Raghuveer Reddy

Effect of external volume expansion on the survival of fat grafts

Introduction: External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear. Aims and Objectives: This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat. Materials and Methods: Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat. Results: All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention. Conclusions: A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.

First two bilateral hand transplantations in India (Part 1): From vision to reality

Introduction: Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015. Materials and Methods: The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services. Results: Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines. Conclusions: The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome

Introduction: This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India. Materials and Methods: The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year. Results: Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand. Conclusion: Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the “standard of care” for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.

First two bilateral hand transplantations in India (Part 2): Technical details

Introduction: This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream. Materials and Methods: The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient. Results: The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines. Conclusions: Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

Soft embalming of cadavers for training purposes: Optimising for long-term use in tropical weather

Background: Surgical and anatomical training has been found to be most optimally simulated in a cadaver than any other available methods. Soft embalming methods have made the bodies more ‘lifelike’ and better suited for training. The widely accepted soft embalming techniques, including Thiel embalming, are designed for temperate climates. Their use in tropical locations has been found to be associated with poor short-term and long-term preservation of the bodies. In fact, adequate reports from tropical countries on effective methods for soft embalming are lacking. Materials and Methods: This article details the modifications made in the Thiel embalming technique over a period of 2 years which has enabled us to preserve the anatomical features of bodies in an optimal way for longer periods in tropical conditions. This study was carried out in a tertiary care referral centre located in a tropical climate zone. A total of 13 frozen and thawed cadavers were used over a period of 2 years for developing such soft embalming technique. The efficacy of the technique was tested using these cadavers for varying types of surgical exercises on multiple occasions. Results: The conventionally described technique of Thiel embalming did not provide desired results. Hence, various modifications to this technique were instituted which helped us to get superior quality of soft-embalmed cadavers. In the final year, these cadavers were used successfully for workshops in flap dissection. Head and neck access surgery, arthroscopic and laparoscopic procedures as well as mock face and hand transplant dissections. Conclusions: The Theil embalming technique for obtaining soft embalmed cadavers, even though found to be best in many centres in the world, has not been found to be suitable to tropical weather. By modifying it, we have succeeded in developing a technique suitable to the tropical weather. This technique yields cadavers suitable for various surgical simulation exercises. This technique also allows the body to be optimally used over several months in multiple occasions. These modifications are very simple and have been described in detail enabling it to be adopted by any surgical skill laboratory in the tropical countries.

SU‐E‐J‐51: Effect of Exactrac 6D Correction On Dose for SRT Patients with IR Body Markers

PURPOSE To study the 6D correction efficacy on dose to the target due to infrared(IR) body marker localization for stereotactic radiotherapy(SRT) patients Methods: Commercially available laboratory skull phantom, made of plastic is used in this study.It is filled with physiotherapy wax and a provision is made to insert CC13 ion-chamber(0.13cc). The dose at a point in skull phantom is measured by CC13 ion-chamber.An ordinary thermoplastic mould is prepared for skull phantom and 5 infrared body markers are placed at different places for localization as shown in figA. CT scan of the phantom is obtained using Siemens PET-CT scanner with and without ion-chamber. Treatment Planning is done on images which are without ion chamber .In the absence of ion chamber to fill the cavity a wax insert is inserted during the CT scan. 3mm slice thickness are obtained and imported to Eclipse treatment planning system(TPS) for contouring and planning.Treatment plans of 3D CRT/IMRT are planned in Eclipse on skull phantom images with isocenter placed at the chamber sensitive volume.The plan is exported to Exactrac imaging system for localization and verification. After setup of skull phantom imaging is done with exactrac stereoscopic imaging system and the 6D shifts (Vertical,logitudenal,lateral,yaw,pitch,roll) are applied. The focus to skin distance(FSD) is noted-Table1.The radiation dose is delivered in Varian Novalis Tx.The charge collected /dose in CC13 ion chamber is noted from the DOSE1 electrometer-Table2.The planned FSD and dose are noted from TPS. RESULTS The mean difference between planned and measured FSD and Dose are 0.55cm and 2.7% respectively. The mean SD of FSD and Dose are 0.383 and 1.58% respectively. CONCLUSION Even though Exactrac-6D couch shifts introduce change in FSD by 1-1.5cm the dose difference is within the range of 3% and is reasonable to treat frame less SRT treatments with IR body markers with ordinary mask.

Mapping of wastelands of Kolar district using false colour composites of thematic mapper (TM) data

This study deals with the technique of remote sensing for identifying and deliniating wastelands in Kolar district of Karnataka. False colour composites of thematic mapper (TM) data supplemented by aerial photographs and toposheets wrere utiliesd for mapping wastelands. A map showing the geographic distribution of the wastelands in the districts was prepared on 1∶250,000 scales by compiling the individual wasteland sheets of 1∶50,000 scale. The seven different catagories of wastelands identified and mapped cover about 11.7% of the area in the district. A procedure for mapping wastelands has been worked out based on the experience gained in Kolar district which is a three phase system comprising image intrepretation of false colour composite of TM data, aerial photo interpretation and limited ground truth verification in the selected doubtful areas. This procedure was found to be adequate enough for mapping wastelands accurately in the shortest possible time with least expense and as such are recommended for mapping wastelands in other districts of the country.