A Novel Technique for Radiographic Diagnosis of Sarcopenia that Accurately Predicts Postoperative Complications in Lower Extremity Free Flap Patients

Abstract Introduction Sarcopenia is linked to poor outcomes throughout the surgical literature and can be assessed on preoperative imaging to potentially aid in risk stratification. This study examined the effects of sarcopenia on surgical morbidity following lower extremity (LE) reconstruction, and also compared two methods of assessment, one of which is novel (“ellipse method”). Methods A retrospective cohort study of 50 patients receiving free flap-based reconstruction of the LE was performed. Bilateral psoas density and area were quantified at L4 through tracing (“traditional method”) and encircling (“ellipse method”) to calculate Hounsfield unit average calculation (HUAC). Logistic regression and receiving operator curve analysis for the primary outcome of any postoperative complication was used to determine HUAC cutoffs (≤ 20.7 vs. ≤ 20.6) for sarcopenia. Risk of complications associated with sarcopenia was evaluated using Fisher's exact tests. Results Twelve patients (24%) met criteria for sarcopenia via the traditional method and 16 (32%) via the ellipse method. By both methods, sarcopenic patients were older and more often female and diabetic. These patients also had higher American Society of Anesthesiologists scores and lower serum prealbumin levels. The ellipse method was found to be more accurate, sensitive, and specific than the traditional method in predicting postoperative morbidity (p = 0.009). Via the ellipse method, sarcopenic patients were at higher risk for any complication (p = 0.002) and were at a higher risk for a deep vein thrombus or pulmonary embolism via the traditional method (p = 0.047). Conclusion Sarcopenia is associated with greater pre- and postoperative morbidity in LE reconstruction. The novel ellipse method is a simplified and accurate method of assessing sarcopenia that can be easily performed in the clinical setting.

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Free Flap microvascular pharyngeal closure results in improved dysphagia-specific quality of life following total laryngectomy

European Journal of Plastic Surgery ◽

10.1007/s00238-021-01893-3 ◽

2021 ◽

Author(s):

Eoin F. Cleere ◽

Sherif Mamdouh ◽

Emma Devoy-Flood ◽

Marie-Therese O’Callaghan ◽

Fiachra Martin ◽

...

Keyword(s):

Quality Of Life ◽

Free Flap ◽

Total Laryngectomy ◽

Postoperative Morbidity ◽

Surgical Morbidity ◽

Level Of Evidence ◽

Md Anderson ◽

Anderson Dysphagia Inventory ◽

Inpatient Length Of Stay

Abstract Background Total laryngectomy (TL) as either a primary or salvage treatment strategy remains an effective oncologic operation in the management of laryngeal cancer. Dysphagia is the most common complication following TL and this has a significant impact on patients’ quality of life (QOL). Following removal of the larynx, a number of pharyngeal closure techniques exist. We aimed to evaluate the effect pharyngeal closure techniques have on dysphagia-specific QOL postoperatively. Methods We retrospectively reviewed patients who had undergone TL at our institution (2014–2019). Patients alive at the time of study were invited to complete the MD Anderson Dysphagia Inventory (MDADI). Outcomes were compared among Primary Closure (PC), Pedicled Pectoralis Major Myocutaneous Flap (PMMF) and Free Flap (FF) closure groups. Results There were 27 patients identified for inclusion. Eight patients (30%) underwent PC, 10 patients (37%) had PMMF-assisted closure and 9 patients (33%) underwent FF-assisted closure. Patients within the FF group scored consistently higher MDADI scores across all subscales (emotional, functional, physical, global) as well as composite MDADI score in comparison to the PC and PMMF groups. FF closure was associated with a reduced inpatient length of stay (LOS). Additionally, no significant differences in postoperative morbidity including rates of pharyngo-cutaneous fistula (PCF) were observed between groups. Conclusions We now advocate FF closure for our patients following salvage TL due to the improved dysphagia-specific QOL, reduced inpatient LOS and lack of additional surgical morbidity. Level of evidence, Level III, therapeutic/prognostic study.

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Use of soleus musculocutaneous perforator‐based propeller flap for lower extremity wound coverage after osteocutaneous fibula free flap harvest

Microsurgery ◽

10.1002/micr.30692 ◽

2020 ◽

Author(s):

Arshad Kaleem ◽

Neel Patel ◽

Enrique Schubert ◽

Ramzey Tursun

Keyword(s):

Lower Extremity ◽

Free Flap ◽

Wound Coverage ◽

Propeller Flap ◽

Fibula Free Flap ◽

Lower Extremity Wound

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Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery

Surgical Innovation ◽

10.1177/1553350621991223 ◽

2021 ◽

pp. 155335062199122

Author(s):

Daniel Heise ◽

Jan Bednarsch ◽

Andreas Kroh ◽

Sandra Schipper ◽

Roman Eickhoff ◽

...

Keyword(s):

Liver Resection ◽

Liver Surgery ◽

Postoperative Morbidity ◽

Operative Time ◽

Multivariable Analysis ◽

Operation Time ◽

Laparoscopic Liver Surgery ◽

Surgical Morbidity ◽

Perioperative Morbidity ◽

Preoperative Albumin

Background. Laparoscopic liver resection (LLR) has emerged as a considerable alternative to conventional liver surgery. However, the increasing complexity of liver resection raises the incidence of postoperative complications. The aim of this study was to identify risk factors for postoperative morbidity in a monocentric cohort of patients undergoing LLR. Methods. All consecutive patients who underwent LLR between 2015 and 2019 at our institution were analyzed for associations between complications with demographics and clinical and operative characteristics by multivariable logistic regression analyses. Results. Our cohort comprised 156 patients who underwent LLR with a mean age of 60.0 ± 14.4 years. General complications and major perioperative morbidity were observed in 19.9% and 9.6% of the patients, respectively. Multivariable analysis identified age>65 years (HR = 2.56; P = .028) and operation time>180 minutes (HR = 4.44; P = .001) as significant predictors of general complications (Clavien ≥1), while albumin<4.3 g/dl (HR = 3.66; P = .033) and also operative time (HR = 23.72; P = .003) were identified as predictors of major postoperative morbidity (Clavien ≥3). Conclusion. Surgical morbidity is based on patient- (age and preoperative albumin) and procedure-related (operative time) characteristics. Careful patient selection is key to improve postoperative outcomes after LLR.

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Outcome Analysis of End-to-End and End-to-Side Anastomoses in 131 Patients Undergoing Microsurgical Free Flap Reconstruction of the Lower Extremity

Journal of Reconstructive Microsurgery Open ◽

10.1055/s-0036-1593815 ◽

2016 ◽

Vol 02 (01) ◽

pp. e7-e14

Author(s):

Sören Könneker ◽

G.F. Broelsch ◽

J.W. Kuhbier ◽

T. Framke ◽

N. Neubert ◽

...

Keyword(s):

Lower Extremity ◽

Free Flap ◽

Statistical Significance ◽

Group Versus ◽

Outcome Analysis ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Flap Survival ◽

Anastomotic Technique ◽

End To End

Background End-to-end and end-to-side anastomoses remain the most common techniques in microsurgical free flap reconstruction. Still, there is an ongoing effort to optimize established techniques and develop novel techniques. Numerous comparative studies have investigated flow dynamics and patency rates of microvascular anastomoses and their impact on flap survival. In contrast, few studies have investigated whether the type of anastomosis influences the outcome of microvascular free flap reconstruction of a lower extremity. Patients and Methods Retrospectively, we investigated the outcome of 131 consecutive free flaps for lower extremity reconstruction related to the anastomotic technique. Results No statistical significance between arterial or venous anastomoses were found regarding the anastomotic techniques (p = 0.5470). However, evaluated separately by vessel type, a trend toward statistical significance for anastomotic technique was observed in the arterial (p = 0.0690) and venous (p = 0.1700) vessels. No thromboses were found in arterial end-to-end anastomoses and venous end-to-side anastomoses. More venous (n = 18) than arterial thromboses (n = 9) occurred in primary anastomoses undergoing microsurgical free flap reconstruction (p = 0.0098). Flap survival rate was 97.37% in the end-to-end arterial group versus 86.36% in the end-to-side group. No thromboses were found in five arterial anastomoses using T-patch technique. Conclusion For lower extremities, there is a connate higher risk for venous thrombosis in anastomotic regions compared with arterial thrombosis. We observed divergent rates for thromboses between end-to-end and end-to-side anastomoses.However, if thrombotic events are explained by anastomotic technique and vessel type, the latter carries more importance.

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Myogenic dedifferentiation is associated with poor outcomes in retroperitoneal dedifferentiated liposarcomas

Rare Tumors ◽

10.1177/2036361320986655 ◽

2021 ◽

Vol 13 ◽

pp. 203636132098665

Author(s):

Garcia-Ortega Dorian Yarih ◽

Caro-Sánchez Claudia HS ◽

Alvarez-Cano Alethia ◽

Alvarez-Bojorquez Mario ◽

Melgarejo-Estefan Emmanuel ◽

...

Keyword(s):

Malignant Tumors ◽

Myogenic Differentiation ◽

Smooth Muscle Actin ◽

Locally Advanced ◽

Distant Recurrence ◽

Differentiation Markers ◽

Surgical Morbidity ◽

Mesenchymal Differentiation ◽

Heterogenous Group ◽

Poor Outcomes

Sarcomas are a heterogenous group of malignant tumors with origin or mesenchymal differentiation, they comprise 1–2% of all solid tumors. Retroperitoneum is the second most frequent site affected. Prognosis is worse compared to the limbs, with a 5y OS of 36–58%, and 50–60% patients will relapse. Dedifferentiated liposarcomas (ddLPS) are more aggressive, it is known that presence of a de-differentiated component increases the probability of distant recurrence and lowers OS. There is little information about the specific impact of each type of de-differentiation. To determine if the presence of myogenic differentiation markers in DDLPS is an adverse prognostic factor. A retrospective, observational, analytic cohort study was performed. Cases identified from the electronic clinical files from the National Cancer Institute in Mexico City, we included cases from January 1st 2005 to December 31st 2016. We correlated the presence of expression of myogenic markers (Smooth muscle actin, Calponin, H-caldesmon, Desmin and Myogenin) in the dedifferentiated component of DDLPS with overall survival and surgical outcomes. One hundred and forty-three cases were analyzed. Eighty-two were liposarcomas, and 38 had a dedifferentiated component. Of these 38 cases, 21(55.3%) were males and, 17(44.7%) were females. Median age was 54.1(27–79) years, median tumor size was 28 cm (13–56). Most patients had locally advanced disease: 32(84.2%) were in stage IIIB. 2.6% had metastatic disease and 5(13.2%) had stage Ib at diagnosis. Myogenic marker expression was found in 18.4% of cases; these patients had a worse median survival than cases with no myogenic expression: 18 months (95% CI 15.4–20.5) vs 32 months (95% CI 21.8–42.1) p = 0.01, we also found a relation with higher postoperative morbidity in these cases ( p = 0.045). The presence of myogenic differentiation markers might be associated with a worse prognosis, in our series it corelated with worse OS, however it is not a common event. Relation with surgical morbidity is to be analyzed in further studies.

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Creation of aNovel Preoperative Imaging Review Acronym to Aid in Revision Endoscopic Sinus Surgery

Otolaryngology ◽

10.1177/01945998211053530 ◽

2021 ◽

pp. 019459982110535

Author(s):

Omar A. Karadaghy ◽

Andrew M. Peterson ◽

Meha Fox ◽

Jacob White ◽

Vidur Bhalla ◽

...

Keyword(s):

Full Text ◽

Endoscopic Sinus Surgery ◽

Sinus Surgery ◽

Preoperative Imaging ◽

Cochrane Central Register ◽

Surgical Morbidity ◽

Screening Criteria ◽

Ovid Medline ◽

Full Text Review ◽

Meta Analyses

Objectives (1) Identify anatomic contributions to chronic rhinosinusitis (CRS) necessitating revision endoscopic sinus surgery (RESS). (2) Create a clinical acronym to guide imaging review prior to RESS that addresses pertinent sites of disease and potential sites of surgical morbidity. Data Sources Ovid MEDLINE, Embase and Medline via Embase.com , Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. Review Methods Systematic search was performed using a combination of standardized terms and keywords. Studies were included if they investigated anatomic contributions to persistent CRS requiring RESS or the relationship between anatomic landmarks and surgical morbidity. Identified studies were screened by title/abstract, followed by full-text review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were strictly followed. Results In total, 599 articles met screening criteria, 89 were eligible for full-text review, and 27 studies were included in the final review. The identified anatomic sites of interests are broad; the most frequently cited anatomic region was retained anterior ethmoid cells (22/27 studies), followed by posterior ethmoid cells (14/27 studies). Using the consolidated information, a clinical acronym, REVISIONS, was created: Residual uncinate, Ethmoid cells (agger, Haller, supraorbital), Vessels (anterior and posterior ethmoid), Infundibulum, Septal deviation, I (eye) compartment, Onodi cell, Natural os, and Skull base slope and integrity. Conclusions The REVISIONS acronym was developed as a tool to distill the unique anatomic contributions of primary endoscopic sinus surgery failure into a format that can be easily incorporated in preoperative radiologic review and surgical planning to optimize outcomes and minimize complications.

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Long-Term Outcome after Successful Lower Extremity Free Flap Salvage

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1675146 ◽

2018 ◽

Vol 35 (04) ◽

pp. 263-269 ◽

Cited By ~ 5

Author(s):

Amir Bigdeli ◽

Emre Gazyakan ◽

Volker Schmidt ◽

Christoph Bauer ◽

Günter Germann ◽

...

Keyword(s):

Lower Extremity ◽

Free Flap ◽

Free Flaps ◽

Term Outcome ◽

Long Term Outcome ◽

Component Score ◽

Sf 36 ◽

The Mean

Background Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage. Methods A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed. Results The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7. Conclusion Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

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Improvised perioperative techniques to meet the challenges of microvascular free flap surgery

Journal of Society of Anesthesiologists of Nepal ◽

10.3126/jsan.v3i2.15626 ◽

2016 ◽

Vol 3 (2) ◽

pp. 99-100

Author(s):

Soumi Pathak ◽

Itee Chowdhury ◽

Ajay Kumar Bhargava

Keyword(s):

Free Flap ◽

Neck Region ◽

Flap Surgery ◽

Surgical Morbidity ◽

Head And Neck Region ◽

Form And Function ◽

Free Flap Surgery ◽

And Function ◽

Microvascular Free Flap

Deformities of the head and neck region after radical oncosurgery can have devastating effects on the appearance of the patient with significant impact on patients quality of life. Reconstruction of such defects continues to be an extremely demanding challenge for plastic surgeons who aim to restore form and function with minimal surgical morbidity. The purpose of this communications is to highlight the various interventions and the protocols that are adopted to decrease the free flap failure rate.

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