Anna Raurell

Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography

Background: Deep inferior epigastric artery perforator (DIEP) flap harvest is associated with a significant rate of venous congestion; however, the reason for this has not yet been fully explained. Contrast-enhanced magnetic resonance angiography enables detailed evaluation of both the arterial and venous anatomies. Methods: A retrospective review of DIEP flaps that underwent preoperative contrast-enhanced magnetic resonance angiography was performed. Outcomes were compared with preoperative radiologic reporting of contrast-enhanced magnetic resonance angiographic imaging, and anatomical data from the scans were also analyzed. Results: Review of 54 DIEP flaps with venous system reporting was performed. Seven DIEP flaps suffered venous congestion, all of which were raised on perforators without direct connections between the venae comitantes and the main arborization of the superficial inferior epigastric vein. In the 47 DIEP flaps without venous congestion, 46 were raised on at least one perforator with a direct venous connection between the perforator venae comitantes and the main arborizations of the superficial inferior epigastric vein. There was an extremely significant association between the absence of a direct connection with the perforator venae comitantes on magnetic resonance angiography and the occurrence of venous congestion (p < 0.0001). Sixty-eight percent of all perforators had direct venous connections, which were significantly more likely to be located in the medial row. Conclusions: DIEP flaps elevated on perforators with venae comitantes with direct venous connections to the main arborization of the superficial inferior epigastric vein are significantly associated with a very low incidence of flap venous congestion. Contrast-enhanced magnetic resonance angiography allows detailed appraisal of the venous anatomy, which may minimize the risk of DIEP flap venous insufficiency and the need for salvage procedures.

Initial Experience With the Use of Biological Implants for Soft Tissue and Chest Wall Reconstruction in Thoracic Surgery

BACKGROUND Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. METHODS A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). RESULTS A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. CONCLUSIONS Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.

Reconstruction and Financial Remuneration Following Soft Tissue Sarcoma Surgery

Soft tissue sarcomas are relatively uncommon, with approximately 3,200 new cases per year in the UK, accounting for 1% of all malignancies. They are a heterogeneous group of malignancies that occur anywhere in the body, and arise from the mesenchyme inclusive of muscle, endothelial cells, cartilage and supporting elements. Diagnosis is based on triple assessment with clinical history, imaging and diagnostic biopsy. Histological stage and grade is based on the Trojani classification. Owing to their complex nature, a specialist sarcoma multidisciplinary team (MDT) manages patients. Treatment options include one or more of surgery with wide or planned marginal excision, isolated limb perfusion, chemotherapy or radiotherapy. Long-term follow-up to rule out recurrence of disease is mandatory.

Sarcomas: Bone and soft tissue tumours

Sarcoma describes a group of malignant, connective tissue tumours of mesenchymal origin; i.e. arising from fat, muscle, bone, blood vessels and nerves. They are rare and typically account for approximately 1.2% of all cancers in the UK. The incidence of sarcomas is highest in young and old people. Early diagnosis followed by prompt and appropriate treatment is vital to reduce the mortality from sarcomas. This article focuses on increasing primary care awareness of the key clinical features of sarcoma and providing an update on relevant guidelines. Management of sarcoma in tertiary centres is also discussed.

Salvage of a TRAM breast reconstruction flap using the retrograde internal mammary artery system

Background: Free tissue transfer provides an optimal means for breast reconstruction in creating an aesthetically natural appearance that is durable over time. The choice of donor vessels vary from surgeon to surgeon, but the internal mammary axis is one of the most popular choices together with the thoracodorsal vessels. Aims and Results: We present the case of a salvaged free transverse rectus abdominis myocutaneous breast reconstruction in which end-to-end antegrade anastomosis to the internal mammary artery (IMA) was not possible due to frail vessel walls, but retrograde anastomosis to the IMA and antegrade anastomosis of internal mammary vessel resulted in a perfused and viable flap. Conclusion: We suggest the use of the retrograde internal mammary arterial system for microsurgical anastomosis when the anterograde flow is not adequate, the vessel wall is friable, and when other more common options are not available.

Radiation induced sarcomas – The Nottingham experience

AimsTo evaluate the incidence, patient demographics, primary tumour characteristics and treatment modalities of patients with radiation induced soft tissue sarcoma (RISTS) presenting to the East Midlands Sarcoma Service at Nottingham City Hospital.MethodsAll consecutive patients with histologically proven RISTS were identified from our pathology database. Case notes were retrospectively reviewed to identify patient demographics, oncological features and treatment outcome.ResultsFrom 1998 to 2011, 24 patients were identified to have RISTS. 17 were female, 7 male. The mean age at time of diagnosis is 67 years (range 40–85 years). The average latency period is 12.8 years (range 1–50). The most common primary oncological diagnosis were breast carcinoma 11 (11, 45.8%) and endometrial carcinoma and testicular tumours (both 3, 12.5%). The sarcoma subtypes were 9 angiosarcomas (37.5%), 6 pleomorphic sarcomas (29.1%), 3 leiomyosarcomas (12.5%), 2 myofibroblastic sarcomas (8.4%), 1 MPNST (4.2%) 1 soft-tissue osteos...