Danielle H. Rochlin

Current concepts and systematic review of vascularized composite allotransplantation of the abdominal wall

Abdominal wall vascularized composite allotransplantation (AW‐VCA) is a rarely utilized technique for large composite abdominal wall defects. The goal of this article is to systematically review the literature and current concepts of AW‐VCA, outline the challenges ahead, and provide an outlook for the future.

Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy

BACKGROUND Surgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes. METHODS Data on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result. RESULTS Twenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases. CONCLUSIONS Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.

Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer.

BACKGROUND: An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE: We report a single surgeon’s experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN: From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS: This study was conducted at an academic, tertiary-care cancer center. PATIENTS: Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS: Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES: The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS: Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS: The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION: This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).

Remaining or Residual First Ribs Are the Cause of Recurrent Thoracic Outlet Syndrome

BACKGROUND Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. METHODS Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. RESULTS Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. CONCLUSIONS Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

Females With Subclavian Vein Thrombosis May Have an Increased Risk of Hypercoagulability

BACKGROUND Subclavian vein thrombosis (SVT) is usually caused by vigorous activity or extensive use of the upper extremity. Patients are tested for hypercoagulability if they present with a spontaneous clot unassociated with such activity. The objective of this study was to determine the prevalence of hypercoagulability in patients undergoing first rib resection and scalenectomy presenting with SVT. METHODS Using a prospectively maintained database from August 2003 through June 2011, patients were retrospectively reviewed for hypercoagulability testing and clinical outcomes. RESULTS One hundred forty-three patients (79 females and 64 males; mean [range] age, 32 [16-71] years) presented with SVT, of whom 55 patients (43 females and 12 males; mean age, 32 [16-61] years) had undergone hypercoagulable testing. Fourteen patients (25.5%) (12 females and 2 males; mean age, 27 [16-46] years) had an abnormal hypercoagulable profile. A factor V Leiden mutation was present in 6 patients, protein S deficiency in 4, a plasminogen-activator inhibitor-1 (PAI-1) deficiency in 2, and 1 patient each with protein C deficiency, anticardiolipin antibodies, factor VII mutation, factor II mutation, and antiphospholipid antibodies. Immediate and long-term postoperative vein patency was similar to patients without hypercoagulability. Patients were placed on lifelong anticoagulation therapy if they had a PAI-1, protein C, or protein S deficiency. CONCLUSIONS Patients with hypercoagulability do as well with first rib resection and scalenectomy for SVT as those without hypercoagulability. In our patient subset, more females were tested owing to a history of spontaneous thrombosis and an increased incidence of hypercoagulable disorders. Because of our findings, we believe younger women with SVT should undergo hypercoagulable testing to identify the need for long-term anticoagulation therapy.

McCleery Syndrome: Etiology and Outcome

Objectives: Patients presenting with swelling of the upper extremity without thrombosis have McCleery syndrome or intermittent compression of the subclavian vein. The purpose of this study was to determine outcomes in these patients who underwent first rib resection and scalenectomy (FRRS). Methods: Using a prospectively maintained database from 2003 to 2011, patients were retrospectively reviewed for presentation, diagnosis, treatment, and clinical outcomes. Results: Of the patients presenting with venous thoracic outlet syndrome, 19 (11%; 13 F/6 M; mean age 26 [10-44]) presented with intermittent arm swelling, of which 3 were identified as having chronic thrombus. A total of 20 FRRS operations were performed. Conclusions: First rib resection and scalenectomy is effective in relieving symptoms in patients with McCleery syndrome. These patients do not generally need a postoperative venogram unless they experience continuing symptoms. In patients with chronic thrombus, routine postoperative venography at 2 weeks is indicated. Patients can present with intermittent compression if an acute episode of deep vein thrombosis is not aggressively treated.

Abstract P13: Abdominal versus Thigh Based Reconstruction of Perineal Defects in Cancer Patients

ConClusion: The results suggest that treatment with AMD3100 or plerixafor, alone or in combination with conventional tacrolimus therapy elevates the number of circulating HSPCs as expected. Additionally this treatment led to increases in circulating donor-derived cells in animals following hindlimb transplant. Despite the ability to increase circulating stem cells and peripheral chimerism these treatments did not significantly prolong graft survival. Further studies will explore this disconnect between chimerism and graft survival as well as explore whether variations in the dosing may be more successful in prolonging graft survival. P13 abdominal versus thigh Based reconstruction of Perineal defects in cancer Patients