Hyperbaric oxygen treatment for mastectomy flap ischaemia: A case series of 50 breasts

INTRODUCTION

Hyperbaric oxygen treatment (HBOT) has been suggested as an effective intervention to limit necrosis of ischaemic skin flaps after mastectomy. The purpose of this study was to evaluate outcomes of HBOT in the largest series of patients to date with mastectomy flap ischaemia.

METHODS

A retrospective analysis was performed of 50 breasts requiring HBOT for mastectomy flap ischaemia. The severity of the ischaemia or necrosis was evaluated by four independent observers using the skin ischaemia necrosis (SKIN) score. Multivariate logistic regression analyses were used to assess associations between risk factors and re-operation.

RESULTS

HBOT was started a median of 3 days (range 1-23) after surgery and continued for a median of 12 sessions (range 6-22). The breast SKIN surface area scores (n = 175 observations by the independent observers) improved in 34% (of observations) and the depth scores deteriorated in 42% (both P < 0.01). Both the surface area and depth scores were associated with the need for re-operation: higher scores, reflecting more severe necrosis of the mastectomy flap, were associated with increased need for re-operation. Twenty-nine breasts (58%) recovered without additional operation. Pre-operative radiotherapy (OR 7.2, 95% CI 1.4-37.3) and postoperative infection (OR 15.4, 95% CI 2.6-89.7) were risk factors for re-operation in multivariate analyses.

CONCLUSIONS

In this case series, the surface area of the breast affected by ischaemia decreased during HBOT, and most breasts (58%) did not undergo an additional operation. A randomised control trial is needed to confirm or refute the possibility that HBOT improves outcome in patients with mastectomy flap ischaemia.

Robotic (super) microsurgery: Feasibility of a new master-slave platform in an in vivo animal model and future directions

Advanced microsurgical procedures are currently limited by human precision and manual dexterity. The potential of robotics in microsurgery is highlighted, including a general overview of applications of robotic assistance in microsurgery and its introduction in different surgical specialties. A new robotic platform especially designed for (super) microsurgery is presented. Results of an in vivo animal study underline its feasibility and encourage further development toward clinical studies. Future directions of robotic microsurgery are proposed.

Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: A multicentre study

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is the first choice for autologous breast reconstruction. The aim of this retrospective cohort study was to analyse the recipient- and donor-site complications and compare them between unilateral and bilateral DIEP flap breast reconstructions.

METHODS

Between January 2010 and December 2014, 530 DIEP flap reconstructions were performed in 426 consecutive patients in three Dutch hospitals. Major and minor complications were categorised into recipient- and donor-site complications. Post-operative flap re-explorations were recorded.

RESULTS

Of the total 530 DIEP flap reconstructions performed (322 unilateral, 104 bilateral), recipient-site complications were major in 9.8% and minor in 20.2%. The patients developed fat necrosis (unilateral 14.0% vs. bilateral 7.7%; OR 1.950; 95% CI 1.071-3.550; p = 0.027) and infection (unilateral 5.6% vs. bilateral 1.9%; OR 3.020; 95% CI 1.007-9.052; p = 0.039) at the recipient site significantly more frequently in the unilateral DIEP flap reconstructions. The donor-site complications were major in 0.9% and minor in 19.5% of the cases. Body mass index (BMI) was significantly associated with complications (donor site: OR 1.137; 95% CI 1.075-1.201; p < 0.001, recipient site: OR 1.073; 95% CI 1.009-1.142; p = 0.026). Flap re-explorations were performed in 5.7% (n = 30) of the cases. Total flap loss occurred in 3.0% (n = 16) of the cases.

CONCLUSIONS

Bilateral DIEP flap breast reconstructions can be performed with the same percentage of complications and re-explorations as unilateral reconstructions and even result in less fat necrosis and infection at the recipient site. Higher BMIs are significantly associated with recipient- and donor-site complications.

[A man with multiple erythematous and hyperpigmented papules]

A 25-year-old male patient developed multiple polycyclic papules after he had been involved in a bombardment in Syria and was hit by metal particles. We recognized the lesions as keloids, a fibroproliferative condition with abundant scar tissue. Our patient was treated with intralesional glucocorticoid injections and pressure therapy.

Effect of hepatic artery embolization on liver hypertrophy response in a rabbit liver VX2 tumor model

BACKGROUND

Portal vein embolization not only induces hypertrophy of the non-embolized liver, but also enhances tumor growth. The latter could be prevented by embolizing the hepatic arteries supplying the tumor-bearing liver segments. This study aimed to determine the effects of transcatheter arterial embolization (TAE) on tumor volume and liver regeneration in a rabbit VX2 tumor model.

METHODS

Twenty-three rabbits underwent subcapsular tumor implantation with a VX2 tumor. Two weeks after implantation, 18 rabbits were used for TAE experiments, 5 were for sham controls. Tumor response and liver regeneration response of the embolized cranial and non-embolized caudal liver lobes were assessed by CT volumetry, liver to body weight index, and the amount of proliferating hepatocytes.

RESULTS

All super-selective arterial tumor embolization procedures were performed successfully. Despite embolization, the tumor volume increased after an initial steady state. The tumor volume after embolization was smaller than that of the sham group, but this difference was not significant. Massive necrosis of the tumor, however, was seen after embolization, without damage of the surrounding liver parenchyma. There was a significant atrophy response of the tumor bearing cranial lobe after super-selective arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized, caudal lobe. This regeneration response was confirmed histologically by a significantly higher number of proliferating hepatocytes on the Ki-67 stained slides.

CONCLUSIONS

Super-selective, bland arterial coil embolization causes massive necrosis of the tumor, despite increase of volume on CT scan. Atrophy of the tumor bearing liver lobe is seen after arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized lobe, despite absence of histological damage of the tumor-surrounding liver parenchyma.

Physiological and biochemical basis of clinical liver function tests: a review

OBJECTIVE

To review the literature on the most clinically relevant and novel liver function tests used for the assessment of hepatic function before liver surgery.

BACKGROUND

Postoperative liver failure is the major cause of mortality and morbidity after partial liver resection and develops as a result of insufficient remnant liver function. Therefore, accurate preoperative assessment of the future remnant liver function is mandatory in the selection of candidates for safe partial liver resection.

METHODS

A MEDLINE search was performed using the key words "liver function tests," "functional studies in the liver," "compromised liver," "physiological basis," and "mechanistic background," with and without Boolean operators.

RESULTS

Passive liver function tests, including biochemical parameters and clinical grading systems, are not accurate enough in predicting outcome after liver surgery. Dynamic quantitative liver function tests, such as the indocyanine green test and galactose elimination capacity, are more accurate as they measure the elimination process of a substance that is cleared and/or metabolized almost exclusively by the liver. However, these tests only measure global liver function. Nuclear imaging techniques ((99m)Tc-galactosyl serum albumin scintigraphy and (99m)Tc-mebrofenin hepatobiliary scintigraphy) can measure both total and future remnant liver function and potentially identify patients at risk for postresectional liver failure.

CONCLUSIONS

Because of the complexity of liver function, one single test does not represent overall liver function. In addition to computed tomography volumetry, quantitative liver function tests should be used to determine whether a safe resection can be performed. Presently, (99m)Tc-mebrofenin hepatobiliary scintigraphy seems to be the most valuable quantitative liver function test, as it can measure multiple aspects of liver function in, specifically, the future remnant liver.

Intrahepatic left to right portoportal venous collateral vascular formation in patients undergoing right portal vein ligation

PURPOSE

We investigated intrahepatic vascular changes in patients undergoing right portal vein ligation (PVL) or portal vein embolization (PVE) in conjunction with the ensuing hypertrophic response and function of the left liver lobe.

METHODS

Between December 2008 and October 2011, 7 patients underwent right PVL and 14 patients PVE. Computed tomographic (CT) volumetry to assess future remnant liver (FRL) and functional hepatobiliary scintigraphy were performed in all patients before and 3 weeks after portal vein occlusion. In 18 patients an intraoperative portography was performed to assess perfusion through the occluded portal branches.

RESULTS

In all patients after initially successful PVL, reperfused portal veins were observed on CT scan 3 weeks after portal occlusion. This was confirmed in all cases during intraoperative portography. Intrahepatic portoportal collaterals were identified in all patients in the PVL group and in one patient in the PVE group. In all other PVE patients, complete occlusion of the embolized portal branches was observed on CT scan and on intraoperative portography. The median increase of FRL volume after PVE was 41.6 % (range 10-305 %), and after PVL was only 8.1 % (range 0-102 %) (p = 0.179). There were no differences in FRL function between both groups.

CONCLUSION

Preoperative PVE and PVL are both methods to induce hypertrophy of the FRL in anticipation of major liver resection. Compared to PVE, PVL seems less efficient in inducing hypertrophy of the nonoccluded left lobe. This could be caused by the formation of intrahepatic portoportal neocollateral vessels, through which the ligated portal branches are reperfused within 3 weeks.

Management of giant liver hemangiomas: an update

Liver hemangiomas are the most common benign liver tumors and are usually incidental findings. Liver hemangiomas are readily demonstrated by abdominal ultrasonography, computed tomography or magnetic resonance imaging. Giant liver hemangiomas are defined by a diameter larger than 5 cm. In patients with a giant liver hemangioma, observation is justified in the absence of symptoms. Surgical resection is indicated in patients with abdominal (mechanical) complaints or complications, or when diagnosis remains inconclusive. Enucleation is the preferred surgical method, according to existing literature and our own experience. Spontaneous or traumatic rupture of a giant hepatic hemangioma is rare, however, the mortality rate is high (36-39%). An uncommon complication of a giant hemangioma is disseminated intravascular coagulation (Kasabach-Merritt syndrome); intervention is then required. Herein, the authors provide a literature update of the current evidence concerning the management of giant hepatic hemangiomas. In addition, the authors assessed treatment strategies and outcomes in a series of patients with giant liver hemangiomas managed in our department.

Predictors of posthepatectomy ascites with or without previous portal vein embolization

AIM

To identify predictors of postoperative ascites after liver resection for patients with or without preoperative portal vein embolization (PVE).

METHODS

Patients undergoing PVE prior to hepatectomy (PVE group; n = 37) were compared with patients who underwent liver resection without PVE (n = 503). Ascites was defined as postoperative daily drainage of clear ascitic fluid exceeding 200 ml/day. Pre-, intra-, and postoperative variables were retrospectively analyzed using uni- and multivariate analyses.

RESULTS

Postoperative ascites was present in 13.5% (5/37) of patients who underwent PVE before hepatectomy, compared to 5.8% (29/503) in the group undergoing liver resection without PVE (p = 0.061). In all patients, cirrhosis (OR 54.505, p < 0.001), operation time (OR 1.004, p = 0.014), and the use of the Pringle maneuver (OR 2.336, p = 0.041) were independent risk predictors for ascites in multivariate analysis. In PVE patients, cirrhosis (OR 0.156, p < 0.001) was the only independent significant predictor of ascites after resection. In patients undergoing liver resection without PVE, independent risk factors with multivariate analysis were operation time (OR 1.005, = 0.001) and cirrhosis (OR 26.609, p < 0.001).

CONCLUSION

Operation time and the use of the Pringle maneuver were significant predictors of ascites after hepatectomy. Cirrhosis was a significant risk factor associated with postoperative ascites.

Staging laparoscopy in patients with hepatocellular carcinoma: is it useful?

BACKGROUND

Staging laparoscopy (SL) is not regularly performed for patients with hepatocellular carcinoma (HCC). It may change treatment strategy, preventing unnecessary open exploration. An additional advantage of SL is possible biopsy of the nontumorous liver to assess fibrosis/cirrhosis. This study aimed to determine whether SL for patients with HCC still is useful.

METHODS

Patients with HCC who underwent SL between January 1999 and December 2011 were analyzed. Their demographics, preoperative imaging studies, surgical findings, and histology were assessed.

RESULTS

The 56 patients (34 men and 22 women; mean age, 60 ± 14 years) in this study underwent SL for assessment of extensive disease or metastases. For two patients, SL was unsuccessful because of intraabdominal adhesions. For four patients (7.1 %), SL showed unresectability because of metastases (n = 1), tumor progression (n = 1), or severe cirrhosis in the contralateral lobe (n = 2). An additional five patients did not undergo laparotomy due to disease progression detected on imaging after SL. Exploratory laparotomy for the remaining 47 patients showed 6 (13 %) additional unresectable tumors due to advanced tumor (n = 5) or nodal metastases (n = 1). Consequently, the yield of SL was 7 % (95 % confidence interval (CI), 3-17 %), and the accuracy was 27 % (95 % CI, 11-52 %). A biopsy of the contralateral liver was performed for 45 patients who underwent SL, leading to changes in management for 4 patients (17 %) with cirrhosis.

CONCLUSIONS

The overall yield of SL for HCC was 7 %, and the accuracy was 27 %. When accurate imaging methods are available and additional percutaneous liver biopsy is implemented as a standard procedure in the preoperative workup of patients with HCC, the benefit of SL will become even less.

Accurate quantitation of Ki67-positive proliferating hepatocytes in rabbit liver by a multicolor immunohistochemical (IHC) approach analyzed with automated tissue and cell segmentation software

Determination of hepatocyte proliferation activity is hampered by the presence of Ki67-positive non-parenchymal cells. We validated a multicolor immunohistochemical (IHC) approach using multispectral tissue and cell segmentation software. Portal vein branches to the cranial liver lobes of 10 rabbits were embolized, leading to atrophy of the cranial lobes and hyperplasia of the caudal lobes. Slides from cranial and caudal lobes (n=20) were double-stained (CK8+18 and Ki67) and triple-stained (CK8+18, Ki67, and CD31). The Ki67 proliferation index was calculated using automated tissue and cell segmentation software and compared with manual counting by two independent observers. A substantial variation was seen in the number of Ki67-positive hepatocytes in the different specimens in both double and triple staining (range, 0-50). Correlation coefficients between manual counting and the digital analysis were 0.76 for observer 1 (p<0.001) and 0.78 for observer 2 (p<0.001) with double staining and R(2) = 0.91 for observer 1 and R(2) = 0.89 for observer 2, p<0.001 with triple staining. In conclusion, in rabbit, the hepatocellular proliferation index can be reliably determined using automated tissue and cell segmentation software in combination with IHC multiple staining. Our findings may be useful in clinical practice when Ki67 proliferation index yields prognostic significance.

Bile salts predict liver regeneration in rabbit model of portal vein embolization

BACKGROUND

Portal vein embolization (PVE) is employed to increase future remnant liver (FRL) volume through induction of hepatocellular regeneration in the nonembolized liver lobe. The regenerative response is commonly determined by CT volumetry after PVE. The aim of the study was to examine plasma bile salts and triglycerides in the prediction of the regenerative response following PVE.

METHODS

PVE of the cranial liver lobe was performed in 15 rabbits, divided into three groups: NaCl (control), gelatin sponge (short-term occlusion), and polyvinyl alcohol particles with coils (PVAc, long-term occlusion). In all rabbits CT volumetry and blood sampling were performed prior to PVE and on days 3 and 7. Plasma bile salts and triglycerides were correlated with volume increase of the nonembolized liver lobe.

RESULTS

After 3 and 7 d, respectively, FRL volume was increased in both embolized groups, with the largest hypertrophy response observed in the PVAc group. Plasma bile salt levels were increased after PVE, especially in the PVAc group at day 3 (P < 0.01 compared to gelatin sponge). Plasma bile salts at day 3 predicted FRL volume increase at day 7 showing a positive correlation of 0.811 (P < 0.001). Levels of triglycerides were not significantly altered in either of the PVE procedures.

CONCLUSIONS

Plasma bile salt levels early after PVE strongly correlated with the regenerative response in a rabbit model of PVE, showing more pronounced elevation with larger volume increase of the nonembolized lobe. Therefore, plasma bile salts, but not triglycerides, can be used in the prediction of the regenerative response after PVE.

Vascular occlusion or not during liver resection: the continuing story

BACKGROUND

Vascular occlusion can be applied during liver resection to reduce blood loss. Herein, we provide an update of the current evidence concerning vascular occlusion.

METHODS

A systematic literature search was conducted to review the effects of liver in- and outflow occlusion techniques during liver resection, focusing on blood loss and hepatic ischemia-reperfusion injury.

RESULTS

The Pringle maneuver (PM) is effective in controlling blood loss; however, there is no indication for routine vascular clamping during hepatic resection in uncomplicated patients. During complex resections and in patients with abnormal liver parenchyma, the intermittent PM is preferred over continuous clamping. Total hepatic vascular exclusion (THVE) is indicated only in resection of tumors involving the inferior caval vein or the caval hepatic junction. THVE can be applied with the preservation of caval vein flow. This mode of selective hepatic vascular exclusion results in less blood loss in combination with the PM.

CONCLUSION

If clamping is necessary during complex resections or in abnormal liver parenchyma, intermittent PM is advised. THVE or selective hepatic vascular exclusion may be considered in tumors involving the inferior caval vein or the caval hepatic junction. There is no evidence supporting the use of ischemic preconditioning, maintenance of a low central venous pressure or of pharmacological interventions during liver resection.

Posthepatectomy bile leakage: how to manage

BACKGROUND

Biliary leakage after liver resection continues to be reported. Management of bile leakage has changed in recent years, with nowadays non-surgical procedures as the preferred treatment.

METHODS

Biliary leakage and management were assessed in 381 patients who underwent liver resection between January 2005 and April 2011.

RESULTS

The overall rate of biliary leakage after liver resection was 5.0%, with a higher incidence in patients who had undergone concomitant hepaticojejunostomy (HJ; 13.6 vs. 3.2%). Hospital stay (p = 0.047), major resections (p = 0.018), operation time (p = 0.011), and relaparotomy (p = 0.002) were risk factors for postoperative bile leakage. Multivariate analysis identified relaparotomy as an independent factor (OR 4.216, p = 0.034). Bile leakage in patients without HJ (n = 10) was managed in 6 patients by percutaneous transhepatic biliary drainage (PTD), and in 3 patients by endoscopic drainage. One patient was treated surgically. All patients with an HJ and postoperative bile leakage (n = 9) underwent PTD.

CONCLUSION

The incidence of posthepatectomy biliary leakage has decreased over time, while PTD and endoscopic stenting are effective treatment modalities. PTD is the treatment of choice in bile leakage after resection combined with HJ.

Open versus laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a systematic review and meta-analysis focusing on major complications

Background

There is an ongoing debate about whether laparoscopic pyloromyotomy (LP) or open pyloromyotomy (OP) is the best option for treating hypertrophic pyloric stenosis (HPS). The aim of this study was to compare the results of both surgical strategies by means of a systematic review and meta-analysis of the available literature.

Methods

A systematic search for randomized clinical trials (RCTs) comparing OP and LP was conducted. Studies were reviewed independently for quality, inclusion and exclusion criteria, and outcomes. Primary outcome was major postoperative complications (i.e., incomplete pyloromyotomy, perforation, and need for reoperation). Secondary outcomes were time to full feed, postoperative hospital stay, and any other postoperative complications.

Results

Four RCTs with a total of 502 patients (OP 255, LP 247) fulfilled the inclusion criteria and were analyzed in this review. These trials showed an absolute incidence of major postoperative complications of 4.9% in the LP group. Meta-analysis showed that LP did not lead to significantly more major postoperative complications (ARR 3%, 95% CI −3 to 8%) than OP. The mean difference in time to full feed was significant (2.27 h, 95% CI −4.26 to −0.29 h) and the mean difference in postoperative hospital stay tended to be shorter (2.41 h, 95% CI −6.10 to 1.28 h), both in favor of LP.

Conclusion

So far, the major postoperative complication rate after LP for HPS is not substantially higher than after OP. Because time to full feed and postoperative hospital stay are at best a few hours shorter after LP than after OP, the laparoscopic technique might be acknowledged as the standard of care if the major postoperative complication rate is low. Hence, this laparoscopic procedure should preferably be performed in centers with pediatric surgeons with expertise in this procedure.

[Giant haemangioma of the liver: diagnosis and treatment]

A liver haemangioma is a benign, usually small tumour comprised of blood vessels, which is often discovered coincidentally; giant haemangiomas are defined as haemangiomas larger than 5 cm. The differential diagnosis includes other hypervascular tumours, such as hepatocellular adenoma, hepatocellular carcinoma, metastasis of a neuro-endocrine tumour or renal cell carcinoma.- The diagnosis is based on abdominal ultrasonography and can be confirmed by a CT or MR scan. A wait-and-see approach is justified in patients without symptoms or with minimal symptoms, even in the presence of a giant haemangioma. Surgical resection of a giant haemangioma is only necessary when the preoperative diagnosis is inconclusive, or when the haemangioma leads to mechanical symptoms or complications. Extirpation is the only effective form of treatment of the giant haemangioma; enucleation is preferred over partial liver resection. A known complication of a giant haemangioma is the occurrence of disseminated intravascular coagulation, the Kasabach-Merritt syndrome; intervention is then demanded.

The Malone antegrade continence enema procedure: the Amsterdam experience

BACKGROUND

The Malone antegrade continence enema (MACE) procedure has been previously described as a safe and effective option for the treatment of children with chronic defecation disorders when maximal medical therapy and conventional treatment have failed.

PURPOSE

To evaluate clinical success, complications, and quality of life of children with chronic defecation disorders with a MACE stoma.

METHODS

A retrospective analysis of 23 patients who underwent the construction of a MACE stoma was performed. Preoperative and postoperative data were evaluated. A specific questionnaire was used to assess patient satisfaction.

RESULTS

A significant increase was found in defecation frequency (1.0 [range, 0-4] pretreatment vs 5.5 [range, 0-28] posttreatment per week; P < .006) and a significant decrease in fecal incontinence frequency (10 [range, 0-14] pretreatment vs 0 [range, 0-14] posttreatment per week; P < .034). Postoperative complications of the MACE procedure were fecal leakage (43%), wound infection (52%), and stomal stenosis (39%). A total of 86% of the patients were satisfied with the results of the Malone stoma (n = 21).

CONCLUSIONS

The MACE procedure is an effective treatment in children with intractable defecation disorders. Postoperative complications are, however, not uncommon. Further refinement of the technique focused to reduce the complication rate is necessary to expand the application of this approach.

Morbidity and quality of life after continent ileostomy in the Netherlands

BACKGROUND

Continent ileostomy (CI) after proctocolectomy is an alternative technique compared to an ileal pouch-anal anastomosis (IPAA). The question arises as to whether this technique is valuable. The aim of this study was to evaluate the role of the continent ileostomy, by patient follow-up satisfaction and quality of life assessment.

METHOD

Twenty-eight patients with a continent ileostomy operated between 1996 and 2007 were compared with patients who received an IPAA or a conventional ileostomy. SF-36 and EORTC QLC-CR38 questionnaires and a specific continent ileostomy questionnaire were used to assess differences and patient satisfaction.

RESULTS

The quality of life in patients with a CI is not significant better or worse than patients with either a conventional ileostomy or an IPAA. On three scales (sexual enjoyment, gastro-intestinal tract symptoms and male sexual problems) statistically significant differences were reported. Overall, nearly all patients are very satisfied with the CI. All patients would make the same decision again and would recommend this procedure to other patients.

CONCLUSION

The continent ileostomy remains to be a suitable alternative for the preservation of continence after a proctocolectomy, especially when an ileal pouch-anal anastomosis is not an option. If a choice has to be made between a CI and conventional ileostomy good preoperative counselling is necessary to make a well founded decision. To minimize complications, these procedures have to be performed in centres with specific expertise. Therefore, knowledge about the CI should be preserved for the future.