, serum glutamic pyruvate transaminase, alkaline phosphatase, creatinine, hemoglobin, urine protein and urine sugar in addition to body weight were taken in to consideration and were analyzed after administration of variable doses of rhizome powder. The dose of 200 mg kg(-1) was identified as the most effective dose as it increased HDL, Hb and bw (P<0.05) with significant decrease in the levels of blood glucose, lipid profile and hepatoprotective enzymes (P<0.001).

Managing biosolids runoff phosphorus using buffer strips enhanced with drinking water treatment residuals

Vegetated buffers strips typically have limited ability to reduce delivery of dissolved phosphorus (DP) from agricultural fields to surface waters. A field study was conducted to evaluate the ability of buffer strips enhanced with drinking water treatment residuals (WTRs) to control runoff P losses from surface-applied biosolids characterized by high water-extractable P (4 g kg(-)(1)). Simulated rainfall (62.4 mm h(-1)) was applied to grassed plots (3 m x 10.7 m including a 2.67 m downslope buffer) surface-amended with biosolids at 102 kg P ha(-1) until 30 min of runoff was collected. With buffer strips top-dressed with WTR (20 Mg ha(-1)), runoff total P (TP = 2.5 mg L(-1)) and total DP (TDP = 1.9 mg L(-1)) were not statistically lower (alpha = 0.05) compared to plots with unamended grass buffers (TP = 2.7 mg L(-1); TDP = 2.6 mg L(-1)). Although the applied WTR had excess capacity (Langmuir P maxima of 25 g P kg(-1)) to sorb all runoff P, kinetic experiments suggest that sheet flow travel time across the buffers ( approximately 30 s) was insufficient for significant P reduction. Effective interception of dissolved P in runoff water by WTR-enhanced buffer strips requires rapid P sorption kinetics and hydrologic flow behavior ensuring sufficient runoff residence time and WTR contact in the buffer. Substantial phosphate-adsorbent contact opportunity may be more easily achieved by incorporating WTRs into P-enriched soils or blending WTRs with applied P sources.

Effects of exercise on heart rate, QT, QTc and QT/QS2 in the Romano-Ward inherited long QT syndrome

Patients with the Romano-Ward inherited long QT syndrome have an incompletely defined cardiac sympathetic system abnormality, and exhibit ventricular arrhythmias during exercise, fear and anxiety. Treadmill and bicycle exercise were used to modulate cardiac autonomic activity in 27 Romano-Ward subjects and 27 normal controls. The heart rate, and the QT, QTc and QT/QS2 (ratio of electrical to mechanical systole) intervals were compared. Subjects with long QT were compared with normals. Those with a long QT interval had the following results: similar resting heart rates; lower rates during moderate (151.6 vs 169.6 beats/min, p = 0.04) and maximal (155.9 vs 182.1 beats/min, p = less than 0.001) exercise; an abnormal QT cycle-length relationship, with failure of the QT to shorten normally with increasing heart rate; an increase in QTc versus a decrease in normals; supine rest QT/QS2 ratio of 1.12 vs 0.93, p = 0.001; and an exercise QT/QS2 that increased by 30%, from 1.12 at rest to 1.45, versus 15%, in normals, from 0.93 to 1.07, p = 0.001. The lower heart rates and excessively prolonged QT/QS2 ratios during exercise further support an abnormality of, or abnormal cardiac response to, sympathetic activity. A QT/QS2 greater than 1.0 at rest, an exercise QT/QS2 ratio greater than 1.17, and an increase in QTc during moderate exercise may be helpful diagnostic findings in patients with borderline long QTc intervals at rest.