Adam C. Cohen

Cultured epithelial autografts for coverage of large burn wounds in eighty-eight patients: The Indiana university experience

Since 1990, the authors have used a new technique for coverage of large burns, which begins with early tangential excision and coverage with cadaver allograft (A), followed by placement of cultured epithelial autograft (CEA) onto an allodermis base (CEA/A). They present their 18-year experience (1990–present) using CEA in 88 patients (20 children and 68 adults) with age range of 6 months to 73 years. A review of prospectively collected data was conducted on adult and pediatric patients grafted with CEA at the Indiana University Medical Center for definitive wound coverage (TBSA 28–98%). These patients were followed up for 3 to 90 months. Complications, take rates, and outpatient follow-ups were noted. The mean final take rate of CEA/A was 72.7%, and the overall patient survival rate was 91% (80 of 88 patients). Complications were classified as early and late, they included: (early) blistering and shearing (31%), pruritis and itching (4.7%), (late) CEA loss (2 patients, 2.3%), and wound contractures (66%). Contracture releases were performed on 32 patients (36%); of which, 18 were children (56%). Cultured keratinocytes provide an excellent alternative or adjunct to conventional split-thickness skin grafting in treating large burn wounds. A dedicated team of physicians, nurses, and therapists well rehearsed in CEA care are vital for success in keratinocyte grafting. The final graft take of 72.7% with a 91% overall survival rate gives much optimism for continuing to use CEA in critically burned patients.

Coverage of large pediatric wounds with cultured epithelial autografts in congenital nevi and burns: Results and technique

The use of cultured epithelial autografts (CEA) for the treatment of large burn wounds has gained popularity in recent years. This technique may circumvent the restrictions of limited donor site availability and hasten permanent wound coverage for large TBSA burns. The availability of a large amount of skin from a small donor site with the promise of permanent wound coverage suggests its use in other conditions such as giant congenital nevi (GCN) as well. The risk of malignant transformation of GCN to melanoma although somewhat controversial is significant enough to warrant early excision in childhood. Cultured keratinocytes may provide one-stage coverage of these large wounds, lessening the number of surgeries and the inherent staging problems of tissue expansion or autografting. A retrospective single institution review of was done for 29 children (20 burns and 9 patients with GCN) who underwent coverage of their large surface area wounds with CEA over an 18-year period. Excellent take rates were noted; 76.4% for burn patients and 66% for patients with GCN. Several strategies in preoperative, perioperative, and postoperative care have been standardized and have helped improve outcome. The keys to success with the CEA technique have been aggressive control of wound sepsis, surgical technique, specific use of topical antimicrobials, dressings, and the standardization of nursing and physiotherapy care. Although the cost of CEA is high, the benefits to patient care make this technique an appealing choice for large wound coverage in the pediatric population.

Age at Diagnosis as a Relative Contraindication for Intervention in Facial Nonmelanoma Skin Cancer

Author Affiliations: Center for Colon and Rectal Surgery, Florida Hospital, Orlando (Lee, Monson); Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Dietz); Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York (Fleming); Department of Surgery, New York University Langone Medical Center, New York (Remzi); Department of Colorectal Surgery, Cleveland Clinic Florida, Weston (Wexner); Division of Research and Optimal Patient Care (Cancer), American College of Surgeons, Chicago, Illinois (Winchester).

Helmet Use and Injury Patterns in Motorcycle-Related Trauma.

Administrative, technical, or material support: Holcomb, Graham. Study supervision: Hawn. Conflict of Interest Disclosures: None reported. Funding/Support: This study is supported by a Department of Veterans Affairs Health Services Research and Development Grant (IIR 09-347). Dr Holcomb is supported by grant T32 HS013852-11 from the Agency for Healthcare Research and Quality. Dr Richman is supported by a Department of Veterans Affairs Career Development Award. Role of the Funder/Sponsor: The Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 3, 2015; Miami Beach, Florida. 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. 2. Iversen LH, Antonsen S, Laurberg S, Lautrup MD. Therapeutic delay reduces survival of rectal cancer but not of colonic cancer. Br J Surg. 2009;96(10):1183-1189. 3. Simunovic M, Rempel E, Thériault ME, et al. Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. Can J Surg. 2009;52(4):E79-E86. 4. Holcomb CN, Graham LA, Richman JS, Itani KM, Maddox TM, Hawn MT. The incremental risk of coronary stents on postoperative adverse events: a matched cohort study [published online April 17, 2015]. Ann Surg. doi:10.1097/SLA .0000000000001246. 5. Jackson GL, Melton LD, Abbott DH, et al. Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs. J Clin Oncol. 2010;28(19): 3176-3181. 6. Paulson EC, Fu X, Epstein AJ. Location and timing of care for colon cancer patients in the VA Health System. J Surg Res. 2013;183(2):639-644.

Tourniquet Use in Wide-Awake Carpal Tunnel Release

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Abstract 20. Tourniquet vs. Epinephrine in Wide-Awake Carpal Tunnel Release

PURPOSE: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use.

The Veterans Affairs Medical Center’s Contribution to Plastic Surgery Education

This population-based study evaluates the levels of case minimums met by plastic surgery residents in Veterans Affairs hospitals.

Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System

ASSOCIATION OF VA SURGEONS Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System Dupuytren contracture is a debilitating disease involving abnormal thickening of the palmar fascia, resulting in pits, nodules, and cords that lead to contracture of the digits. Prevalence in the veteran population is approximately 306 per 100 000 individuals.1 Surgic al management of Dupuytren contracture includes removal or release of the fascia via open fasciectomy, open fasciotomy, closed fasciotomy, and most recently, injectable collagenase. A doubleblind placebo-controlled trial published in 2010 showed a significantly greater mean increase in range of motion in the group that received collagenase (35.4°) than in the group that received placebo (7.6°) (P < .001); in addition, 50.7% of all joints treated with collagenase achieved a range of motion 0° to 5° of normal.2 With the US Food and Drug Administration approval of collagenase from Clostridium histolyticum in 2010, it was predicted that there would be increased use of collagenase, with an associated decrease in palmar fasciectomy and fasciotomy within the Veterans Affairs (VA) system.

Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures

ASSOCIATION OF VA SURGEONS Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures Nonmelanoma skin cancer (NMSC) is the most common type of skin cancer in the United States.1 The incidence of NMSC has nearly doubled in the past 20 years, creating a significant financial burden on health care systems.1 The current recommended surgical treatment of NMSC is complete reexcision of the biopsy scar with a several-millimeter margin. Studies2-4 have shown spontaneous clearance rates of 24% to 72% after biopsy and have tried to identify associated characteristics. Previous data from our institution suggest that the clinical appearance of a scar was associated with no cancer after surgical excision.5 The purpose of this study was to determine whether clearance of NMSC in excisional specimens can be predicted based on the appearance of a lesion after biopsy and on the demographic characteristics of the patient.