Laurent Lantieri

Anti-HLA sensitization in extensively burned patients: extent, associated factors, and reduction in potential access to vascularized composite allotransplantation

Extensively burned patients receive iterative blood transfusions and skin allografts that often lead to HLA sensitization, and potentially impede access to vascularized composite allotransplantation (VCA). In this retrospective, single‐center study, anti‐HLA sensitization was measured by single‐antigen‐flow bead analysis in patients with deep, second‐ and third‐degree burns over ≥40% total body surface area (TBSA). Association of HLA sensitization with blood transfusions, skin allografts, and pregnancies was analyzed by bivariate analysis. The eligibility for transplantation was assessed using calculated panel reactive antibodies (cPRA). Twenty‐nine patients aged 32 ± 14 years, including 11 women, presented with a mean burned TBSA of 54 ± 11%. Fifteen patients received skin allografts, comprising those who received cryopreserved (n = 3) or glycerol‐preserved (n = 7) allografts, or both (n = 5). An average 36 ± 13 packed red blood cell (PRBC) units were transfused per patient. In sera samples collected 38 ± 13 months after the burns, all patients except one presented with anti‐HLA antibodies, of which 13 patients (45%) had complement‐fixing antibodies. Eighteen patients (62%) were considered highly sensitized (cPRA≥85%). Cryopreserved, but not glycerol‐preserved skin allografts, history of pregnancy, and number of PRBC units were associated with HLA sensitization. Extensively burned patients may become highly HLA sensitized during acute care and hence not qualify for VCA. Alternatives to skin allografts might help preserve their later access to VCA.

Analyse médico-économique du lambeau libre de DIEP en reconstruction mammaire

BACKGROUND We postulate that the absence of a CPT code for DIEP (deep inferior epigastric perforator) free flap in breast reconstruction is in part responsible for the delayed adoption of this modern technique in France. In order to provide data to our regulating health agency, we determined the cost of this technique compared to a gold standard. We performed a cost-identification study, comparing costs of DIEP free flap versus latissimus dorsi pedicled flap with implant (LD+I) in secondary breast reconstruction following irradiation. METHODS Over a 12-month period, direct medical and non-medical costs as well as indirect costs were recorded in both groups (DIEP and LD+I). RESULTS In an academic department funded by the national health system, total cost of a secondary breast reconstruction by DIEP free flap was 10,671 ± 3005€ (n=57) versus 8218 ± 2049€ (n=18) for the LD+I group (P<0.05). Mean OR occupation time was 390 ± 64minutes for DIEP versus 283 ± 44minutes for LD+I (P<0.05). Mean hospital stay was 6 ± 2 days for DIEP versus 5 ± 2 days for LD+I (P>0.05). CONCLUSION DIEP free flap technique offers a long lasting breast reconstruction at an reasonable expense compared to the LD+I (+22%). Furthermore, in an academic department, collaboration of two microsurgeons during DIEP flaps allows OR times to drop significantly and become competitive with LD+I.

Reconstruction mammaire par lambeau de superior gluteal artery perforator (SGAP) sans changement d’installation. À propos de huit cas

INTRODUCTION The superior gluteal artery perforator flap (SGAP) typically requires a peroperative change of the patients position that increase the duration time of the procedure and the hospitalization. The aim of this study is to present our serie of eight consecutive SGAP flaps without setup change, and to precise the surgical technique we used. PATIENTS AND METHODS This is a retrospective series of eight consecutive SGAP flaps performed between September 2001 and March 2010. All these flaps were performed without peroperative setup change. We studied the number of perforators used and their origins, the type of recipient vessels, the duration time of the procedure and the hospitalization. We also analyzed the morphological and functional outcomes for the donor site. RESULTS All eight flaps were raised on a single septo-cutaneous perforator located between the gluteus maximus and gluteus medius muscles. The internal mammary vessels were chosen as recipients in all cases. The average duration time of the operation was 6 hours and 5 minutes. We report one flap loss. No functional or morphological complications were reported on the donor site. The morphological results on the reconstructed breast were satisfactory or very satisfactory in most cases. CONCLUSION A satisfying breast reconstruction can be achieved with the SGAP flap without changing setup. The use of the septo-cutaneous branch between the gluteus maximus and gluteus medius muscles lengthens the pedicle and reduces the surgery time by facilitating the dissection. SGAP is therefore another autologous technique for breast reconstruction with low morbidity, when a DIEP flap cannot be harvested.

A new strategy for prophylactic surgery in BRCA women: Combined mastectomy and laparoscopic salpingo-oophorectomy with immediate reconstruction by double DIEP flap.

BACKGROUND Prophylactic surgery remains the most effective modality for reducing both breast and ovarian cancer rate in woman at high risk, such as BRCA1 or BRCA2. Autologous breast reconstruction with bilateral deep inferior epigastric perforator (DIEP) flap allows predictable and durable results. However, existing two-step approach separating salpingo-oophorectomy and reconstruction could even make DIEP flap impossible, or make insufflation more difficult during laparoscopy. Other authors described one-step procedure but with open laparotomy. The goal of this study was to verify the feasibility of a simultaneous procedure, including laparoscopic salpingo-oophorectomy. METHODS We included BRCA mutation careers scheduled for simultaneous laparoscopic salpingo-oophorectomy, and bilateral breast reconstruction with DIEP flaps. The first step of the procedure was laparoscopic salpingo-oophorectomy and ports had to be strategically placed to avoid interference with the following procedure. The second step was bilateral breast reconstruction with DIEP flaps. We reviewed medical charts. Surgical procedure was analyzed for duration, revisions and surgical complications. RESULTS During 1-year period, eight patients agreed to a simultaneous procedure. All of them were BRCA positive, mean age was 38.3years (range, 39-50), and mean BMI was 28.3kg/m(2) (range, 21-33). The mean duration of the entire procedure was 524minutes (range, 405-630) and the mean hospital stay 9.2 days (range, 8-14). There was 100% flap survival. No abdominal wall dehiscence occurred. CONCLUSION One-step procedure for prophylactic surgery of ovarian and breast hereditary malignancies is feasible. First salpingo-oophorectomy with open laparoscopy then bilateral immediate or delayed breast reconstruction with DIEP flaps can be performed.

Extensively burned patients still need blood transfusions and skin allografts: unavoidable HLA sensitization requires optimization of VCA access

Dear Sirs, We thank Gaucher and Jarraya [1] for their comments on our study [2]. This first Single Antigen Flow Bead (SAFB) analysis of the strength and breadth of human leukocyte antigen sensitization (supporting information in our study [2]) in extensively burned patients was initiated after facing reduced access to Vascularized Composite Allograft (VCA) transplants for burned candidates. We described its impact on future VCA access and addressed the sensitizing factors and their alternatives. A recent report confirmed this risks of humoral rejection of VCA on sensitized patients [3]. Transfusions are unavoidable in acute care of extensively burned patients. Blood salvage procedures despite feasible have not been widespread due to their poor efficiency/risk (major sepsis) ratio after burns [4]. Red blood cells (RBC) present some HLA molecules that remain a cause of sensitization. In Leffell et al.’s study [5] kidney transplant candidates receiving leucoreduced transfusions presented a 20% risk of HLA sensitization versus 2.4% for nontransfused patient. In our study, all burns patients excepted one (not 100% of the patients, as mentioned by Gaucher and Jarraya) were sensitized, with a relative risk to be hypersensitized 3.3 fold higher when compared to kidney transplantation candidates. This could be explained by quantitative differences in RBC transfusions; however, the amounts of RBC received by the kidney transplant candidates were unavailable, as in Leffell’s study. Skin allografts keep a role after extensive burns, provided a risk benefit ratio analysis in the light of a potential VCA indication. Burns surface under or over 70% TBSA are, respectively, led to use CPSA as overlay on skin autograft (widely meshed or micrografted) [6] or for woundbed preparation before application of cultured autologous keratinocytes (CAK) [7]. As overlay, skin xenografts offer comparable efficacy and cost to CPSA [8], while dermal matrix offers poor adherence to CAK. If Kua et al. [9] compared glycerol (GPSA) with cryopreserved (CPSA) skin allografts for full-thickness burns, it retrieved no significant difference neither for mortality rates nor for length of stay. Richters et al. [10] study reported a very low T-cell response to allogenic glycerol-treated epidermal cells. No immunogenic comparison had been reported between GPSA and CPSA; however, such clinical comparison would require extensive multicentric assessment for a limited clinical relevance. The question of the potentiation between RBC and CPSA would require an animal study. The transfusion of HLA-matched RBC is not clinically applicable due to the number of units required for the acute care. It requires the development of transfusion components lacking the expression of HLA alloantigens. Skin banks with CPSA stocks allowing for HLA-matched skin grafting are not realistic. Antibody reductions by desensitization protocols in highly sensitized kidney transplant candidates are not long lasting and frequently recur. The limited number of patients to survive such extensive burns might limit the development and validation of any HLA sensitization multiparametric score. Gaucher and Jarraya stated that HLA sensitization must be avoided to keep open the option for VCA. This should be moderated as HLA sensitization do not preclude any VCA transplantation but increase the proportion of potential transplants carrying higher risks of humoral rejection. The priority to life-saving procedures for extensive face or hand burns patients should be combined with effort to reduce their sensitization. Their access to transplants can be optimized significantly by replacing the gender-matching usually applied for VCA by a size/morphological one.

Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator Flap

Background The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small‐ and medium‐sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience. Patients and Methods In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those (n = 17) of a bra cup greater than or equal to C who underwent 21 fleur‐de‐lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups. Results The average flap weight was 480 g (range: 340‐735 g) for the fleur‐de‐lys PAP flap group compared with 222 g (range: 187‐325 g) for the horizontal PAP flap procedure (p < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur‐de‐lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur‐de‐lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group (NS). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group (NS). Conclusion The fleur‐de‐lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium‐ or large‐sized breasts, the fleur‐de‐lys PAP flap seems to be ideal when a DIEP flap‐based reconstruction is contraindicated.

Calvarial metastasis of renal cell carcinoma

The calvarium is an extremely unusual site of metastasis of renal cell carcinoma. We report a 62-year-old man who was enrolled for palliative medical management for an exophytic calvarial metastasis. His quality of life was greatly compromised with everyday local care and bandages due to recurrent events of infection and bleeding, limiting his social life. Surgical palliative surgery was carried out to improve the patients quality of life. After tumour resection, the resultant defects of the calvarium and the scalp were covered by a muscular latissimus dorsi free flap and a fascia lata graft as dural substitute. There was no evidence of local recurrence or distant metastasis during the 3 years follow-up. Consequently, resection of solitary metastasis in the early stage is the treatment of choice with a chance to cure the metastasis and avoid associated morbidity that may occur if the lesion is left untreated.

Ultrasound-Guided Bilateral Transversus Abdominis Plane (US-TAP) Block for Postoperative Analgesia After Breast Reconstruction by Deep Intra Epigastric Perforator (DIEP) Flap

Autologous breast reconstruction by deep inferior epigastric perforator (DIEP) flap provides higher postoperative pain at the abdominal donor site than at the thoracic one. The authors evaluated the analgesic efficacy of ultrasound-guided transverse abdominis plane block for postoperative analgesia after immediate breast reconstruction by DIEP flap through an open prospective study of 30 consecutive women undergoing immediate DIEP flap breast reconstruction after modified radical mastectomy for cancer. The last 15 patients received a bilateral ultrasound-guided block with 1.5 mg/kg ropivacaine on each side after DIEP flap harvesting, under general anesthesia. All patients received postoperative acetaminophen and patient-controlled intravenous morphine and were assessed for morphine use, satisfaction with pain relief, and adverse effects. Morphine requirements were significantly lower in the block group than in the control group. Bilateral ultrasound-guided transversus abdominis plane block after breast reconstruction by DIEP flap reduces the interval and cumulative morphine requirements for the first 24 and 48 h, respectively.

Extensively burns patients are not unsuitable candidates to vascularized composite allotransplantations but require optimization in access to suitable transplants

We have read with a great interest the report from Win TS et al. on HLA sensitization in 14 extensively burns patients (TBSA over 40%) who received cryopreserved skin allografts. Over 30 face transplantations have been done worldwide, including one third of burns patients and we congratulate Win et al. for their interest on this topic. Their study is of importance when considering the reduced access to vascularized composite allografts (VCA) in general and not only for face transplant or burns candidates and deserves some comments. VCA requirements in extensively burns patients should not be reduced to face transplantations as upper limbs are often involved. Those patients will often require combined VCA with higher risks of technical failure and medical complications that cumulate to the risks related to the high sensitization. We reported the withdraw from the waiting list of a burned face transplant candidate due to a high (cPRA> 85%) HLA sensitization. We also previously reported the intense and wide HLA sensitization of 29 extensively burns patients with a subsequent extremely reduced access to VCA transplantation with acceptable risks. The concept of “transplant with acceptable risks” is important, as the HLA sensitization is not an absolute contra indication to VCA transplantion, contrary to a positive crossmatch, depending on the risks of early severe rejection as reported by Dr Pomahac’s team (Boston) that the team and patients will opt to face for those procedures. The reported average cPRA value of 87,7 27,6% is comparable to the one we noticed. More than the average