Matthew R. Kaufman

Postoperative medical complications: Not microsurgical complications: Negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer

Background: Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care. Methods: A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions. Results: Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient’s life, occurred in 5 percent of the patients, but there was a 37 percent incidence of “minor” medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs. Conclusion: Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand.

Background: A single surgeon’s experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively. Methods: Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n = 11), dorsal wrist and hand (n = 24), palmar wrist and hand (n = 12), and thumb amputations (n = 5); after release of thumb-index finger web space contractures (n = 6) and radioulnar synostosis (n = 2); before toe-to-thumb transfers (n = 3); for reconstruction following tumor excision (n = 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis (n = 5). Results: Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution. Conclusions: This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedicled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand.

Functional Restoration of Diaphragmatic Paralysis: An Evaluation of Phrenic Nerve Reconstruction

BACKGROUND Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options. METHODS An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications. RESULTS In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values. CONCLUSIONS Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy.

Diaphragm paralysis caused by transverse cervical artery compression of the phrenic nerve: The Red Cross syndrome

BACKGROUND The etiology of diaphragm paralysis is often elusive unless an iatrogenic or traumatic injury to the phrenic nerve can be clearly implicated. Until recently, there has been little interest in the pathophysiology of diaphragm paralysis since few treatment options existed. METHODS We present three cases of symptomatic diaphragm paralysis in which a clear clinico-pathologic diagnosis could be identified, specifically a vascular compression of the phrenic nerve in the neck caused by a tortuous or adherent transverse cervical artery. RESULTS In two patients the vascular compression followed a preceding traction injury, whereas in one patient an inter-scalene nerve block had been performed. Following vascular decompression, all three patients regained diaphragmatic motion on fluoroscopic chest radiographs, and experienced a resolution of respiratory symptoms. CONCLUSION We suggest that vascular compression of the phrenic nerve in the neck may occur following traumatic or iatrogenic injuries, and result in symptomatic diaphragm paralysis.

Diaphragmatic Reinnervation in Ventilator-Dependent Patients with Cervical Spinal Cord Injury and Concomitant Phrenic Nerve Lesions Using Simultaneous Nerve Transfers and Implantable Neurostimulators

BACKGROUND Patients who are ventilator dependent as a result of combined cervical spinal cord injury and phrenic nerve lesions are generally considered to be unsuitable candidates for diaphragmatic pacing due to loss of phrenic nerve integrity and denervation of the diaphragm. There is limited data regarding efficacy of simultaneous nerve transfers and diaphragmatic pacemakers in the treatment of this patient population. METHODS A retrospective review was conducted of 14 consecutive patients with combined lesions of the cervical spinal cord and phrenic nerves, and with complete ventilator dependence, who were treated with simultaneous microsurgical nerve transfer and implantation of diaphragmatic pacemakers. Parameters of interest included time to recovery of diaphragm electromyographic activity, average time pacing without the ventilator, and percent reduction in ventilator dependence. RESULTS Recovery of diaphragm electromyographic activity was demonstrated in 13 of 14 (93%) patients. Eight of these 13 (62%) patients achieved sustainable periods (> 1 h/d) of ventilator weaning (mean = 10 h/d [n = 8]). Two patients recovered voluntary control of diaphragmatic activity and regained the capacity for spontaneous respiration. The one patient who did not exhibit diaphragmatic reinnervation remains within 12 months of initial treatment. Surgical intervention resulted in a 25% reduction (p < 0.05) in ventilator dependency. CONCLUSION We have demonstrated that simultaneous nerve transfers and pacemaker implantation can result in reinnervation of the diaphragm and lead to successful ventilator weaning. Our favorable outcomes support consideration of this surgical method for appropriate patients who would otherwise have no alternative therapy to achieve sustained periods of ventilator independence.

Nerve allograft transplantation for functional restoration of the upper extremity: case series

Abstract Background Major trauma to the spinal cord or upper extremity often results in severe sensory and motor disturbances from injuries to the brachial plexus and its insertion into the spinal cord. Functional restoration with nerve grafting neurotization and tendon transfers is the mainstay of treatment. Results may be incomplete due to a limited supply of autologous material for nerve grafts. The factors deemed most integral for success are early surgical intervention, reconstruction of all levels of injury, and maximization of the number of axonal conduits per nerve repair. Objective To report the second series of nerve allograft transplantation using cadaveric nerve graft and our experience with living-related nerve transplants. Participants Eight patients, seven men and one woman, average age 23 years (range 18–34), with multi-level brachial plexus injuries were selected for transplantation using either cadaveric allografts or living-related donors. Methods Grafts were harvested and preserved in the University of Wisconsin Cold Storage Solution at 5°C for up to 7 days. The immunosuppressive protocol was initiated at the time of surgery and was discontinued at approximately 1 year, or when signs of regeneration were evident. Parameters for assessment included mechanism of injury, interval between injury and treatment, level(s) of deficit, post-operative return of function, pain relief, need for revision surgery, complications, and improvement in quality of life. Results Surgery was performed using living-related donor grafts in six patients, and cadaveric grafts in two patients. Immunosuppression was tolerated for the duration of treatment in all but one patient in whom early termination occurred due to non-compliance. There were no cases of graft rejection as of most recent follow-up. Seven patients showed signs of regeneration, demonstrated by return of sensory and motor function and/or a migrating Tinels sign. One patient was non-compliant with the post-operative regimen and experienced minimal return of function despite a reduction in pain. Conclusions Despite the small number of subjects, it appears that nerve allograft transplantation may be performed safely, permitting non-prioritized repair of long-segment peripheral nerve defects and maximizing the number of axonal conduits per nerve repair. For patients with long, multi-level brachial plexus injuries or combined upper and lower extremity nerve deficits, the use of nerve allograft allows a more complete repair that may translate into greater functional restoration than autografting alone.

Expanded Role and Usefulness of the Mini-Abdominoplasty.

INTRODUCTION: While gluteal augmentation has been a common surgical procedure in western society, it was not as popular as mammoplasty or liposuction in Asian countries. However, as the perspective of beauty changes, more and more oriental women prefer curvy figures than skinny ones. As a result, gluteal augmentation with silicone implant has gained its popularity in our country over the past few years.

Complex incisional hernias repaired in conjunction with the Bony Anchoring Reinforcement System (BARS) prevents hernia recurrence

BackgroundComplex abdominal wall reconstruction and incisional hernia repair have been plagued by high recurrence rates, especially after multiple repair attempts and in those patients with high body mass index. We present an adjunct technique to validated procedures of hernia repair.MethodsThis study is a retrospective analysis of 63 patients between January 2006 and August 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally, and the pubic symphysis after the abdominal fascia was reconstructed.ResultsPatient mean follow-up was 3.1 years (range 6 months to 6 years). None of the 63 patients had recurrent abdominal wall hernias. One patient, from early in the series, had post-operative bulging, which was retreated successfully using the current revised bone anchoring protocol. Five patients developed mesh infections; none of whom required radical debridement or removal of mesh.ConclusionsThe BARS technique for abdominal wall reconstruction provides an excellent reinforcement of fascial reconstruction with decreased hernia recurrence rates.Level of Evidence: Level IV, therapeutic study.

A rare case of staphylococcal toxic shock syndrome after abdominoplasty.

Toxic shock syndrome (TSS) is a serious, potentially life-threatening condition resulting from an overwhelming immunological response to an exotoxin released by Staphylococcus aureus. TSS has rarely been described as a complication after elective aesthetic plastic surgery. We present here the case of a patient who underwent abdominoplasty after massive weight loss and had a near-fatal case of TSS 6 weeks after surgery. Prolonged use of closed suction drains may have been the ultimate source of virulent bacterial growth leading to systemic toxicity. To our knowledge, TSS has not been reported as a complication after abdominoplasty, nor has a case with such a delayed presentation of the disease been described.

Introduction to Rehabilitative Surgery

The paralyzed or severely neurologically impaired patient is one of the greatest challenges in long-term chronic care that we face as clinicians, whether we are therapists or neurologists, physiatrists, or surgeons. Because of the complexity of their treatment and the severity of their injury, these patients may be viewed as a hopeless cause for many physicians, especially surgeons. Optimization of their care – and potentially improvement in quality and length of life – requires a complex and delicate interaction between multiple surgical and medical specialties across disciplines and time.