Subcutaneous Vulvar Flap Viability Evaluation With Near-Infrared Probe and Indocyanine Green for Vulvar Cancer Reconstructive Surgery: A Feasible Technique

Introduction: Vulvar cancer is a rare condition affecting older women and accounts for 3–5% of all gynecological cancers. Primary surgical treatment involves the removal of a large amount of tissue for which reconstructive surgery is often necessary with a high rate of postoperative complications. Despite several techniques for the evaluation of vulvar flap viability have been proposed, many methods cannot be performed during surgery and require expensive devices often missing in a gynecological clinic. This study aims to verify the feasibility and the safety of the vulvar flap viability evaluation through a near-infrared endoscopic probe and Indocyanine green (ICG) tracer in a small group of patients and to evaluate long-term vulvar flap outcomes.Methods: Patients with primary vulvar cancer who required surgical treatment and subsequent vulvar flap reconstructive surgery were prospectively included in the study. A 25 mg ICG vial diluted in 20 ml of saline solution was intravenously infused before closing the skin edges of the flaps. All patients were given 0.2 mg/kg body weight of intravenous ICG. After 10–15 min, a near-infrared endoscopic probe was used to evaluate the vulvar flap viability.Results: Of the 18 patients who underwent radical vulvectomy for vulvar cancer during the study period, 15 were included in the analysis. All packaged surgical flaps showed tracer uptake on the surgical margin. No intro-operative complications were recorded neither surgery-related nor to dye infusion. No surgical infection, dehiscence, or necrosis was recorded.Conclusions: Vulvar flap viability assessment using Indocyanine green and a laparoscopic infrared probe is a feasible method. All cases included in the analysis showed a dye uptake on the surgical edge of the flap. Further, prospective studies are needed to confirm the method in clinical practice and to evaluate its superiority over simple subjective clinical evaluation.

Innovative Technique for the Closure of Rectovaginal Fistula Using Amplatzer™ Septal Occluder

Rectovaginal fistulas (RVF) result from an abnormal epithelial connection between the vagina and the rectum, allowing the intestinal contents to pass through the vagina.1 Patients may clinically present with vaginal faeces or gas discharge in addition to inflammation in the pelvic cavity, which may lead to severe infection and poor quality of life.2 RVF is seen in women who previously received treatment for a malignant disease in the pelvic region. The malignancies in the pelvic area are often treated with radiotherapy. This treatment results in tissue damage and poor healing.3 Management of postoperative RVF is difficult and the results are often unsatisfactory. Currently there is no widely accepted and standardized treatment for RVF.3, 4 In the treatment of RVF, various surgical flaps (endorectal or vaginal), vascular tissue flaps (Martius, gracilis), grafts or biomaterials have been used.3,5,6 This case shows the first results using the Amplatzer™ Septal Occluder for the closure of rectovaginal fistula.

552 Limb Salvage: Amputations Prevented with Dehydrated Human Amnion/Chorion Membrane Allografts (dHACM) Used in Combination with Decellularized Human Collagen Matrix (dHCM)

Introduction Burn and traumatic limb injuries with exposed bone/tendon typically require surgical flaps or amputations for healing. Some burn patients are not candidates for these invasive techniques. Placental amniotic membrane has been used as a wound dressing for more than 100 years and may offer an alternative to flaps and/or amputations. Processed dehydrated human amnion/chorion membrane (dHACM), from human placental tissue, contains type 1 human collagen as well as non-viable cells and 285 identified regulatory proteins including growth factors, chemokines, cytokines, metalloproteinases, and other tissue growth and inflammatory mediators. dHACM has been successfully used as a dressing for wound ulcers, burns, donor sites, & surgical debridement. This study reports the use of dHCAM as a limb salvage tool in four patients with severe injuries. Methods This is a retrospective case series of patients suffering severe lower extremity injury with bone/tendon exposure that had applied dHACM/dHCM over or packed (depending on wound depth), then covered with 3% bismuth tribromophenate petrolatum dressing & glycerol/ hydroxyethylcellulose lubricant. Negative pressure wound therapy (NPWT) was initiated; wound re-evaluation occurred in seven days. dHACM/dHCM was reapplied if required (bone still exposed). Results There were 3 males and 1 female with three burns and one NSTI. The mean±sd (median) age was 58±23 (61) years; % total burn surface area 3±3 (2); length of hospital stay 48±30 (40) days; number of tangential excisions & debridements 6.5±1 (6.5); days from admission to product application 49±47 (34) and discharge 24±19 (19) days; negative pressure wound therapy (NPWT) 53±6 (56) days. All four patients continued treatment upon discharge with clinic visits and home NPWT. All recovered with good results and no complications. Treatment may be continued with NPWT therapy at home or in a skilled nursing facility. Patients healed after two to three dHACM/dHCM applications and did not require leg or foot amputations. Conclusions In select limb salvage cases, dHACM/HCM may be a promising alternative to extremity amputations, tissue transfer flaps or other techniques for secondary intention healing of wounds with bone/tendon exposure.

Effect of periapical surgery on oral health-related quality of life in the first postoperative week using the Dutch version of Oral Health Impact Profile-14

Objective To evaluate whether periapical surgery affects oral health-related quality of life (OHRQoL) within the first postoperative week. Study design The primary outcomes in 133 patients (54 men, 79 women; mean age 50.8 years) undergoing periapical surgery were the Oral Health Impact Profile-14 (OHIP-14) score and postoperative sequelae, including pain, analgesic intake, swelling, limited mouth opening, chewing difficulties, and postoperative infection. Results We found a significant effect on OHIP-14, pain, and analgesics, which decreased throughout the week. We found no significant differences in mean OHIP-14, pain scores, or analgesic use for gender, medical history, surgical flaps, operation time, or location of the operated teeth. Younger patients had a higher OHIP-14 score in the first 2 days after surgery and more pain on the first postoperative day. Women experienced more pain during the first 3 days. Smokers had a higher OHIP-14 score on the first postoperative day and greater pain during the first 3 days compared to non-smokers. Conclusion We identified a low incidence of pain and reduced OHRQoL following periapical surgery. The postoperative reduction in OHRQoL and pain were of short duration, with maximum intensity in the early postoperative period and rapidly decreasing with time.

Reconstruction of a Mangled Hand with a Thoracodorsal Artery Perforator Free Flap: A Report of Two Cases

Mangled hands are a severely injured condition that is a rare and challenging problem for reconstructive surgeons. Surgical flaps such as anterolateral thigh, radial forearm, or thoracodorsal artery flaps have been used for multiple-digit resurfacing. In this report, we describe two cases of complex defects that included multiple digits in patients who underwent reconstruction with thoracodorsal artery perforator (TDAP) free flaps. All massive soft tissue defects were completely covered with a TDAP free flap. The thinner perforator flap could be harvested, and the patients regained the ability to pinch and grasp. Therefore, the authors present two cases of mangled hands successfully treated with TDAP free flap.

4511 Bio-Compatible Implantable Oxygen Sensor Technology with Real-Time Monitoring of Surgical Flaps and Reimplantation

OBJECTIVES/GOALS: Current surgical flap and replantation monitoring techniques have limitations in detecting the pathologic state, calibration and cost-to-patient issues. Our hypothesis is that novel implantable oxygen sensors can provide a more efficient, accurate, and reliable monitoring of tissue oxygenation. METHODS/STUDY POPULATION: Experimental sensors were used with an exogenous remote used as a reader once implanted (Fig. 1) A rat tissue perfusion model with three regions of an SIEA flap as well as into adjacent control sites was made (Tip, Middle, and Base) Blood flow was greatest at the base, diminishing towards the Tip, thus creating a perfusion gradient. Changes in tissue oxygen tension PO2 were estimated by the steady-state fluorescence of the optical sensors using an IVIS imaging system. The sensors were used to collect data from days 0, 3, and 7 as a reading of Tissue Oxygen Tension (TOT) with ANOVA used to assess for statistical significance in blood oxygen data with respect to relative perfusion status. RESULTS/ANTICIPATED RESULTS: Inspired FiO2 was decreased from 100% to 12% with a corresponding change in the TOT readings from all sensors. (Fig. 2) The tip portion of the flap demonstrated the most profound detection of tissue necrosis, with the middle demonstrating the second most necrosis and the base demonstrating the least with correlating TOT sensor readings. (Fig. 3) Acute vascular compromise of the feeding blood vessels in the pedicle was immediately detected within 70 seconds (*p<0.05). (Fig. 4) DISCUSSION/SIGNIFICANCE OF IMPACT: This study introduces and validates a recent technique to monitor acute vascular occlusion, flap viability, and necrosis in the immediate postoperative period in a validated rodent model. Future directions of this novel technology will aim to reproduce these findings in clinical feasibility studies.

Lymphangiosis Carcinomatosa in a Patient with Giant Cutaneous SCC: Cervicopectoral Advancement Flap in Combination with Tunnel Transposition Flap from the Back as Promising Treatment Approach?

BACKGROUND: One of the features characterising cutaneous SCC as high-risk is lymphovascular infiltration. The diffuse lymphangitic spread of carcinogenic cells is defined as the so-called lymphangitis carcinomatosa. In some cases, it is the only and first sign to alert the presence of an underlying malignancy. Therefore, biopsy in patients with clinical data on lymphangiosis carcinomatosa is of paramount importance. CASE REPORT: We present a 77-year-old man with a progressively growing tumour formation in the area of the right shoulder, clinically suspected for SCC. During the dermatological examination, it was found that the lesion was surrounded by an infiltrated, perilesional relief shaft, which was histologically verified as lymphangitis carcinomatosa. The tumour formation was removed by radical excision and formation of a large skin-subcutaneous defect. To correct the surgical defect, a cervico-pectoral flap was performed, followed by tunnel transposition of the scapular graft through the deltoid muscle. The preoperative, ultrasound-marked artery was the arteria circumflexa scapulae dextra, which was used as the foot of the scapular graft and at the same time ensuring its blood supply. After the performed surgical flaps there remains a small uncovered surgical defect, which was left for subsequent secondary healing or full thickness mesh graft. The subsequent histological examination of the removed tumour formation detected the presence of squamous cell carcinoma. CONCLUSION: Patients with the simultaneous presence of two different pathological cutaneous changes, located in the immediate proximity often require a multidisciplinary and complex treatment approach. For tumour formations close to the area of the neck, the cervical-pectoral flap provides optimal cosmetic recovery of the surgical defect. The tunnel transposition is an individualised, unconventional and difficult to implement the approach, which however showed a good therapeutic result. On the other hand, the preoperative histological examination of reddish peritumoral localised tentacles leads to 1) diagnosis of lymphangiosis carcinomatosa as well as 2) the subsequent precise determination of the limits of surgical excision, which is a large number of cases saves the need for secondary re-excision in these patients.

Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats

ABSTRACT Objective: to validate an experimental model for the measurement of glycemic levels in surgical flaps with the use of common glucometers, and to analyze the diagnostic criteria for hypoperfusion of such flaps. Methods: we performed vertical myocutaneous rectus abdominis flaps with upper pedicles bilaterally in 20 male Wistar rats, divided into two groups: with and without venous occlusion of the pedicle. We measured glucose levels in the flaps and in the systemic circulation with standard glucometers. We tested the accuracy of alternative diagnostic criteria for the detection of hypoperfusion. Results: from 15 minutes of venous occlusion on, there was a significant reduction in glucose levels measured in the congested flap (p<0.001). Using a minimum difference of 20mg/dl in the glycemic levels between the flap and systemic blood, 30 minutes after occlusion, as a diagnostic criterion, the sensitivity was 100% (95% CI 83.99-100%) and specificity of 90% (95% CI 69.90-97.21%) for the diagnosis of flap congestion. Conclusion: It is possible to measure glucose levels in vertical myocutaneous rectus abdominis flaps of Wistar rats, perfused or congested, using a common glucometer. The diagnostic criteria that compare the glucose levels in the flaps with the systemic ones were more accurate in the evaluation of tissue perfusion.