The Benefits of the Supercharged Ileocolic Flap in Patients Who Underwent Total Esophagectomy and Gastrectomy

Background Patients who undergo total esophagectomy and gastrectomy present a challenging scenario for reconstructive surgeons. Several techniques have been described. However, the best choice is still a matter of debate. We aim to report our experience with the supercharged ileocolic flap, then to compare the long-term functional outcomes in cancer and caustic injury patients. We investigate the safest route of transposition and demonstrate the importance of supercharging the flap. Last, we perform a literature review to compare our results with the ones reported in the literature. Methods A total of 36 patients underwent the supercharged ileocolic flap procedure. The details reviewed included the type of defect, flap characteristic, route of transposition, complications, patient survival, and swallowing evaluation. Survival and long-term function preservation were considered as the main outcomes. A secondary end-point was the identification of the safest route of transposition. We extracted the pertinent literature on supercharged bowel flaps from 1995 to July 2020 Results All flaps survived; only two flaps were partially lost. Thirty-three percent of the cohort experienced postoperative complications; the most common was leakage of the cervical anastomosis (17%), followed by neck wound infection (8%). The 5-year dysphagia-free survival rate was 87% in corrosive injury patients and 78% in cancer patients. The mean time to be free from dysphagia after surgery was 25.12 ± 4.55 months for corrosive patients and 39.56 ± 9.45 months for cancer patients (p = 0.118). The safest route of transposition was retrosternal extra-mediastinal. From the literature review, the data from 11 studies were extracted. Conclusion The supercharged ileocolic flap is a robust option for total esophageal replacement when the stomach is not available and the retrosternal route is the safest for transposition. The functional outcomes are excellent, with acceptable morbidity and a good life expectancy, either in cancer and noncancer patients. Supercharging the flap is recommended.

Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support

ABSTRACT Introduction Military trauma registries can identify broad epidemiological trends from neck wounds but cannot reliably demonstrate temporal casualty from clinical interventions or differentiate penetrating neck injuries (PNI) from those that do not breach platysma. Materials and Methods All casualties presenting with a neck wound to a Role 3 Medical Treatment Facility in Afghanistan between January 1, 2016 and September 15, 2019 were retrospectively identified using the Emergency Room database. These were matched to records from the Operating Room database, and computed tomography (CT) scans reviewed to determine damage to the neck region. Results During this period, 78 casualties presented to the Emergency Room with a neck wound. Forty-one casualties underwent surgery for a neck wound, all of whom had a CT scan. Of these, 35/41 (85%) were deep to platysma (PNI). Casualties with PNI underwent neck exploration in 71% of casualties (25/35), with 8/25 (32%) having surgical exploration at Role 2 where CT is not present. Exploration was more likely in Zones 1 and 2 (8/10, 80% and 18/22, 82%, respectively) compared to Zone 3 (2/8, 25%). Conclusion Hemodynamically unstable patients in Zones 1 and 2 generally underwent surgery before CT, confirming that the low threshold for exploration in such patients remains. Only 25% (2/8) of Zone 3 PNI were explored, with the high negative predictive value of CT angiography providing confidence that it was capable of excluding major injury in the majority of cases. No deaths from PNI that survived to treatment at Role 3 were identified, lending evidence to the current management protocols being utilized in Afghanistan.

Prostatic epithelial cells and their high expressions of CKIP-1 affect the TGF-β1 expression levels which might reduce the scar formation in remodeling stage at prostatic urethral wounds after wound repair

Objective There are less scar formations in some wounds after wound repair. Our earlier study had shown that the amount of collagen fibers in canine prostatic urethra wound were less than in bladder neck wound after 2-μm laser resection of the prostate (TmLRP) and partial bladder neck mucosa at 4 weeks. The purpose of this study was to observe the amount of scar tissue and characterize the probable causes of “less scar healing” in prostatic urethra wound. Methods A total of 12 healthy adult male crossbred canines underwent resection of prostate and partial bladder neck mucosa using 2-μm laser. The prostatic urethra and bladder neck wound specimens were harvested at 3, 4, 8 and 12 weeks after operation, respectively. The histopathologic characteristics were observed by hematoxylin and eosin(HE)staining, and the expression of transforming growth factor-β1 (TGF-β1) and casein kinase-2 interacting protein-1 (CKIP-1) were examined by immunohistochemistry in prostatic urethra and bladder neck wound, respectively. Overexpressed CKIP-1 human prostate epithelial cells (BPH-1 cells) were established and the expression of TGF-β1 was detected by Western blotting. Furthermore, a non-contact co-culture system of BPH-1 cells and human fibroblast (HFF-1) cells was used to observe the effects of BPH-1 cell and their high CKIP-1 levels on the expression of TGF-β1 in HFF-1 in vitro. Results The histology showed that there were a large number of prostatic epithelium and a small amount of scar tissue in prostatic urethra wound, while no epithelial cells and more scar tissue in bladder neck wound at 4, 8 and 12 weeks after repair. There were a higher expression level of TGF-β1 in prostate epithelial cells and fibroblasts and a lower expression level of CKIP-1 in prostate epithelial cells at 3 weeks after surgery in prostatic urethral wound. Compared to week 3, the TGF-β1 expression decreased both in prostate epithelial cells and fibroblasts at 4, 8 and 12 weeks in prostatic urethral wound (p < 0.05 or p < 0.01). The CKIP-1 expression increased in prostate epithelial cells at 4, 8 and 12 weeks compared to 3 weeks in prostatic urethra wound (p < 0.01). A higher TGF-β1 expression level of fibroblasts was observed in bladder neck wound at 3 weeks. And there was no significant change in the expression of TGF-β1 of fibroblasts in 3, 4, 8 and 12 weeks after operation in bladder neck wound. Both the prostate urethra and bladder neck wound fibroblasts showed weak expression of CKIP-1 and there was no significant change in 3, 4, 8 and 12 weeks. The vitro experiments showed that the TGF-β1 expression in BPH-1 cells with CKIP-1 overexpression decreased 25% compared with control group (p < 0.05). Furthermore, the expression of TGF-β1 in HFF-1 cells of co-cultured group decreased by 20% compared with Control group (p < 0.05); the expression of TGF-β1 in HFF-1 cells of overexpression co-culture group were reduced by 15% compared with co-cultured group (p < 0.01). Conclusions A large number of prostate epithelial cells in prostatic urethra wound may be one of the causes of less formation of scar tissue after repair. The prostate epithelial cells might reduce expression level of TGF-β1 by raising CKIP-1 expression and inhibit expression of TGF-β1 in peripheral fibroblasts at remodeling stage to reduce the excessive proliferation of fibrous cells and the excessive scar formation.