Vishwanath Chegireddy

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction

IntroductionInternal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings.MethodsA retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed.Results581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation.ConclusionsOpportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation.Level of Evidence IVCase series.

Porcine Acellular Lung Matrix in Wound Healing and Hernia Repair

The introduction of synthetic polypropylene mesh in hernia repair has improved the results of herniorrhaphy. To introduce mesh is to introduce foreign bodies that can impact the human body and may lead to inflammation, infection, fibrosis, calcification, seromas, or adhesions to vital organs such as the bowel. Bioprosthetic meshes, generated from source organs source such as the dermis or small intestine, have emerged as commercially available products for use in hernia repair. The authors discuss the ideal mesh, tissue engineering and hernia repair, bioprosthetic mesh and use in the contaminated field, and porcine acellular lung matrix (PALM) as a natural scaffold capable of cell attachment, while maintaining cell viability was investigated as a novel prosthetic for repair and has demonstrated enhanced incorporation and short-term mechanical stability in a chronic ventral incisional hernia model with bridging repair.

Evaluation of the single medial circummuscular perforator DIEP flap: Outcomes and comparison to traditional transmuscular single perforator flap

Successful breast reconstruction using deep inferior epigastric perforator (DIEP) flaps depends on optimal perforator choice. Circummuscular wraparound medial perforators allow for no rectus dissection and minimal fascial incisions, often presenting as an ideal option. The aim of our study is to evaluate outcomes of the single medial wraparound perforator flap in comparison to more traditional transmuscular single‐perforator DIEP flaps.

Two successful cases of DIEP flaps for breast reconstruction in patients with Factor V Leiden

Abstract Factor V Leiden (FVL) is the most common inherited hypercoagulable condition. It is a genetic disorder caused by a missense mutation that prevents inactivation of Factor V in the clotting cascade, leading to overproduction of thrombin and excess clotting. This pathophysiological process is especially unfavorable in patients undergoing free tissue transfer. Many authors have noted a propensity for both venous and arterial thrombosis leading to partial or complete flap loss. To date, there have been no published reports of patients with FVL undergoing deep inferior epigastric perforator flap reconstruction without flap complications. Here, the authors present two cases of successful free tissue transfer for breast reconstruction in patients with diagnosed FVL. The perioperative thromboelastography lab values are evaluated to help guide anticoagulation regimen for these high-risk procedures.

Training Effects of Visual Stroboscopic Impairment on Surgical Performance: A Randomized-Controlled Trial

OBJECTIVEnThere have been numerous advances to accelerate and improve quality and dexterous proficiency of surgical training to meet the growing US demand of graduating surgeons. The authors aimed to investigate the learning effects of such limited visual input on the surgical proficiency in untrained novice surgeons.nnnDESIGNnA prospective randomized-controlled study was created with 11 participants in the study and 11 in the control group.nnnSETTINGnAn inanimate surgical simulation lab of a tertiary academic institution (Houston Methodist Hospital, Houston, Texas).nnnPARTICIPANTSnAdult medical students in the experimental group were wearing stroboscopic eyewear while performing the same tasks as students in the control group with normal vision. For 5 weeks, the subjects were scored during 3 standardized surgical tasks from the American College of Surgeons and the Association of Program Directors in Surgery Resident Skills Curriculum: knot tying, simple interrupted sutures, and a running stitch. Pretrial, we employed the State-Trait Anxiety Inventory and post-trial, the NASA Task Load Index.nnnRESULTSnThe demographic characteristics of our study participants were uniformly distributed between the 2 cohorts: each group had 7 males and 4 females. Average ages were 23.6 and 24.2 years (pu202f=u202f0.471). The anxiety was low during all 5 sessions and indifferent between both groups. At the end of the study, no changes were observed in the stroboscopic group for the knot-tying task (pu202f=u202f0.619). However, for the simple interrupted and the running stitch, the students with stroboscopic glasses performed significantly better (pu202f=u202f0.001 and pu202f=u202f0.024, respectively). The stroboscopic students also had significantly lower NASA workload scores (pu202f=u202f0.001).nnnCONCLUSIONSnRegular training with stroboscopic glasses that limit visual input has a significant positive effect on the technical skills of novice surgical trainees with regards to more complex tasks such as multiple simple interrupted suturing or running suture. Intermittently impaired vision is beneficial in the early education of students and surgical residents.

Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography

Background Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patients coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications. Methods A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points. Results A total of hundred patients were identified, who underwent 172 abdominal‐based free flaps for breast reconstruction. TEG was more dynamic compared with PT or aPTT and demonstrated borderline hypocoagulate values intraoperatively upon unfractionated heparin administration and hypercoagulate values postoperatively. In contrast, PT and aPTT demonstrated a continuously hypocoagulable state. Complications included five thrombotic events and three hematomas. The thrombotic cases had much steeper increases of TEG‐ G between surgery and postoperative day 2 (p = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery. Conclusion The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients changing coagulation status.

Multi-institutional analysis of independent predictors for burn mortality in the United States

BackgroundPrevious reports individually identified different factors that predict death after burns. The authors employed the multi-center American Burn Association’s (ABA) National Burn Repository (NBR) to elucidate which parameters have the highest negative impact on burn mortality.MethodsWe audited data from the NBR v8.0 for the years 2002–2011 and included 137,061 patients in our study. The cases were stratified into two cohorts based on the primary outcome of death/survival and then evaluated for demographic data, intraoperative details, and their morbidity after admission. A multivariable regression analysis aimed to identify independent risk factors associated with mortality.ResultsA total of 3.3% of patients in this analysis did not survive their burn injuries. Of those, 52.0% expired within 7xa0days after admission. Patients in the mortality cohort were of older age (pu2009<u20090.001), more frequently female (pu2009<u20090.001), and had more pre-existing comorbidities (pu2009<u20090.001). Total body surface area (TBSA), inhalation injury, hospitalization time, and occurrence of complications were higher compared to survivors (pu2009<u20090.001). Lack of insurance (odds ratio (OR)u2009=u20091.84, confidence interval (CI) 1.38–2.46), diabetes (ORu2009=u20091.24, CI 1.01–1.53), any complication (ORu2009=u20094.09, CI 3.27–5.12), inhalation injury (ORu2009=u20093.84, CI 3.38–4.36), and the need for operative procedures (ORu2009=u20092.60, CI 2.20–3.08) were the strongest independent contributors to mortality after burns (pu2009<u20090.001). Age (ORu2009=u20091.07, CI 1.06–1.07) and TBSA (ORu2009=u20091.09, CI 1.09–1.09) were significant on a continuous scale (pu2009<u20090.001) while overall comorbidities were not a statistical risk factor.ConclusionUninsured status, inhalation injury, in-hospital complications, and operative procedures were the strongest mortality predictors after burns. Since most fatal outcomes (52.0%) occur within 7xa0days after injury, physicians and medical staff need to be aware of these risk factors upon patient admission to a burn center.