Andrew J. Vardanian

Liver Transplantation Criteria For Hepatocellular Carcinoma Should Be Expanded: A 22-Year Experience With 467 Patients at UCLA

Objective:To assess the efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) and the impact of current staging criteria on long term survival. Summary Background Data:HCC is becoming an increasingly common indication for OLT. Medicare approves OLT only for HCCs meeting the Milan criteria, thus limiting OLT for an expanding pool of potential liver recipients. We analyzed our experience with OLT for HCC to determine if expansion of criteria for OLT for HCC is warranted. Methods:All patients undergoing OLT for HCC from 1984 to 2006 were evaluated. Outcomes were compared for patients who met Milan criteria (single tumor ≤5 cm, maximum of 3 total tumors with none >3 cm), University of California, San Francisco (UCSF) criteria (single tumor <6.5 cm, maximum of 3 total tumors with none >4.5 cm, and cumulative tumor size <8 cm), or exceeded UCSF criteria. Results:A total of 467 transplants were performed for HCC. At mean follow up of 6.6 ± 0.9 years, recurrence rate was 21.2%, and overall 1, 3, and 5-year survival was 82%, 65%, and 52%, respectively. Patients meeting Milan criteria had similar 5-year post-transplant survival to patients meeting UCSF criteria by preoperative imaging (79% vs. 64%; P = 0.061) and explant pathology (86% vs. 71%; P = 0.057). Survival for patients with tumors beyond UCSF criteria was significantly lower and was below 50% at 5 years. Multivariate analysis showed that tumor number (P < 0.001), lymphovascular invasion (P < 0.001), and poor differentiation (P = 0.002) independently predicted poor survival. Conclusions:This largest single institution experience with OLT for HCC demonstrates prolonged survival after liver transplantation for tumors beyond Milan criteria but within UCSF criteria, both when classified by preoperative imaging and by explant pathology. Measured expansion of OLT criteria is justified for tumors not exceeding the UCSF criteria.

Molecular Mediators of Liver Ischemia and Reperfusion Injury : A Brief Review

Ischemia and reperfusion injury is a dynamic process that involves multiple organ systems in various clinical states including transplantation, trauma, and surgery. Research into this field has identified key molecular and signaling players that mediate, modulate, or augment cellular, tissue, and organ injury during this disease process. Further elucidation of the molecular mechanisms should provide the rationale to identify much-needed novel therapeutic options to prevent or ameliorate organ damage due to ischemia and reperfusion in clinics.

Type I, but not type II, interferon is critical in liver injury induced after ischemia and reperfusion

We have documented the key role of toll‐like receptor 4 (TLR4) activation and its signaling pathway mediated by interferon (IFN) regulatory factor 3, in the induction of inflammation leading to the hepatocellular damage during liver ischemia/reperfusion injury (IRI). Because type I IFN is the major downstream activation product of that pathway, we studied its role in comparison with IFN‐γ. Groups of type I (IFNAR), type II (IFNGR) IFN receptor–deficient mice, along with wild‐type (WT) controls were subjected to partial liver warm ischemia (90 minutes) followed by reperfusion (1‐6 hours). Interestingly, IFNAR knockout (KO) but not IFNGR KO mice were protected from IR‐induced liver damage, as evidenced by decreased serum alanine aminotransferase and preservation of tissue architecture. IR‐triggered intrahepatic pro‐inflammatory response, assessed by tumor necrosis factor (TNF‐α), interleukin 6 (IL‐6), and chemokine (C‐X‐C motif) ligand 10 (CXCL‐10) expression, was diminished selectively in IFNAR KO mice. Consistent with these findings, our in vitro cell culture studies have shown that: (1) although hepatocytes alone failed to respond to lipopolysaccharide (LPS), when co‐cultured with macrophages they did respond to LPS via macrophage‐derived IFN‐β; (2) macrophages required type I IFN to sustain CXCL10 production in response to LPS. This study documents that type I, but not type II, IFN pathway is required for IR‐triggered liver inflammation/damage. Type I IFN mediates potential synergy between nonparenchyma and parenchyma cells in response to TLR4 activation. (HEPATOLOGY 2007.)

Social media use and impact on plastic surgery practice.

Background: Social media platforms have revolutionized the way human beings communicate, yet there is little evidence describing how the plastic surgery community has adopted social media. In this article, the authors evaluate current trends in social media use by practicing plastic surgeons. Methods: An anonymous survey on the use of social media was distributed to members of the American Society of Plastic Surgeons. Prevalent patterns of social media implementation were elucidated. Results: One-half of respondents were regular social media users. Reasons for using social media included the beliefs that incorporation of social media into medical practice is inevitable (56.7 percent), that they are an effective marketing tool (52.1 percent), and that they provide a forum for patient education (49 percent). Surgeons with a primarily aesthetic surgery practice were more likely to use social media. Most respondents (64.6 percent) stated that social media had no effect on their practice, whereas 33.8 percent reported a positive impact and 1.5 percent reported a negative impact. Conclusions: This study depicts current patterns of social media use by plastic surgeons, including motivations driving its implementation and impressions on its impact. Many feel that social media are an effective marketing tool that generates increased exposure and referrals. A small number of surgeons have experienced negative repercussions from social media involvement. Our study reveals the presence of a void. There is a definite interest among those surveyed in developing best practice standards and oversight to ensure ethical use of social media platforms throughout the plastic surgery community. Continuing discussion regarding these matters should be ongoing as our experience with social media in plastic surgery evolves.

The use of negative pressure wound therapy in severe open lower extremity fractures: identifying the association between length of therapy and surgical outcomes

BACKGROUND Negative pressure wound therapy (NPWT) is a widely accepted method of temporary coverage for complex lower extremity wounds before definitive reconstruction. However, the precise role of NPWT in the perioperative management of patients with complicated lower extremity injuries remains unclear. In this study, we examine the effect of NPWT on flap complications and overall outcomes based on timing of soft-tissue reconstruction relative to initial injury and implementation of NPWT. METHODS We retrospectively reviewed the medical records of 32 consecutive patients presenting to a single institution receiving lower extremity reconstruction after Gustilo class IIIB or IIIC open tibial fractures over a 5-y period. Length of hospitalization, number of surgical procedures, flap failure, infection, and nonunion were parameters of interest in this study. RESULTS The incidence of complications in patients treated with NPWT was lower compared with patients who underwent wet-to-dry dressing changes, regardless of when surgery was performed. The highest rate of complications was observed in patients operated on >6 wk after injury and who received wet-to-dry dressing changes wound care. By comparison, those who underwent surgery within 1 wk of injury and who were bridged with NPWT had the lowest rate of complications. CONCLUSIONS The use of NPWT therapy in the perioperative management of patients with open lower extremity fractures reduces complication rates associated with limb salvage surgery. Our results suggest that NPWT can be used as a temporizing measure to optimize patients before flap surgery, effectively lengthening the window of opportunity for definitive reconstruction.

Comparison of Immediate Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix in the Setting of Post-Mastectomy Radiation

RESULTS: A total of 67 immediate TE-based breast reconstructions were included [ADM group n=47 (70.1%) nonADM group n=20 (29.9%)]. Patient characteristics including age at time of reconstruction (mean 48 ±11 vs. 47±10 years) and BMI (mean 24.4±5 vs. 22±3 kg/m2) were similar between groups (P>0.05). In univariate analyses, capsular contracture, inframammary fold (IMF) problems, infection, and wound problems were similar between both groups (P>0.05). After adjusting for clinical characteristics and postoperative complications with multivariate logistic regression, these trends remained. ADM use was not associated with less capsular contracture, IMF problems, wound problems, reoperations, or implant failure requiring fl ap salvage in the setting of post mastectomy radiation.

Comparison of Immediate Implant-Based Reconstruction with and without Acellular Dermal Matrix

RESULTS: A total of 203 patients underwent 337 immediate expander-based breast reconstructions [ADM group n=208 (61.7%) non-ADM group n=129 (38.3%)]. Patient characteristics such as age (mean 49 ±11 vs. 47±10 years) and BMI (mean 23±5 vs. 23±3 kg/m2) were similar between groups (p>0.05). Complications occurred in one third of our patients (33.5%). In univariate analyses ADM use had lower overall complications (OR 0.61, 95% CI 0.38-0.97), less capsular contracture (OR 0.16, 95% CI 0.73-0.38), problems with the IMF (OR 0.370, 95% CI 0.19-0.71), bottoming out (OR 0.35, 95% CI 0.150.81), rippling (OR 0.32, 95% CI 0.13-0.80) and mechanical shifting of the implant (OR 0.19, 95% CI 0.06-0.60). Incidence of seroma/hematoma (p=0.59), infection (p=0.31), and wound complications (p=0.26) did not differ between groups. Aesthetic outcome ratings were higher in the ADM group. In multivariate logistic regression, after adjusting for clinical characteristics and post-operative complications, ADM use was associated with less capsular contracture (OR 0.18, 95% CI 0.08-0.43), mechanical shifting (OR 0.23, 95% CI 0.06-0.78), and less problems of the IMF (OR 0.49, 95% CI 0.23-1.01).