Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy

OBJECTIVE

To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice.

METHODS

We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications.

RESULTS

We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity.

CONCLUSION

Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study

BACKGROUND

Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps.

METHODS

Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes.

RESULTS

Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction.

CONCLUSIONS

Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: systematic review and a new case series

INTRODUCTION

There is currently no gold standard for the treatment of Stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ). The question remains whether osseous reconstruction can offer an additional gain in outcome given the theoretical risk of non-union at the resection margins and recurrence in the osseous free flap. The objective was to conduct a systematic review of articles describing outcomes of osseous microsurgical reconstruction in cases of BRONJ with a minimum follow-up of 12 months, and to present the long-term outcomes of a new case series of three patients.

MATERIAL AND METHODS

A multi-database QUORUM-based single-reviewer systematic review identified eight papers that fulfilled the selection criteria. There are only case series and case reports available (Level 4 of the Oxford Evidence-based medicine scale). A total of 31 patients were analysed including the cases described in this article.

CONCLUSION

The limited overall rate of non-union at the resection margins and the 6.5% recurrence rate of BRONJ in the transplant counters the theoretical objections and advocates for considering osseous free flap reconstruction in the treatment of refractory BRONJ Stage III lesions. However, additional data derived from larger case series or case-control studies are imperative to support this hypothesis.

[Reversed plantar metatarsal artery island flap for coverage of the plantar defects at the first and second toes]

OBJECTIVE

To investigate the clinical effect of reversed plantar metatarsal artery island flap in repairing the plantar soft tissue defects at the first and second toes.

METHODS

12 cases with plantar soft tissue defects at the first and second toes were repaired by reversed plantar metatarsal artery island flap which size ranged from 2 cm x 3 cm to 4 cm x 6 cm, including 5 cases at emergency, 5 cases with the donor site defects at great toes after free lateral pulp flap transfer, and 2 cases with the donor site defects at second toes after free medial pulp flap transfer.

RESULTS

All the reversed plantar metatarsal artery island flaps at the first and second toes survived uneventfully with desirable appearance and sensation over a 3-35 month follow-up. No complication happened at the donor sites.

CONCLUSIONS

It is an reliable method to adopt the reversed plantar metatarsal artery island flap for the plantar soft tissue defects at the first and second toes, with the advantages of stable blood vessels, high survival rate, good skin texture and few complications.