PATIENT AND OBSERVER SCAR ASSESSMENT FOLLOWING BASAL CELL CARCINOMA SURGERY: MULTICENTER QUASI EXPERIMENTAL STUDY

Objective: To assess patient and observer reported scar quality after Basal cell carcinoma surgery of face using the Patient and Observer Scar Assessment Scale (POSAS). Study Design: Quasi experimental study. Place and Duration of Study: Dermatology Department, Tertiary Care Hospitals at Multan and Karachi and Plastic Surgery Department, Tertiary Care Hospital Multan, from Apr to Sep 2020. Methodology: Patients with basal cell carcinoma that full filled inclusion and exclusion criteria were enrolled by consecutive sampling technique at Dermatology and Plastic Surgery Department after informed consent. Surgical excision was followed by reconstruction of defect either by direct closure or by rotation or advancement flap. Surgical scar was assessed independently at 8 weeks by POSAS. Data was analyzed with SPSS-23. Results: A total of 27 patients were enrolled in study. There were 11 (37.9%) males and 16 (59.25%) females between ages of 45-70 years. Basal cell carcinoma was located on cheek in 15 (55.5%), nose in 9 (33.3%), temple 2 (7.4%) and forehead 1 (3.7%) cases. Direct closure was performed in 6 (22.2%), rotation flaps in 10 (40.7%), and advancement flaps in 11 (40.7%) cases. Mean score of observer opinion about surgical scar between different surgical techniques was not statistically significant (p=0.191). How-ever, mean score of patient opinion of scar between different surgical techniques was statistically significant (p=0.032). Conclusion: POSAS is a valid tool for scar evaluation by patient and observer-reported scar qualities after Basal cell carcinoma surgery.

V-shaped radial forearm free flap is a new way to reduce the morbidity of the donor area

Background. Radial forearm free flap is one of the most frequently used in the head and neck reconstruction. A significant disadvantage is the appearance of the donor site. We have developed and introduced into clinical practice a V-shaped fabrication skin of the flap, which allows direct closure of the donor site and reduces morbidity. Aim. To assess the possibility of direct closure of the donor site and to reduce the morbidity of the donor site when performing the V-shaped fabrication of the skin area of the flap. Materials and methods. During the period from 2014 to 2020, the radial free flap was used in 43 cases. In 15 (35%) cases, a V-shaped fabrication of the skin area was used during flap harvest, which made it possible to carry out a direct closure of the donor site. The length of the skin area stretched from the top of the wrist, not reaching 34 cm to the elbow bend and varied from 715 cm, on average 12 cm. The width of the flap was determined by the elasticity of the forearm skin, was maximum in the middle third and varied from 2 up to 4 cm, averaging 3.3 cm. If necessary, the upper and lower edges of the skin area can be sutured together, as well as the entire medial edge of the flap. This technique increases the flap width by almost 2 times. This arrangement was applied in 8 cases. Results. When comparing the results of using the two techniques, the following data were obtained: "V-shaped" fabrication of the skin was used mainly in women (11/15 73%) for reconstruction limited defects in the retromolar region (5/15), soft (4/15) or hard palate (6/15). Most of the patients had localized T1-T2 (10/15) stage. None of the patients had any problems with the healing of the donor area. An excellent aesthetic result was obtained in all patients. In the group of standard harvest, the predominance of males was noted (17/28). Defects had a varied localization, most patients was with relapses after chemo-radiation treatment (10/28) or primary locally advanced T3-T4 stage process (6/28) 16, with a localized T1-T2 stage (11/28) 11, in one case, delayed reconstruction was performed. In all cases, the plastic of the donor site was performed with a split skin autograft. Partial necrosis of the donor site flap was observed in 9 patients (32%), in 4 cases with exposure of the flexor muscle tendon. Conclusion. As a result of the comparative analysis of the two methods, we concluded that the use of V-shaped fabrication of the skin area of the radial forearm flap allows to obtain better aesthetic results of the donor site, however, the use of this technique leads to a significant reduction in the length of the vascular pedicle and a decrease in the width of the flap.

Symptomatic interdural cerebrospinal fluid collections after surgery for idiopathic spinal cord herniation: illustrative case

BACKGROUND Idiopathic spinal cord herniation (ISCH) is very rare. Some reports have described postoperative ventral cerebrospinal fluid (CSF) collections in patients with ISCH; however, such collections are asymptomatic in most patients, and there is no consensus regarding whether they are part of the natural history or a complication. OBSERVATIONS A 30-year-old man with ISCH underwent direct closure of a duplicated dura mater. Eight months postoperatively, he developed reworsening of right lower limb paresis and new severe right arm pain and paresis. Three-dimensional magnetic resonance imaging revealed ventral CSF collections, which the authors judged as the responsible lesions. The authors initially considered these collections to be present in the epidural space, extradurally compressing the dural sac and resulting in myelopathy. An epidural blood patch failed; however, a CSF drainage test resulted in dramatic improvement. The authors therefore determined that the CSF collections were located in the interdural space, not the epidural space. A lumboperitoneal (LP) shunt was performed to reduce the CSF pressure. The patient’s symptoms improved immediately postoperatively. He had developed no recurrence of symptoms 6 months after surgery. LESSONS Ventral interdural CSF collections after ISCH surgery can cause reworsening of myelopathy and may be cured by a LP shunt to control CSF pressure.

The Anesthesia & Anesthetists of the First Open Heart Surgery of Bangladesh

Although a few closed heart operations were performed in the late 1960s, well organized approach to open heart surgery began in Bangladesh only after establishment of Institute of Cardiovascular Diseases (ICVD) in 1978. A Japanese team of surgeons, anesthetists, nurses and technicians provided extensive support in capacity building of the local human resources. Ultimately the first open heart surgery of Bangladesh, the direct closure of Atrial Septal Defect of an 18 year old college student, was performed on 18th September 1981. It was great news of that time. People came to know about the success story of the ICVD director then Colonel M Abdul Malik, a renowned cardiologist cum team leader and the Bangladeshi surgeon duo Dr M Nabi Alam Khan and Dr S R Khan. But somehow the anesthetists, an important part of the team were out of focus and have been forgotten over time. Led by Prof Khalilur Rahman, the anesthetist team of the day included Dr Nurul Islam, Dr Abdul Hadi, Dr Delowar Hossain, Dr A Y F Ellahi Chowdhury and Dr Monir Hossain. This article is an attempt to remind their contribution and expressing respect and gratitude to the anesthetists of that pioneering team. Bangladesh Heart Journal 2021; 36(1) : 55-60

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

Background To compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs). Methods The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates. Results A total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001). Conclusions In the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

1291 COVID-19 And Skin Cancer Mohs Service: Are We on The Line?

Introduction Mohs surgery is a technique of surgical excision indicated for high-risk basal cell carcinomas involving contemporaneous histopathological assessment to ensure clear margins at the time of excision. Post-Mohs excision, patients should undergo reconstruction by plastic surgeons. Aim To explore the impact of the COVID-19 pandemic on a post-Mohs plastic surgery reconstructive service. Method A single-centre, retrospective analysis of patient undergoing post-Mohs reconstruction between March and September 2020 – including the first national lockdown period. This was compared with the same period in 2019. Key outcome measures included: Results In 2019, between March and September, 12 patients were referred for Mohs surgery and reconstruction versus 23 in 2020. In 2019, patients referred for Mohs waited a mean of 101 days between their clinic appointment and surgery, versus 97 days in 2020. No Mohs surgery was performed during the first lockdown and patients referred during this period waited a mean of 150 days for surgery versus 81 days in this period in 2019. The proportion of patient undergoing direct closure or full thickness skin grafting to post-Mohs defects increased by 20% while the number undergoing local flap reconstruction decreased by 12% in 2020 compared to 2019. Conclusions While overall waiting times improved in 2020, those patients referred during the lockdown experienced longer waits for Mohs surgery. The increased proportion of patients undergoing simpler reconstructive techniques in 2020 may reflect pressure on operating time due to the period of inactivity during the lockdown.

Early results of total endoscopic closure for atrial septal defect in children at Cardiovascular Center, E Hospital, Hanoi, Viet Nam

Introduction: Atrial Septal Defect is the most common congenital heart disease. Minimally invasive cardiac surgery is being perfomed routinely at several cardiovascular centers in Vietnam. At E Cardiovascular Center, from 2016 to 2019, we performed total endoscopic closure for atrial septal defect in children using 4 trocars. From 2020 to present, we have reduced the number of trocars to three. This report was to evaluate the effectiveness and early results of total endoscopic closure with 3 trocars for atrial septal defect in children. Method: Twelve children underwent ASD closure from 1/2020 to 5/2021, with mean age of 7.7 years old (range from 2.5 to 11); mean weight was 20.8 kilograms (range from 12 to 40). All the patients underwent the operation with peripheral cardiopulmonary bypass (CPB). Result: The mean peripheral circulation time was 70 minutes (range from 56 to100 minutes) on beating hearts. There were 8 cases with patch-closure and 4 cases with direct-closure. After operations, we reexamined by echocardiography, the atrial septal defects were closed completely with no residual shunt, the common femoral arteries at the cannula position were normal and no stenosis were present. Conclusion: Totally endoscopic closure for ASD on beating hearts with 3 trocars is save with a very good short-term results.

Chondroid Syringoma Involving the Sub-brow Area

Purpose: Chondroid syringoma of the skin is a rare subcutaneous tumor and localization in the eyelid and orbital region that has rarely been described. We report a case of chondroid syringoma that involved the sub-brow region and was accompanied by hair loss. Case summary: A 57-year-old women presented with a mass on the lateral side of the left sub-brow region which was observed 25 years earlier. The mass, which recurred 2 months after surgery at another hospital through a skin incision was accompanied by an itching sensation. The mass was not tender or ulcerated but was reddish with superficial blood vessels and had a smooth surface with hair loss at the site of the mass. The mass showed high signal intensity on a T2-weighted magnetic resonance image and a round echogenic nodule with an irregular hypoechoic portion was observed on ultrasonography. A full-thickness excision including the adjacent normal tissue of the sub-brow mass and direct closure were subsequently performed. The pathological diagnosis was chondroid syringoma which was revealed as numerous tubular structures with various lumens in a collagenous stroma. Mucinous and fibrous findings were also observed. No recurrence was detected during the first 2 years after surgery. Conclusions: Chondroid syringoma in the eyelid and sub-brow region is uncommon. Complete resection is required to differentiate it from a malignancy and reduce the possibility of recurrence. Incomplete resection or capsular rupture during removal of the tumor could induce recurrence or a malignant change in the tumor.

Long-term outcomes following surgical repair of coronary artery fistula in adults

Background and aim of the study: Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults. Methods: We retrospectively investigated 13 consecutive patients undergoing surgical repair of CAF in our institution between 2008 and 2019 (67.3±10.4 years old, 38% male). CAF types were coronary artery-pulmonary artery fistula (77%), coronary artery-coronary sinus fistula (15%), and both (8%). CAFs originated from the left coronary artery (38%), right coronary artery (8%), and bilateral coronary arteries (38%). Pulmonary and systemic flow (Qp/Qs) was measured in seven patients (54%), with a mean value of 1.52. Seven patients underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases. Results: All procedures were conducted under cardiopulmonary bypass. Surgical procedures were direct epicardial ligation of fistula (92%), direct closure of CAF through pulmonary artery incision (38%), direct closure of CAF through coronary sinus incision (8%), or patch closure of CAF through coronary artery incision (8%). Myocardial perfusion scintigraphy showed asymptomatic myocardial ischemia in the right coronary area after surgery in one patient. There were no deaths perioperatively or during follow-up (mean 66.6 months). There were no coronary or other CAF-related events. Conclusions: Several anatomical variations in CAF were observed which coexist with cardiac disease. Long-term outcomes following surgical repair were satisfactory, and the concurrent intervention of CAFs during surgery for comorbid cardiac disease is useful to prevent future complications related CAFs in adults.

Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? a retrospective case-control study

Background & aim: Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique. Materials and Methods: We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds. Results: From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace– group (p = 0.002). Conclusion: The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.