Ryckie G. Wade

The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction: A systematic review and meta-analysis

BACKGROUND The rate of bilateral mastectomy and bilateral breast reconstruction is increasing. The DIEP flap is an ideal method of breast reconstruction. The difference in risk of adverse outcomes between unilateral and bilateral DIEP flap breast reconstruction is unclear. The aim of this review is to investigate this relationship. METHODS Authors searched Ovid EMBASE and MEDLINE from database inception to March 2012, for reports of DIEP flap breast reconstruction studies. After screening, data were extracted on flap-related, donor-site and systemic adverse events. Descriptive statistics were generated for all pooled data. We performed meta-analysis of direct comparisons to generate relative risk (RR) ratios with 95% confidence intervals (CI) using a random-effects model. RESULTS Overall, 17 case-series of 2398 women were included. Compared with unilateral DIEP flap breast reconstruction, bilateral reconstruction was associated with a significantly higher risk of total flap failure (RR 3.31 [95% CI 1.50-7.28]; p = 0.003) and breast seroma (RR 7.15 [95% CI 1.21-42.36]; p = 0.03). Differences between other outcomes were non-significant, although descriptive analysis appeared to favour unilateral reconstruction. CONCLUSIONS The current literature related to DIEP flap breast reconstruction appears to be of low quality. However, this is the first systematic review confirming that bilateral DIEP flap breast reconstruction is associated with a significantly higher risk of total flap failure compared to unilateral DIEP flap breast reconstruction. This review will allow clinicians to better inform patients of the risks of adverse outcomes in DIEP flap breast reconstruction. It also highlights the need for higher quality research in this area.

Venous perforators in DIEAP flaps: An observational anatomical study using duplex ultrasonography *

BACKGROUND The DIEAP flap has gained popularity for breast reconstruction worldwide. Despite DIEAP flap arterial anatomy being well known, venous congestion is still an important complication and the literature on DIEAP flap venous anatomy is lacking. Venous drainage is less predictable and research on venous perforators is of increasing interest. The aim of this study was to investigate the anatomical distribution, diameters and relationships between arterial and venous perforators and their source vessels using Duplex ultrasonography, in order to evaluate the potential benefits of pre-operative evaluation of DIEAP flap venous perforators. METHODS Prospectively, 140 patients undergoing DIEAP flap breast reconstruction, were pre-operatively assessed using Duplex ultrasonography for location and diameter of arterial and venous perforators, DIEA, DIEV, and SIEV. Perforators were plotted laterally and inferiorly from the umbilicus. Means were compared using t-tests. Pearsons correlation coefficients were calculated. RESULTS We identified 702 arterial and 355 venous perforators in 280 lower hemi-abdomens. No venous perforators were identified in 9 (6.5%) patients; none on the right in 25 (17.9%) and none on the left in 36 (25.7%). Venous perforators were larger on the right (p=0.031) but DIEV and SIEV diameters were not statistically different on either sides. The diameters of DIEA, DIEV, perforating arteries and veins were correlated, but unrelated to the diameter of the SIEV. When a medium/large perforator vein is identified first, there is a 93.5% chance of finding an associated medium/large perforator artery; this reduces to 69.8% when a medium/large perforator artery is first identified. CONCLUSIONS There is no correlation between the sizes of perforator veins and DIEV, and the size of the SIEV. Our data suggests that first identifying a medium/large venous perforator increases the chances of finding a better suitable perforator complex. Pre-operative evaluation of venous perforators may be of great interest for its potential clinical benefits.

Is it Safe to Ligate the Left Renal Vein During Open Abdominal Aortic Aneurysm Repair

BACKGROUND Open repair of juxta-renal abdominal aortic aneurysms (AAA) sometimes involves the ligation and division of the left renal vein (LRV). Some surgeons advocate repair, but this is not common practice. The aim was to study the effect of LRV ligation on renal function. METHODS A retrospective audit of all open AAA repairs between February 2004 and September 2007 in our unit was completed. Pre- and postoperative renal function was assessed with the estimated glomerular filtration rate (eGFR), using an established formula. RESULTS Two hundred sixty-one open AAA repairs were performed in the study period. The LRV was ligated in 18.8%; mean age was 75.5 years, 35 were men, mean AAA diameter was 7.8 cm, there were 7 elective, 22 urgent, and 19 emergency AAA repairs. Renal function with LRV ligated was compared with the 212 patients without LRV ligation by independent samples t-testing. The baseline mean serum creatinine and glomerular filtration rate in the LRV ligated group were 115.1 micromol/L and 60.6, respectively, which were similar to the LRV not ligated group (p > 0.05). The renal function at postoperative day 1, day 7, and weeks 2-6 was similar in the two groups (p > 0.05). The postoperative renal function on day 1 was significantly worse compared to baseline (p < 0.05), but not at day 7 and weeks 2-6 (p > 0.05). CONCLUSION In patients undergoing LRV ligation, there is an initial drop in renal function which improves over 2-6 weeks. At each stage, the renal function is similar to patients in whom the LRV is not ligated. LRV ligation is safe during open AAA repair.

Orbital varix thrombosis: a rare cause of unilateral proptosis

Orbital varices are thin walled, low flow, distensible veins which may rarely present with periorbital pain, proptosis or visual loss. Most orbital varices may be managed conservatively and only warrant surgery in the presence of recurrent thrombosis, disfiguring proptosis or acute visual loss. This report concerns an 84-year-old Caucasian woman who was admitted following a fall and noted to have isolated proptosis of the right eye, with vertical diplopia. All biochemical and haematological investigations were normal. A CT scan of the orbits demonstrated a serpiginous soft tissue mass within the superior portion of the right orbit, consistent with a thrombosed orbital varix. Conservative management was agreed with prism glasses and ophthalmological follow-up.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery.

Abstract Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken. Fluid input included crystalloids, colloids, or blood products. Fluid output included urine, blood, or suctioned fluid. Postoperative fluid balance was calculated as fluid input − output. Fluid input between groups was not different. Fluid output was greater in the ED group (P = 0.008). The ED group showed less fluid balance (P = 0.023), less anesthetic time (P = 0.001), less hospital stay (mean 1.9 days; P = 0.147), less monitoring and flap complications (P = 0.062). ED monitoring demonstrated no monitoring complications, provides a favorable postoperative fluid balance, and may reduce flap complications and hospital stay.

Try Google Translate to overcome language barriers

In 2007 Jones debated whether the NHS should curb spending on translation services.1 In 2011 the NHS might consider Google Translate—a free application for iPhones and Android devices and an effective alternative way of communicating with non-English speakers. The user …

Skin involvement in Dupuytren’s disease

Whether the palmar skin has a role in the development, propagation or recurrence of Dupuytren’s disease remains unclear. Clinical assessment for skin involvement is difficult and its correlation with histology uncertain. We prospectively biopsied the palmar skin of consecutive patients undergoing single digit fasciectomy (for primary Dupuytren’s disease without clinically involved skin) and dermofasciectomy (for clinically involved skin or recurrence) in order to investigate this relationship. We found dermal fibromatosis in 22 of 44 patients (50%) undergoing fasciectomy and 41 of 59 patients (70%) undergoing dermofasciectomy. Dermal fibromatosis appeared to be associated with greater preoperative angular deformity, presence of palmar nodules and occupations involving manual labour. Dermal fibromatosis exists in the absence of clinical features of skin involvement and we hypothesize that the skin may have a greater role in the development and propagation of Dupuytren’s disease than previously thought. Level of evidence: III

Radial artery blood gas sampling: a randomized controlled trial of lidocaine local anesthesia

Radial artery puncture is a common procedure and yet the role of local anesthesia for reducing the pain of this procedure continues to be debated. Clinical practice is variable and there is potential for substantial financial savings. This is the first randomized trial to investigate the effectiveness of subcutaneously injected lidocaine anesthesia on the perceived pain of radial artery puncture and the financial impact.

Hand surgery for Multicentric Reticulohistiocytosis: A new avenue of treatment and review of the literature.

INTRODUCTION Multicentric Reticulohistiocytosis (MRH) is a rare non-Langerhans cell histiocytosis characterised by destructive polyarthritis and violaceous skin papules. PRESENTATION OF CASE In 2010, a 70-year-old woman with Palindromic Rheumatism was diagnosed with MRH. Within a few months, she developed ankylosis of the small joints of both hands which resulted in severe fixed flexion deformities of the fingers and thumbs. The joint disease failed to respond to medical therapies and the palmar skin of her left hand was becoming increasingly macerated. Therefore, she elected to undergo arthrodesis of the metacarpophalangeal joints to allow hand hygiene. DISCUSSION To-date, this is the first report of a surgical intervention for this rare condition and represents a novel avenue of potential therapy. Medical therapies for MRH are usually ineffective in preventing the debilitating small joint disease which often develops and there is on-going research into newer agents and alternative surgical techniques. CONCLUSION Once medical therapies are exhausted, clinicians should consider the input of Hand Surgeons in managing the inevitable and mutilating joint disease of this rare condition.

Perceived impact of EWTD on UK doctors

Doctors have historically worked long hours to provide patient care but also to gain experience. Over the last decade, working hours have decreased significantly, and the introduction of the European Working Time Directive (EWTD) has formalised this. In August 2009, junior doctors (but not consultants) will be limited to a 48-hour working week (see http://www.dh.gov.uk/en/Managingyourorganisation/Huma nresourcesandtraining/Modernisingworkforceplanninghome/Europeanworkingtimedirective/index.htm). There are concerns at all levels of the profession that doctors will not be adequately trained to function at the standard of a current NHS consultant. Doctors with the least experience make the most errors and familiarity with situations and equipment is directly related to competency.