Jeffrey G. Trost

Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy

BACKGROUND Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention. METHODS All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Childrens Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed. RESULTS A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3). CONCLUSIONS CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation.

Bronchial artery revascularization and en bloc lung transplant in children

BACKGROUND Long-term success in pediatric lung transplantation is limited by infection and bronchiolitis obliterans syndrome (BOS). The bilateral sequential lung transplantation (BSLT) technique may result in airway ischemia leading to bronchial stenosis, dehiscence, or loss of small airways. En bloc lung transplant (EBLT) with bronchial artery revascularization (BAR) minimizes airway ischemia, thus promoting superior airway healing. BAR also allows for safe tracheal anastomosis, circumventing the need for bilateral bronchial anastomoses in small children. METHODS This was a retrospective review of bilateral transplantations from 2005 to 2014. Both techniques were used in parallel. Redo and multiorgan transplants were excluded. RESULTS There were 119 recipients comprising 88 BSLTs and 31 EBLTs. Follow-up time was 3 years (interquartile range, 1-5 years). Donor ischemic and cardiopulmonary bypass times were not different between techniques (p = 0.48 and p = 0.18, respectively). Degree of graft dysfunction and cellular rejection scores were not different (p = 0.83 and p = 0.93, respectively). There were 3 hospital deaths after BSLT and 2 after EBLT (p = 0.60). Overall survival was 61% for the BSLT group and 77% for the EBLT group (p = 0.54). Freedom from BOS was 71% in the BSLT group and 94% in the EBLT group (p = 0.08). On routine bronchoscopy, 57% BSLT and 16% EBLT patients had 1 or more airway ischemic findings (p < 0.0001). Multivariate analysis showed BSLT was associated with higher ischemic injury (relative risk, 2.86; 95 confidence interval, 1.3-6.5; p = 0.01) and non-airway complications (relative risk, 4.62; 95% confidence interval, 1.1-20.2; p = 0.04) but not airway reinterventions (p = 0.07). Airway dehiscence occurred in 3 BSLT patients. CONCLUSIONS Pediatric EBLT with BAR can be safely performed without increasing operative or graft ischemic times. Airway ischemia and non-airway complications were significantly reduced when BAR was combined with tracheal anastomosis, potentially diminishing morbidity caused by anastomotic healing complications.

Separation of Thoraco-omphalo-ischiopagus Conjoined Twins: Surgical Planning, Management, and Outcomes.

Background: Conjoined twins are a rare medical phenomenon that offers a unique challenge for medical professionals. The complex anatomy of conjoined twins dictates their survival and amenability to separation, making each case different in terms of medical management, surgical planning, and patient outcomes. Thoraco-omphalo-ischiopagus twins, joined from the thorax to the pelvis, are one of the rarest orientations recorded in the medical literature, and successful separation of this subset of conjoined twins has not been documented. This report presents a novel case of thoraco-omphalo-ischiopagus tetrapus twins who were successfully separated at 10 months of age. The preoperative planning, operative details, and postoperative course are discussed as they relate to the reconstructive effort. Methods: Three-dimensional medical modeling was pursued early in the planning process and was used to estimate the soft-tissue requirements for reconstruction and to design custom tissue expanders. Results: The reconstructive effort required postponement until respiratory status was optimized. Even with elaborate preoperative planning, primary closure of the abdomen was limited because of tissue edema and other less predictable patient factors. Delayed closure of the abdominal wall was made possible with negative-pressure wound therapy and secondary flap advancements. Conclusion: Preoperative coordination with necessary vendors, a multidisciplinary surgical effort, and optimal timing of the surgical intervention all contribute to the successful separation and long-term survival of thoraco-omphalo-ischiopagus conjoined twins. Clinical Question/Level of Evidence: Therapeutic, V.

Total Ear Reconstruction Using Porous Polyethylene

Abstract Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor‐based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full‐thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.

Identical Twins with Crouzon Syndrome: Eight-Year Follow-up, Genetic Considerations, and Operative Management

A case report of monozygotic (MZ) twins with Crouzon syndrome was previously published to highlight variables in clinical presentation. The postnatal and epigenetic causes for this variation are not well understood. An 8-year follow-up discusses their pertinent clinic course with consideration of genetic and nongenetic variables. The phenotypic and symptomatic obstacles encountered since their initial assessment are reviewed, and the use of three-dimensional Medical Modeling (Golden, CO) as a preoperative planning strategy is addressed. Analyzing the longitudinal clinical course of MZ twins with syndromic craniosynostosis will help better predict and provide optimal treatment.

Common Pediatric Skin Lesions: A Comprehensive Review of the Current Literature.

The timely diagnosis and treatment of dermatologic disease in the pediatric population can be challenging. A basic, yet comprehensive knowledge of common lesions is essential for a successful practice in plastic surgery. In this article, the authors describe vascular, cystic, and pigmented cutaneous lesions that are commonly encountered in the pediatric population. Epidemiology, pathogenesis, clinical course, and management options are discussed for each.

Common Adult Skin and Soft Tissue Lesions

A strong foundational knowledge of dermatologic disease is crucial for a successful practice in plastic surgery. A plastic surgeon should be able to identify and appreciate common dermatologic diseases that may require medical and/or surgical evaluation and management. In this article, the authors describe epidermal/dermal, infectious, pigmented, and malignant cutaneous lesions that are commonly encountered in practice. Descriptions include the epidemiology, pathogenesis, clinical course, and management options for each type of lesion.

Review of "Headache in Patients With Pituitary Lesions: A Longitudinal Cohort Study" by Rizzoli P, Iuliano S, Weizenbaum E, and Laws E in Neurosurgery 78:316-323, 2016.

S tate medical examining boards serve as a delegated authority in exercising states’ inherent power to protect public’s health and safety. Staffed by practicing physicians, the medical boards are rooted in the profession’s tradition of self-regulation. This fusion of private structure and public regulatory bodies resolves the conflict between professional autonomy and state control. However, when the medical boards engage in anticompetitive conducts that run afoul of federal antitrust laws, the question arises as to whether such organizations are immune as state actors or liable as private entities. The author of this article provides a review of Supreme Court jurisprudence on this issue in light of the Court’s latest decision on North Carolina State Board of Dental Examiners vs. Federal Trade Commission. By their very nature, boards of medical examiners control entry into the profession and set up policies that could be classified as exclusionary, or incompatible with free market ideals. Historically, professional associations claimed that the learned professions are distinct from trade or commerce under antitrust laws, thus immune from the related liability. However, a series of Supreme Court decisions since the 1970s have obliterated this argument and have shown that attorneys, engineers, and physicians could be subject to antitrust scrutiny. In its 2014 to 2015 term, the Supreme Court delivered another decision on this issue concerning the North Carolina dental board and its aggressive actions against teeth-whitening services offered by nondentists. The dental board was responding to complaints from fellow dentists regarding the increasing number of low-priced teeth-whitening businesses being established in the state of North Carolina. The board issued nearly 50 cease-and-desist letters (among other tactics), effectively eliminating commercial teethwhitening services by nondentists within the state. The Federal Trade Commission accused the dental board of engaging in unfair competition. The dental board, noting its official designation as ‘‘the agency of the state,’’ claimed Parker immunity as its defense. The Parker doctrine grants state governments exemption to antitrust regulations, owing to states’ identity as sovereign entities that predated and reserved broader powers under the US Constitution. However, the Supreme Court found that the dental board was a public/private hybrid that is controlled by practicing dentists without a clear and active state supervision; therefore, it is not qualified for Parker immunity. The Court’s 6-3 decision highlighted the risk of selfinterested behavior when regulators are chosen among the regulated. In the aftermath of this ruling, a wide range of medical societies have voiced concerns about federal regulators’ and courts’ intervention to the ‘‘150-year tradition of state regulation by boards of practicing doctors.’’ A likely implication of the decision, according to the author, is the prospect of stiffer resistance when medical boards unilaterally seek to promulgate and apply standards that can stymie outside competition. In charting the way ahead for medical regulation, the author believes that professional sovereignty relies on practitioners to adhere to higher ethical standards and the medical boards to pass antitrust muster.