Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds

2021 ◽  
Author(s):  
David J. Cinats ◽  
Brian J. Harley ◽  
Jon B. Loftus
Keyword(s):  
Free Flap ◽  
Treatment Protocol ◽  
Wound Dehiscence ◽  
Free Flaps ◽  
Contralateral Side ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Cervical Region ◽  
Flap Loss ◽  
Wound Size

Abstract Introduction Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6–20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2–4). Mean wound size was 189 cm2 with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.

Abstract 15737: Passive Range of Motion Exercise to Enhance Growth in Infants Following the Norwood Procedure: A Pilot Study

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Linda M Lambert ◽  
Nicholas Dagincourt ◽  
Victoria Pemberton ◽  
Felicia L Trachtenberg ◽  
Shelley Andreas ◽  
...  
Keyword(s):  
Range Of Motion ◽  
Physical Therapist ◽  
Vital Signs ◽  
Exercise Program ◽  
Somatic Growth ◽  
Wound Dehiscence ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Z Score ◽  
Norwood Operation

Background: Growth impairment is common in infants with single ventricle (SV) physiology, especially after the Norwood operation. Passive range of motion (ROM) exercise increases somatic growth in preterm infants without adverse effects but has not been studied in infants with SV. Objective: To evaluate the safety and feasibility of a passive ROM exercise program in infants with SV physiology. Methods: Passive ROM exercise was administered to all extremities daily according to a standardized protocol, by a trained physical therapist, during post-Norwood hospitalization for up to 21 days or until discharge. Vital signs were measured pre-, intra- and post-procedure and height and weight were measured at baseline, 14 and 21 days, and 3 months of age or at the time of their pre-Glenn visit. Feasibility was determined by percent of days that medium (50-75%) or high (>75%) completion of the ROM exercise was performed. Adverse events (AE) were collected up to 3 months of age or pre-Glenn visit; all were adjudicated by the medical monitor. Results: Of 20 infants enrolled at 3 institutions, 70% were male. Parents voluntarily withdrew 1 subject on day 3. Median age at enrollment was 8 days (5-23), with the first ROM exercise started on a median post op day 4 (2-12). Median hospital length of stay following surgery was 15 days (9-131), allowing for an average of 13.4 in-hospital days/patient (3-21) for attempted ROM exercise. High completion of the exercise protocol across all subjects was achieved on 88% of eligible days and medium completion was achieved on an additional 2% of the days. Of 11 AE’s reported in 6 subjects; all were expected and one was determined to be possibly related to the study intervention (midsternal wound dehiscence). There were no clinically significant changes in vital signs. At 3 months, weight for age z-score (-0.84 ±1.2) and length for age z-score (-0.83 ±1.31) were higher than previous reports in SV populations. Conclusion: A passive ROM exercise program is safe and feasible in infants with SV physiology and may improve growth following Norwood operation. Larger studies are required to explore the optimal duration of passive ROM exercise and its effect on growth.

scholarly journals Flap Viability after Direct Immediate Application of Negative Pressure Wound Therapy on Free Flaps: A Systematic Review and Pooled Analysis of Reported Outcomes

2019 ◽  
Vol 04 (02) ◽  
pp. e77-e82
Author(s):  
Jude L. Opoku-Agyeman ◽  
David V. Matera ◽  
Jamee E. Simone ◽  
Amir B. Behnam
Keyword(s):  
Systematic Review ◽  
Free Flap ◽  
Negative Pressure ◽  
Negative Pressure Wound Therapy ◽  
Free Flaps ◽  
Pooled Analysis ◽  
Cochrane Library ◽  
Wound Therapy ◽  
Flap Failure ◽  
Flap Loss

Abstract Background The use of negative pressure wound therapy (NPWT) devices has gained wide acceptance in the management of wounds. There have been a few reported cases of its use immediately after free tissue transfer. This is the first systematic review and pooled analysis on the immediate use of NPWT for free flaps with emphasis on the rate of free flap loss. Methods The authors performed a systematic review that focused on the rate of total free flap loss after immediate application of NPWT. EMBASE, Cochrane Library, Ovid Medicine, MEDLINE, Google Scholar, and PubMed databases were searched from 1997 to April of 2019. Peer-reviewed articles published in the English language were included. Results Ten articles were included in the review, yielding 211 free flap procedures. All studies were retrospective cohort studies except for two that were prospective studies and one that was a case series. The overall complete flap failure rate was n = 7 (3.3%). The most commonly reconstructed area was the lower extremity (n = 158 [74.9%]) followed by head and neck (n = 42 [19.9%]) and upper extremity (n = 11 [5.2%]). The vacuum pressure ranged from 75 to 125 mm/Hg. The time of application of the NPWT ranged from 5 to 7 days. The etiologies of wound defects were from trauma (n = 82 [63.6%]), tumor extirpation (n = 43 [33.3%]), and infection and burn (n = 4 [3.1%]). Conclusion The immediate application of NPWT on free flaps does not seem to be associated with an increased risk of flap failure.

Early Suspicion of Heparin-Induced Thrombocytopenia for Successful Free Flap Salvage: Reports of Two Cases

2020 ◽  
Author(s):  
Turan Mehdizade ◽  
Osman Kelahmetoglu ◽  
Volkan Gurkan ◽  
Güven Çetin ◽  
Ethem Guneren
Keyword(s):  
Early Diagnosis ◽  
Effective Treatment ◽  
Free Flap ◽  
Free Flaps ◽  
Platelet Factor 4 ◽  
Platelet Factor ◽  
Heparin Induced Thrombocytopenia ◽  
Flap Failure ◽  
Flap Loss ◽  
Heparin Treatment

AbstractHeparin-induced thrombocytopenia (HIT) is an underestimated complication of heparin treatment. Flap loss and related morbidity (even mortality) are caused by occlusion of the capillary vessels by a highly immunogenic complex formed by adherence of antiheparin antibodies to platelet factor 4. Early suspicion and effective treatment of HIT developing in two free flaps are described. We report on the management of two patients with HIT. Both patients were treated successfully by early suspicion and hematology consultation. Heparin products were discontinued; the patients were switched to a nonheparin anticoagulant. We emphasize the importance of early diagnosis, hematologist assessment, and a change to a nonheparin anticoagulant to prevent flap failure and possibly the catastrophic consequences of such failure.

scholarly journals Microvascular free flap for head and neck reconstruction: our experiences with 218 free flaps for head and neck reconstructions

2021 ◽  
Vol 7 (12) ◽  
pp. 1868
Author(s):  
N. Brian Shunyu ◽  
Suvamoy Chakraborty ◽  
Lomtu Ronrang ◽  
Zareen Lynrah ◽  
Hanifa Aktar ◽  
...  
Keyword(s):  
Survival Rate ◽  
Head And Neck ◽  
Free Flap ◽  
Free Flaps ◽  
Radical Resection ◽  
Complete Loss ◽  
Head And Neck Reconstruction ◽  
Flap Survival ◽  
Flap Loss ◽  
Microvascular Free Flap

<p class="abstract"><strong>Background:</strong> Defect following radical resection for advance head and neck cancers are complex and without doubt microvascular free flap offer the best reconstructive option. The purpose of this study is to investigate the flap survival rate and review each vascular compromised flaps.</p><p class="abstract"><strong>Methods:</strong> This is a reviewed of 218 microvascular free flaps done for reconstruction of 204 head and neck patients. There were 112 (51.3%) radial forearm flaps (RFF), 82 (37.6%) fibula flaps (FF) and 24 (11%) anterior lateral thigh (ALT) flaps.  </p><p class="abstract"><strong>Results:</strong> There were 16 complete flap loss and 3 partial flap loss, giving an overall flap survival rate 91.8% (19/218) and flap survival in turn of complete loss 92.7% (16/218). In RFF, there were 7 complete and 1 partial flap loss, giving an overall flap survival rate 92.9% (8/112) and flap survival in turn of complete loss 93.8% (7/112). In FF, there were 6 complete flap loss, giving a flap survival rate 92.7% (6/82). In ALT flap, there were 3 complete and 2 partial flaps loss, giving an overall flap survival rate 79.2% (5/24) and flap survival in turn of flap complete loss 87.5% (3/24). In our series vascular flaps complications rate was 12.3% (27/218), with a salvageable rate of 29.6% (8/27). The most salvageable flap was RFF 46.6% (7/15).</p><p><strong>Conclusions:</strong> The study re-enforce the learning curve in microvascular free flap and RFF is a good flap for a beginner. </p>

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

2021 ◽  
Author(s):  
Emre Gazyakan ◽  
Lingyun Xiong ◽  
Jiaming Sun ◽  
Ulrich Kneser ◽  
Christoph Hirche
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Matched Pair ◽  
Complication Rates ◽  
Matched Pair Analysis ◽  
Flap Loss ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Pair Analysis

Abstract Objective Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. Patients and Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.

scholarly journals Introduction of severe traumatic brain injury care protocol is associated with reduction in mortality for pediatric patients: a case study of Children’s Healthcare of Atlanta’s neurotrauma program

2018 ◽  
Vol 22 (2) ◽  
pp. 165-172 ◽  
Author(s):  
Andrew Reisner ◽  
Joshua J. Chern ◽  
Karen Walson ◽  
Natalie Tillman ◽  
Toni Petrillo-Albarano ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Treatment Guidelines ◽  
Guideline Implementation ◽  
Treatment Protocol ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Care Protocol ◽  
Severe Tbi ◽  
The Impact

OBJECTIVEEvidence shows mixed efficacy of applying guidelines for the treatment of traumatic brain injury (TBI) in children. A multidisciplinary team at a children’s health system standardized intensive care unit–based TBI care using guidelines and best practices. The authors sought to investigate the impact of guideline implementation on outcomes.METHODSA multidisciplinary group developed a TBI care protocol based on published TBI treatment guidelines and consensus, which was implemented in March 2011. The authors retrospectively compared preimplementation outcomes (May 2009 to March 2011) and postimplementation outcomes (April 2011 to March 2014) among patients < 18 years of age admitted with severe TBI (Glasgow Coma Scale score ≤ 8) and potential survivability who underwent intracranial pressure (ICP) monitoring. Measures included mortality, hospital length of stay (LOS), ventilator LOS, critical ICP elevation time (percentage or total time that ICP was > 40 mm Hg), and survivor functionality at discharge (measured by the WeeFIM score). Data were analyzed using Student t-tests.RESULTSA total of 71 and 121 patients were included pre- and postimplementation, respectively. Mortality (32% vs 19%; p < 0.001) and length of critical ICP elevation (> 20 mm Hg; 26.3% vs 15%; p = 0.001) decreased after protocol implementation. WeeFIM discharge scores were not statistically different (57.6 vs 58.9; p = 0.9). Hospital LOS (median 19.6 days; p = 0.68) and ventilator LOS (median 10 days; p = 0.24) were unchanged.CONCLUSIONSA multidisciplinary effort to develop, disseminate, and implement an evidence-based TBI treatment protocol at a children’s hospital was associated with improved outcomes, including survival and reduced time of ICP elevation. This type of ICP-based protocol can serve as a guide for other institutions looking to reduce practice disparity in the treatment of severe TBI.

Radial Forearm Free Flap Reconstruction of Glossectomy Defects Without Tracheostomy

2021 ◽  
pp. 000348942110382
Author(s):  
Tara J. Wu ◽  
Satvir Saggi ◽  
Karam W. Badran ◽  
Albert Y. Han ◽  
Jordan P. Sand ◽  
...  
Keyword(s):  
Neck Dissection ◽  
Free Flap ◽  
Hospital Length ◽  
Tongue Base ◽  
Hospital Length Of Stay ◽  
Radial Forearm Free Flap ◽  
Free Flap Reconstruction ◽  
Respiratory Complications ◽  
Average Hospital ◽  
Radial Forearm

Objectives: To assess the feasibility of radial forearm free flap (RFFF) reconstruction of glossectomy defects without tracheostomy tube (TT). Methods: Retrospective review of patients with at least oral tongue defects who underwent RFFF reconstruction. Pre- and intra-operative factors were documented. Post-operative respiratory complications included inability to extubate, pneumonia, or need for re-intubation or TT within 30 days. Results: Twenty-one patients underwent RFFF reconstruction without TT, and 36 patients with TT. The average hospital length of stay was 1.5 days shorter in those without TT ( P < .01). Two patients who underwent TT placement experienced a respiratory complication ( P = .27). There were no respiratory complications among those without TT. After multivariate analyses, large tongue base defect (>25% resection, P < .001) and bilateral neck dissection ( P < .001) were independently associated with TT placement. Conclusions: In our experience, RFFF reconstruction of glossectomy defects is feasible without TT among selected patients with small tongue base defects (≤25% resection) and unilateral neck dissection.

scholarly journals Clinical outcomes and survival analysis of Remdesivir as a treatment option for moderate to severe COVID-19 patients.

2021 ◽  
Author(s):  
Iman Aboelsaad ◽  
Rasha Ashmawy ◽  
Doaa Mahrous ◽  
Sandy Sharaf ◽  
Shahinda Aly ◽  
...  
Keyword(s):  
Survival Analysis ◽  
Treatment Protocol ◽  
Patient Characteristics ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
P Value ◽  
Composite Outcome ◽  
New Therapeutic Approaches ◽  
Significant Difference ◽  
The Difference

Abstract Background: Remdesivir is a broad-spectrum antiviral approved as promising medicine worldwide for deadly pandemic COVID-19 disease. The debate of its efficacy is interesting between different studies with consideration of several factors. We planned this study to evaluate a huge clinical outcome (primary composite outcome) of mortality rate, need for MV, and escalation of care among Remdesivir (RDV) and non-Remdesivir (NoRDV)groups.Methods: Patients with a PCR - confirmed diagnosis of moderate and severe COVID-19 were observed retrospectively as two comparative groups, before and after including remdesivir in the treatment protocol, from August 2020 to February 2021.Result: From 509 hospitalized patients; 35% received Remdesivir among them 64% were severe patients. Median age, 59 years, was equal in both groups, and there was no significant difference between the two groups regarding gender, baseline characteristics, and co-morbidities. Unlike, the median hospital length of stay was lower among the RDV group (8 days) than the NoRDV (9 days), P= 0.004.The composite outcome occurred in 17.7% in RDV and 22.2% in NoRDV but the difference was statistically insignificant (p-value 0.289). Adjusted logistic regression showed a non-significant lower association of the composite outcome with RDV use (OR 0.623, 95CI% 0.37-1.02), and a significant reduction occurred in patients <60 years old (OR 0.39, 95%CI 0.17 – 0.83). However, survival analysis for mortality, MV, and transfer to a higher level revealed insignificant differences in the median time between groups. Subgroup analyses showed that RDV utilization had a non-significant effect on the risk of all three outcomes across different groups. Conclusion: Despite controlling all patient characteristics, treatment with RDV did not show any improved impact on patient outcomes over other antivirals and standard care. There is a pressing need for further studies to explore and evaluate new therapeutic approaches or combinations.

scholarly journals Factors Predicting Total Free Flap Loss after Microsurgical Reconstruction Following the Radical Ablation of Head and Neck Cancers

2013 ◽  
Vol 2013 ◽  
pp. 1-5 ◽  
Author(s):  
Masaki Fujioka
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Radiation Treatment ◽  
Free Flaps ◽  
Head And Neck Reconstruction ◽  
Tumor Type ◽  
Flap Necrosis ◽  
Microsurgical Reconstruction ◽  
Flap Failure ◽  
Flap Loss

Background. With greater experience in microsurgical reconstruction, free tissue transfer has become common and reliable. However, total flap necrosis after microsurgical reconstruction is sometimes seen in patients who have undergone radical ablation of head and neck malignancies. We investigated factors predicting free flap loss in head and neck reconstruction. Methods. We reviewed the records of 111 free flap reconstructions carried out among 107 patients with head and neck cancer who required radical resection and microsurgical reconstruction in our unit from 2004 through 2010. Among these patients, 6 showed total flap necrosis postoperatively. We investigated the associations between primary or recurrent tumor, type of flaps, chemotherapy, and radiotherapy and flap loss. Results. Five of 20 (25.0%) patients who underwent radiotherapy developed flap necrosis: among the 91 patient who did not undergo radiotherapy, only one (1.1%) developed. Preoperative radiotherapy was statistically identified as the most important risk factor for postoperative flap failure. Conclusions. Patients receiving radiation treatment are more likely to develop total flap failure when they undergo reconstructive surgery with free flaps after tumor ablation, because the combination of endarteritis and chronic ischemia caused by radiation damaged endothelial membrane in the recipient vessels, consequently, thrombosis tends to develop.

Carotid endarterectomy following thrombolysis for acute ischaemic stroke

VASA ◽  
2017 ◽  
Vol 46 (2) ◽  
pp. 116-120 ◽  
Author(s):  
Naz Ahmed ◽  
Damian Kelleher ◽  
Manmohan Madan ◽  
Sarita Sochart ◽  
George A. Antoniou
Keyword(s):  
Ischaemic Stroke ◽  
Carotid Endarterectomy ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Wound Complications ◽  
Cardiac Complications ◽  
High Dependency ◽  
Low Incidence

Abstract. Background: Insufficient evidence exists to support the safety of carotid endarterectomy (CEA) following intravenous thrombolysis (IVT) for acute ischaemic stroke. Our study aimed to report a single-centre experience of patients treated over a five-year period. Patients and methods: Departmental computerised databases were interrogated to identify patients who suffered an ischaemic stroke and subsequently underwent thrombolysis followed by CEA. Mortality and stroke within 30 days of surgery were defined as the primary outcome end points. Results: Over a five-year period, 177 out of a total of 679 carotid endarterectomies (26 %) were performed in patients presenting with acute ischaemic stroke. Twenty-five patients (14 %) received IVT prior to CEA in the form of alteplase. Sixty percent of patients were male with a mean age of 68 years. Sixteen patients (64 %) underwent CEA within 14 days of IVT and the median interval between thrombolysis and CEA was 7.5 days (range, 3–50 days). One female patient died of a further intraoperative stroke within 30 days of surgery, yielding a mortality rate of 4 %. Two patients (8 %) suffered from cardiac complications postoperatively resulting in a short high dependency unit stay. Another two patients (8 %) developed local wound complications, which were managed conservatively without the need for re-operation. The median hospital length of stay was 4.5 days (range, 1–33 days). Conclusions: Our experience indicates that CEA post-thrombolysis has a low incidence of mortality. Further high quality evidence is required before CEA can be routinely recommended following IVT for acute ischaemic stroke.

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