Andrej Banic

Dynamic study of the distribution of microcirculatory blood flow in multiple splanchnic organs in septic shock.

ObjectivesTo study dynamic distribution of microcirculatory blood flow in multiple splanchnic organs during septic shock; to test the hypothesis that changes in microcirculatory blood flow in splanchnic organs correlate with changes in regional flow during septic shock. DesignA prospective, controlled, animal study. SettingAnimal laboratory in a university medical center. SubjectsNine anesthetized and mechanically ventilated domestic pigs. InterventionsSystemic flow (cardiac output) was measured with thermodilution and regional (superior mesenteric artery) flow with transit time flowmetry. Local blood flow (microcirculatory flow) was continuously measured in splanchnic organs (gastric, jejunal, and colon mucosa, liver, and pancreas) and the kidney with multichannel laser Doppler flowmetry. Septic shock was induced with fecal peritonitis. After 240 mins of sepsis, intravenous fluids were administered to alter hypodynamic shock to hyperdynamic septic shock. Measurements and Main ResultsIn this severe septic shock model, systemic and regional flows decreased by ∼50% during the first 240 mins. Similar reductions were recorded in microcirculatory flow in the mucosa of the stomach (−41%;p < .001) and colon (−47%;p < .001). In the jejunal mucosa, on the other hand, flow remained virtually unchanged. Microcirculatory flow was also significantly decreased in the liver (−49%;p < .001), pancreas (−56%;p < .001), and kidney (−44%;p < .001). Administration of intravenous fluids at 240 mins was followed by three-fold increases in systemic and regional flows (∼70% above baseline). In the jejunal mucosa, flow also increased significantly above baseline (42%;p < .001), whereas in the stomach and the colon, it barely reached baseline. Kidney blood flow increased to baseline, whereas pancreas and liver flows remained 26% (p < .05) and 34% (p < .001), respectively, below baseline. ConclusionChanges in microcirculatory blood flow in the splanchnic organs are heterogeneous, both in early hypodynamic and in hyperdynamic septic shock, and cannot be predicted from changes in systemic or regional flows. Microcirculatory blood flow in the jejunal mucosa remains constant during early septic shock, whereas pancreatic blood flow decreases significantly more than regional flow.

Functional assessment of chest wall integrity after methylmethacrylate reconstruction

BACKGROUND All patients with extensive resection of the anterolateral chest wall and the sternum followed by reconstruction with methylmethacrylate substitutes were assessed prospectively 6 months after the operation to delineate chest wall integrity with pulmonary function and cine-magnetic resonance imaging. METHODS Twenty-six patients underwent chest wall reconstruction by use of methylmethacrylate between 1994 and 1998 due to primary tumors in 35%, metastases in 27%, T3 lung cancer in 19%, and debridement for radionecrosis and osteomyelitis in 19% of patients. Three to eight ribs were resected and additional sternum resection was performed in 39% of patients. RESULTS There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. Prosthesis dislocation occurred in 1 patient and infection in 2 patients during follow-up. Nineteen patients (73%) suffered no restrictions of daily activities. Clinical examination revealed normal shoulder girdle function in 77% of patients. There was no significant difference between preoperative and postoperative FEV1 (forced expiratory volume in 1 second) measurements in patients with lobectomy or wedge resections. Cinemagnetic resonance imaging revealed concordant chest wall movements during respiration in 92% of patients without paradoxical movements or implant dislocations being observed. CONCLUSIONS Large defects of the anterolateral chest wall and sternum can be reconstructed efficiently with methylmethacrylate substitutes with minimal morbidity and excellent cosmetic and functional outcome.

Descending necrotizing mediastinitis: surgical treatment via clamshell approach.

BACKGROUND Descending necrotizing mediastinitis requires an early and aggressive surgical approach to reduce the high morbidity and mortality associated with this disease. The clamshell incision has provided excellent exposure of the entire mediastinum and both pleural cavities and was assessed in patients suffering from descending necrotizing mediastinitis. METHODS Three patients with descending necrotizing mediastinitis and bilateral pleural empyema due to invasive streptococcal infections were operated on with this method. Radical debridement of the mediastinum and bilateral decortication was performed through a clamshell incision, including pericardiectomy in 2 patients. All patients received initially a high dose of antibiotic regimen, 2 had bilateral chest tube drainage, and 1 had mediastinal drainage and pleural debridement via cervical mediastinotomy and thoracoscopy, respectively. All these measures alone, however, failed to control the disease. RESULTS The clamshell incision offered an excellent exposure for bilateral decortication and debridement of the entire mediastinum including pericardiectomy. One patient, who was referred in critically ill condition, died of multiorgan failure in the postoperative period. The remaining 2 patients recovered without further interventions and without evidence of phrenic nerve palsy, sternum osteomyelitis, or sternal override. CONCLUSIONS The clamshell approach offers an excellent exposure for a complete one-stage surgical treatment with mediastinal debridement and bilateral decortication in patients suffering from descending necrotizing mediastinitis in the absence of profound septic shock.

Effects of Sodium Nitroprusside and Phenylephrine on Blood Flow in Free Musculocutaneous Flaps during General Anesthesia

Background: Hypoperfusion and necrosis in free flaps used to correct tissue defects remain important clinical problems The authors studied the effects of two vasoactive drugs, sodium nitroprusside and phenylephrine, which are used frequently in anesthetic practice, on total blood flow and microcirculatory flow in free musculocutaneous flaps during general anesthesia Metbods : In a porcine model (n = 9) in which clinical conditions for anesthesia and microvascular surgery were simulated, latissimus dorsi free flaps were transferred to the lower extremity. Total blood flow in the flaps was measured using ultrasound flowmetry and microcirculatory flow was measured using laser Doppler flowmetry. The effects of sodium nitroprusside and phenylephrine were studied during local infusion through the feeding artery of the flap and during systemic administration. Results: Systemic sodium nitroprusside caused a 30% decrease in mean arterial pressure, but cardiac output did not change. The total flow in the flap decreased by 40% (P < 0.01), and microcirculatory flow decreased by 23% in the skin (P < 0.01) and by 30% in the muscle (P < 0.01) of the flap. Sodium nitroprusside infused locally into the flap artery increased the total flap flow by 20% (P < 0.01). Systemic phenylephrine caused a 30% increase in mean arterial pressure, whereas heart rate, cardiac output, and flap blood flow did not change, local phenylephrine caused a 30% decrease (P < 0.01) in the total flap flow. Conclusions: Systemic phenylephrine in a dose increasing the systemic vascular resistance and arterial pressure by 30% appears to have no adverse effects on blood flow in free musculocutaneous flaps. Sodium nitroprusside, however, in a dose causing a 30% decrease in systemic vascular resistance and arterial pressure, causes a severe reduction in free flap blood flow despite maintaining cardiac output.

Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation.

Background: Breast reconstruction by latissimus dorsi myocutaneous flap in combination with a prosthesis is a widely used, well-established procedure. Short- and medium-term evaluation after this procedure is well described in the literature, but there have been no evaluations of the late course (over 10 years) published until now. Methods: In a retrospective study, 68 patients operated on by means of this technique at the authors’ institution from 1981 to 1993 resulting in a minimal follow-up of 10 years were included. Patients were invited to an interrogation, clinical examination, and photographic documentation (n = 51). Incidence of late flap or prosthesis-related complications, number of and indications for corrective procedures, and the correlation of the patients’ subjective judgment and objective results in the late course have been the main interest of the authors’ survey. Results: The authors found that 50 percent of the patients needed a late reoperation for change or removal of the prosthesis. Seven (10 percent) of 68 patients needed a definitive removal of the implant in the late course. Assessment of the photographic documentation of the late result by four nonprofessionals showed that the objective aesthetic results of a considerable number of the authors’ reconstructions were not sufficient. Conclusion: The procedure combines two basic techniques of reconstructive surgery, the soft-tissue restoration by a pedicled flap as the autologous reconstructive component and the volume reconstruction by prosthesis. Therefore, these patients are subject to a cumulation of the basic morbidity of the two techniques. The authors conclude that the indication for this procedure should be restricted to patients not qualifying for “pure” reconstructive techniques.

Redistribution of Microcirculatory Blood Flow within the Intestinal Wall during Sepsis and General Anesthesia

Background Hypoperfusion of the intestinal mucosa remains an important clinical problem during sepsis. Impairment of the autoregulation of microcirculatory blood flow in the intestinal tract has been suggested to play an important role in the development of multiple organ failure during sepsis and surgery. The authors studied microcirculatory blood flow in the gastrointestinal tract in anesthetized subjects during early septic shock. Methods Eighteen pigs were intravenously anesthetized and mechanically ventilated. Regional blood flow in the superior mesenteric artery was measured with ultrasound transit time flowmetry. Microcirculatory blood flow was continuously measured with a six-channel laser Doppler flowmetry system in the mucosa and the muscularis of the stomach, jejunum, and colon. Eleven pigs were assigned to the sepsis group, while seven animal served as sham controls. Sepsis was induced with fecal peritonitis, and intravenous fluids were administered after 240 min of sepsis to alter hypodynamic sepsis to hyperdynamic sepsis. Results In the control group, all monitored flow data remained stable throughout the study. During the hypodynamic phase of sepsis, cardiac output, superior mesenteric artery flow, and microcirculatory blood flow in the gastric mucosa decreased by 45%, 51%, and 40%, respectively, compared to baseline (P < 0.01 in all). Microcirculatory blood flow in the muscularis of the stomach, jejunum, and colon decreased by 55%, 64%, and 70%, respectively (P < 0.001 in all). In contrast, flow in the jejunal and colonic mucosa remained virtually unchanged. During the hyperdynamic phase of sepsis, there was a threefold increase in cardiac output and superior mesenteric artery flow. Blood flow in the gastric, jejunal, and colonic mucosa also increased (22%, 24%, and 31% above baseline, respectively). Flow in the muscularis of the stomach returned to baseline, while in the jejunum and colon, flow in the muscularis remained significantly below baseline (55% and 45%, respectively, P < 0.01). Conclusions It appears that in early septic shock, autoregulation of microcirculatory blood flow is largely intact in the intestinal mucosa in anesthetized pigs, explaining why microcirculatory blood flow remained virtually unchanged. This may be facilitated through redistribution of flow within the intestinal wall, from the muscularis toward the mucosa.

Review of 197 consecutive free flap reconstructions in the lower extremity

Complications and failures after microvascular free tissue transfer for lower extremity reconstruction have a negative impact on postoperative course and final outcome. Therefore, a 10-year analysis on lower extremity reconstruction with free flaps was performed with a special emphasis on patient co-morbidities such as cardiovascular diseases, diabetes mellitus, body mass index and history of smoking, in order to identify potential risk factors. Complications such as haematoma, seroma, infection, wound dehiscence, as well as partial flap loss, postoperative thrombosis of the anastomosis and eventual total flap loss were gathered from the medical records. Limb salvage was 100%, however 40% suffered from complications ranging from minor wound dehiscence to total flap loss. None of the above-mentioned potential risk factors was associated with an increased rate of complications. However, in flaps that required revision for thrombosis, the age of the patients was significantly higher in the group of flaps that eventually failed when compared to flaps that were salvaged. In conclusion, lower extremity reconstruction with microvascular free tissue transfer is a safe and reliable procedure with a high success rate, however partial flap loss remains an important issue. Increased age was the only factor identified with an increased risk for subsequent flap loss in cases that were revised for thrombosis.

A comparative evaluation of intrathoracic latissimus dorsi and serratus anterior muscle transposition

BACKGROUND Comparison of intrathoracic latissimus dorsi (LD) versus serratus anterior (SA) muscle transposition for treatment of infected spaces, broncho-pleural fistulae, and for prophylactic reinforcement of the mediastinum after extended resections following induction therapy. PATIENTS AND METHODS Twenty LD and 17 SA transfers were performed for prophylactic reinforcement (11 LD; nine SA), and treatment of infections (nine LD; eight SA) from 1995 to 1998. RESULTS The 30-day mortality was 0% following prophylactic reinforcement and 29% following treatment of infections (three LD; two SA). Prophylactic mediastinal reinforcement was successful in 11 of 11 patients with LD and nine of nine with SA transpositions, and treatment of infected spaces in eight of nine patients with LD and two of three with SA transfers. Morbidity requiring re-intervention consisted of flap necrosis (one LD), bleeding (one SA), and skin necrosis over a winged scapula (one SA). Subcutaneous seromas and chest wall complaints were more frequent following LD (45 and 36%, respectively) compared with SA transfers (29 and 27%, respectively), whereas impaired shoulder girdle function was more frequent after SA than after LD transfer (27 vs. 21%). CONCLUSION Intrathoracic LD and SA muscle transpositions are both efficient for the prevention or control of infections following complex thoracic surgery, and are both associated with similar and acceptable morbidity and long-term sequelae.

Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum

BACKGROUND Radical debridement, followed by muscle flap cover, has significantly reduced morbidity and mortality of infected sternotomy wounds. The pectoralis major, rectus abdominis, and greater omentum flaps are most commonly used, whereas the latissimus dorsi muscle is rarely employed. METHODS In 7 patients with persistent infection and necrosis of the sternum, radical and extensive debridement including the sternum, costochondral arches, manubrium and sternoclavicular joints was performed. A free latissimus dorsi flap was used for soft tissue reconstruction without additional stabilization of the chest wall. RESULTS All flaps survived without revision of the anastomosis. In the follow-up period (22 months to 5 years) no recurrent infection was observed. Three patients died during the study period (3 to 24 months after operation) due to causes not related to sternum operation. No additional weakness, pain, or restricted movements of the shoulders due to missing sternum was observed. CONCLUSIONS Our findings suggest that the use of free latissimus dorsi flap after complete sternectomy for infection has several advantages: it provides abundant tissue to allow radical and extensive debridement, obliterates completely the dead space, and helps to control infection. Even without additional chest wall reconstruction it gives enough stability to allow pain-free normal daily activities.

Surgical management of gynecomastia - a 10-year analysis

BackgroundGynecomastia is defined as the benign enlargement of the male breast. Most studies on surgical treatment of gynecomastia show only small series and lack histopathology results. The aim of this study was to analyze the surgical approach in the treatment of gynecomastia and the related outcome over a 10-year period.Patients and methodsAll patients undergoing surgical gynecomastia corrections in our department between 1996 and 2006 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and histological results.ResultsA total of 100 patients with 160 operations were included. Techniques included subcutaneous mastectomy alone or with additional hand-assisted liposuction, isolated liposuction, and formal breast reduction. Atypical histological findings were found in 3% of the patients (spindle-cell hemangioendothelioma, papilloma). The surgical revision rate among all patients was 7%. Body mass index and a weight of the resected specimen higher than 40 g were identified as significant risk factors for complications (p < 0.05).ConclusionsThe treatment of gynecomastia requires an individualized approach. Caution must be taken in performing large resections, which are associated with increased complication rates. Histological tissue analysis should be routinely performed in all true gynecomastia corrections, because histological results may reveal atypical cellular pathology.