Brenton Franklin

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Abstract Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007–2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Predicting Abdominal Closure After Component Separation for Complex Ventral Hernias Maximizing the Use of Preoperative Computed Tomography

BackgroundComponent separation techniques (CSTs) have allowed for midline fascial reapproximation in large midline ventral hernias. In certain cases, however, fascial apposition is not feasible, resulting in a bridged repair that is suboptimal. Previous estimates on myofascial advancement are based on hernia location and do not take into account variability between patients. Examination of preoperative computed tomography (CT) may provide insight into these variabilities and may allow for prediction of abdominal closure with CST. Study DesignA retrospective review was conducted of patients who underwent abdominal wall reconstruction from 2007 to 2012 with CST. Preoperative CT was obtained, and specific parameters were analyzed using image analysis software. Logistic regression was used to predict ideal operative closure. Multivariate analyses were adjusted for age and sex. An a priori value was set at P < 0.05. ResultsFifty-four patients met the criteria and had preoperative CT available for analysis. Forty-eight patients had fascial reapproximation achieved, whereas 6 patients had a bridged repair. Age, sex, weight, and body mass index were similar between groups (P > 0.05). Significant differences were seen between groups in 3 variables: transverse defect size (19.8 vs 10 cm, P < 0.05), defect area (420 vs 184.2 cm2, P < 0.05), and percent abdominal wall defect (18.9% vs 10.6%, P < 0.05). ConclusionsPreoperative determination of abdominal wall defect ratios and hernia defect areas may represent a more accurate method to predict abdominal wall closure after CST. Predicting midline approximation after CST is critical because outcomes after bridged repair can result in higher recurrence rates.

Factors associated with failed hardware salvage in high-risk patients after microsurgical lower extremity reconstruction.

BackgroundLower extremity hardware salvage remains challenging in patients with complex comorbidities. The purpose of this study was to identify factors associated with failed hardware salvage after microsurgical lower extremity reconstruction. MethodsA retrospective, institutional review board-approved review was performed of patients who underwent lower extremity hardware salvage via free tissue transfer from 2004 to 2010. Outcomes were binarized into successful versus failed hardware salvage, with failure defined as nonelective removal. Patient demographics, wound characteristics, microbiology, and pathology were compared. ResultsThirty-four patients underwent lower extremity hardware salvage via free tissue transfer, with an average follow-up of 3.2 years (range, 0.3–7.0 years). Of these patients, 15 (44.1%) had successful hardware salvage and 19 (55.9%) required hardware removal. By demographics, a higher prevalence of multiple comorbidities was found in patients with failed hardware salvage. Wound characteristics revealed a significantly longer time to hardware coverage and longer duration of intravenous antibiotics in failed versus successful hardware salvage patients (38.9 vs 9.3 weeks, P = 0.02; 6.5 vs 4.1 weeks, P = 0.03, respectively). Initial wound cultures demonstrated a significantly higher frequency of positive growth in patients with failed versus successful hardware salvage (100.0% vs 57.1%, P = 0.003). Initial pathology revealed a borderline—significantly higher frequency of chronic osteomyelitis in failed versus successful salvage patients (66.7% vs 33.3%, P = 0.08). ConclusionsIn this retrospective review of microsurgical lower extremity reconstruction, factors associated with failed hardware salvage included multiple comorbidities, longer time to hardware coverage, increased duration of intravenous antibiotics, positive initial wound cultures, and chronic osteomyelitis on initial pathology.

Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients.

Introduction: Microsurgical lower extremity flap reconstruction provides a valuable option for soft tissue reconstruction in comorbid patients. Limb salvage with flap reconstruction can result in limb length preservation. Despite this, few studies have examined the impact of salvage on patient‐centered metrics in this cohort of patients. Therefore, we investigated quality of life and patient satisfaction following microsurgical lower extremity reconstruction in this high‐risk patient population. Factors that resulted in improved patient‐centered outcomes were also identified. Methods: A retrospective review was conducted of all patients who had lower extremity free flap reconstruction (FFR) following lower extremity wounds. High‐risk patients were identified as having multiple comorbidities and chronic wounds. Patients with traumatic wounds were excluded from analysis. Quality of life was evaluated with the Short Form‐12 (SF‐12) validated survey. Phone interviews were conducted for survey evaluations. Results: From 2005 to 2010, 57 patients had lower extremity flap reconstruction that met the inclusion criteria. Average follow‐up was 236.6 weeks (range, 111–461). Comorbidities included diabetes (36%), PVD (24.6%), and ESRD (7%). Limb length preservation and ambulation occurred in 82.5% (47/57). Revisional surgery occurred in 33.3% (19/57). Survey response rate was 63%. Average SF‐12 PCS and MCS scores were 44.9 and 59.8 for patients able to achieve ambulation and 27.6 and 61.2 for nonambulatory patients. Conclusions: Microsurgical flap reconstruction is a valuable reconstructive option in high‐risk patients. Quality of life is comparable with a normalized population if limb salvage is successful. Quality of life is decreased significantly when failure to ambulate occurs in this patient cohort.

Proceed™ Mesh for Laparoscopic Ventral Hernia Repair

A laparoscopic approach to ventral hernia repair using Proceed mesh was associated with low conversion rate and no major complications in this study of single surgeons experience.

Revisiting the scapular flap: applications in extremity coverage for our U.S. combat casualties.

Background: Combat injuries commonly result in massive bony and soft-tissue destruction within the extremities. These extremity wounds often require large free tissue transfers and/or composite flaps for definitive reconstruction. In U.S. military war trauma experience, the authors’ practice has found the scapular flap increasingly useful for reconstruction of complex extremity injuries. The purpose of this study is to report the authors’ experience using the scapular flap in extremity reconstruction and evaluate the indications for use in the authors’ patient population. Methods: All consecutive limb salvage cases requiring free flaps from 2009 to 2012 at Walter Reed National Military Medical Center were reviewed retrospectively. Scapular flap cases were identified. Data collected included Injury Severity Score, flap characteristics, and complications. Results: Twelve scapular free flaps were performed for extremity reconstruction for combat-related trauma, representing 16.2 percent of all microsurgical reconstructions during that period. Cases included eight traditional scapular flaps, two osteocutaneous scapular flaps, one chimeric latissimus/scapular flap, and one chimeric parascapular/scapular/scapula bone flap. The complication rate was 17 percent, consisting of one flap hematoma and one donor-site dehiscence. Complication rates were similar between scapular flaps, other fasciocutaneous flaps, and muscle flaps. Conclusions: In a decade of war trauma, the authors’ practice has found the scapular flap useful for reconstruction of complex extremity injuries. This flap is uniquely suited to the authors’ patients, given the severity of their injuries and rehabilitation needs. The scapular flap continues to have various indications in injuries seen within the authors’ military population that may be applicable to the authors’ civilian patient counterparts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Impact of Connective Tissue Disease on Oncologic Breast Surgery and Reconstruction.

BackgroundThe impact of connective tissue disease (CTD) on outcomes following breast surgery and reconstruction is unknown. The purpose of this study was to evaluate the effect of both CTDs and systemic immunomodulatory therapy on outcomes following breast surgery and reconstruction. MethodsA retrospective review was performed of all patients from 2005 to 2010 with an active CTD who underwent breast surgery with or without reconstruction. Surgical events were assigned to 1 of 4 groups: ablative surgery alone, autologous reconstruction, implant reconstruction, and revision surgery. Logistic regression was utilized to examine the relationship between complications and type of surgery, CTD diagnosis, and immunomodulatory therapy. Four non-CTD control groups were then compiled for outcome comparison. The a priori P-value was set at P < 0.05, and all tests were 2 sided. ResultsThirty-three patients with CTD underwent112 procedures. Diagnoses included psoriasis/psoriatic arthritis (n = 12), rheumatoid arthritis (n = 10), lupus (n = 4), scleroderma (n = 3), Sjogren syndrome (n = 2), mixed CTD (n = 1), and seronegative polyarthritis (n = 1). Nineteen of 33 (58%) patients who received systemic treatment for CTD in the perioperative period were less likely to experience a minor complication compared with those without treatment (odds ratio= 0.69; P = 0.019). There were no differences in postoperative complications in patients with CTD compared with control groups. ConclusionsAblative breast surgery and reconstruction among patients with CTDs can be performed safely with low perioperative complication rates. Patients receiving systemic therapy, and continuing their regimens perioperatively, experience complication rates similar to those not requiring therapy.

Abstract 165: IMPACT OF CONNECTIVE TISSUE DISEASE ON OUTCOMES FOLLOWING BREAST SURGERY AND RECONSTRUCTION

Methods: A retrospective review was conducted of all patients who underwent breast surgery from 2005-2010. Patients were identi ed as having breast surgery and having an active diagnosis of a connective tissue disease. Logistic regression was utilized to examine the relationship between peri-operative complications and type of surgery, CTD diagnosis, and immunosuppression. The a priori p-value was set at p<0.05 and all tests were two-sided.

A case of video-assisted retroperitoneal debridement in a patient with HELLP syndrome.

Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome describes a cohort of disease processes that may have devastating consequences for the peripartum patient. Although the hemopoetic and hepatic systems are classically involved, we illustrate a case of walled-off pancreatic necrosis occurring in a woman with HELLP syndrome. Initially managed with resuscitation, steroids, and plasmapheresis, the patient developed necrotizing pancreatitis that overtime became walled-off. Despite attempts at percutaneous drainage, the patient ultimately had a video-assisted retroperitoneal debridement. As there are no descriptions in the literature of walled-off pancreatic necrosis stemming from HELLP syndrome, this case provides a new avenue from which to study the pathophysiology and provides a management strategy for this problem.

Factors Associated with Failed Hardware Salvage in High Risk Patients Following Microsurgical Lower Extremity Reconstruction

reSultS: 34 patients were identified, with an average followup of 2.6 years (0.3 – 7.0 years). Fifteen patients had successful salvage; 19 patients required hardware removal, representing a 55.9% failure rate. Comparison of patient demographics revealed similar surgical age, BMI, and co-morbidities between successful versus failed hardware salvage groups. Analysis of wound characteristics revealed significantly longer time to hardware coverage and longer duration of IV antibiotic coverage in failed versus successful hardware salvage patients (38.9 versus 9.3 weeks, p = 0.02; and 6.5 versus 4.1 weeks, p = 0.03, respectively). Initial wound cultures demonstrated a significantly higher positive growth with failed versus successful salvage (100.0% versus 57.1%, p = 0.003); the distribution of microbial flora on initial and final cultures was similar between groups. Initial pathology revealed higher frequency of chronic osteomyelitis in failed versus successful hardware salvage patients (66.7% versus 33.3%, p = 0.08); absence of osteomyelitis and presence of acute osteomyelitis were similar between groups.