Complex Reconstructive Procedures Research Articles

Applications of Indocyanine Green (ICG) Fluorescence in Pediatric Colorectal Conditions

Postoperative success in pediatric colorectal surgery hinges on achieving adequate perfusion during complex reconstructive procedures. This review synthesizes findings from recent publications regarding the application of Indocyanine Green (ICG) in various surgical interventions for conditions such as Hirschsprung disease, anorectal malformations, cloacal reconstructions, and others.Preliminary evidence suggests that ICG fluorescence enhances intraoperative decision-making by improving vascular visualization and assessing tissue perfusion. Compared to conventional methods, ICG may offer superior evaluation of intestinal perfusion.While initial reports indicate a favorable safety profile for ICG use in pediatric patients, further prospective studies are needed to confirm these observations, quantify benefits, and assess its impact on surgical outcomes. By providing real-time perfusion data, ICG holds promise for enhancing surgical precision and improving patient outcomes in pediatric colorectal surgery.

Effectiveness of zygomatic-implant fixed rehabilitation for the atrophic edentulous maxilla: protocol for a systematic review and network meta-analysis

BackgroundAtrophic edentulous maxilla is a debilitating condition caused by the progressive and irreversible bone resorption following loss of teeth, that results in bone of inadequate volume and density. This makes conventional implant therapy extremely challenging without complex reconstructive procedures. Several techniques such as sinus augmentation, short implants, and tilted implants have been used for the rehabilitation of the atrophic maxilla. In recent years, zygomatic implants have emerged as a graftless rehabilitation technique. However, few studies compare zygomatic-implant fixed rehabilitation with other fixed rehabilitation techniques. The existing body of evidence on zygomatic implants is largely based on clinical and disease-oriented outcomes.MethodsA network meta-analysis (NMA) will be conducted in order to compare the effectiveness of zygomatic-implant fixed rehabilitation with the other rehabilitation techniques. Experimental and observational studies comparing different implant-assisted fixed rehabilitation in adults with atrophic maxilla will be included. The primary and secondary outcomes will be patient’s satisfaction and quality of life respectively. Additional outcomes include the implant’s survival/success, and biological and prosthetic complications. An electronic search will be performed through various databases for articles in English and French, without time limits. Risk of bias will be assessed using the Revised Cochrane Risk-of-Bias tool for randomized controlled trials, and ROBINS-I for non-randomized and observational studies. Two independent reviewers will screen the titles and abstracts and extract data. Any discrepancy between reviewers will be discussed and resolved through consensus or with the help of a third reviewer.Pairwise meta-analyses will be performed using a random effects model. I2, τ2, transitivity, subgroup/meta-regression analyses will assess and explain heterogeneity and distribution of effect modifiers. A network plot will be created to connect the different interventions directly and indirectly. Interventions will be ranked using the surface under cumulative ranking curve. Confidence in the results of the NMA will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).DiscussionThis study will be the first to assess the effectiveness of zygomatic-implant fixed rehabilitation for the atrophic maxilla using NMA. The evidence obtained will aid clinical decision-making and will advance the knowledge of the rehabilitation techniques for the atrophic maxilla.Systematic review registrationPROSPERO CRD42023353303.

Utilization of Indocyanine Green (ICG) Fluorescence in Patients with Pediatric Colorectal Diseases: The Current Applications and Reported Outcomes.

In pediatric colorectal surgery, achieving and visualizing adequate perfusion during complex reconstructive procedures are paramount to ensure postoperative success. However, intraoperative identification of proper perfusion remains a challeng. This review synthesizes findings from the literature spanning from January 2010 to March 2024, sourced from Medline/PubMed, EMBASE, and other databases, to evaluate the role of indocyanine green (ICG) fluorescence imaging in enhancing surgical outcomes. Specifically, it explores the use of ICG in surgeries related to Hirschsprung disease, anorectal malformations, cloacal reconstructions, vaginal agenesis, bladder augmentation, and the construction of antegrade continence channels. Preliminary evidence suggests that ICG fluorescence significantly aids in intraoperative decision-making by improving the visualization of vascular networks and assessing tissue perfusion. Despite the limited number of studies, initial findings indicate that ICG may offer advantages over traditional clinical assessments for intestinal perfusion. Its application has demonstrated a promising safety profile in pediatric patients, underscoring the need for larger, prospective studies to validate these observations, quantify benefits, and further assess its impact on clinical outcomes. The potential of ICG to enhance pediatric colorectal surgery by providing real-time, accurate perfusion data could significantly improve surgical precision and patient recovery.

A novel solution for the patient with knee ankylosing spondylitis: a case report

Link of Video Abstract: https://youtu.be/wskQdvBx0c0 Background: Knee ankylosis is a joint condition that causes functional limitation that becomes more severe when accompanied by pain. Arthroplasty is a complex and intricate reconstruction procedure that is more challenging when there is a structural limitation that requires a technique modification. In this report, we presented a rare case of a young patient with knee ankylosis and flexion contracture treated with arthroplasty. Case Presentation: A 20-year-old young woman came to the hospital with stiffness in her left knee, inability to sit well and crouch, and difficulty getting up from sitting. Based on the physical examination and X-ray of the left knee, the patient showed bone ankylosis on the femorotibial joint with a 100 flexion, which confirmed knee ankylosis. Arthroplasty was performed with a parapatellar medial approach. After eight months of supervision, the patient was able to perform an active flexion within 1050 and a full extension on the left knee. In our patient, arthroplasty brought a satisfying functional outcome and pain reduction, which was also supported by previous studies with the same procedure on ankylosis patients. Conclusion: Arthroplasty can be considered the main therapy option for joint deformities due to its more satisfying outcomes.

Mohs surgery for female genital Paget’s disease: a prospective observational trial

Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy. This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease. We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival. Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99). Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.

Vesicovaginal Fistulas (VVF): New Dilemmas and Prospectives Review of the Literature

Although they were first described in 2050 BC in Egypt, Vesicovaginal Fistulas (VVF) still remain a challenging entity for both patients and healthcare services. They often result in the continuous, involuntary leakage of urine into the vaginal canal, leading to significant physical discomfort, psychological distress, and social isolation for the affected individuals. Etiology of VVF remains miscellaneous, with the most common etiology being based on obstetric complications during prolonged labor, particularly in developing and low-resource settings. Other causes include pelvic surgery, radiation therapy, trauma, congenital and underlying medical conditions. Effective diagnosis of VVF relies on the combination of clinical assessment, medical history, physical examination, and diagnostic procedures such as cystoscopy, imaging techniques, and dye tests. Proper detection consists crucial concerning successful treatment and can significantly improve the patient's quality of life. Therapeutic mapping approaches for VVF include both surgical and non-surgical interventions. Conservative management may include catheterization, proper nutrition, and the use of vaginal pessaries. However, surgical intervention remains primary treatment option for most cases, aiming the repair of the fistula and restore normal urinary and reproductive function. Surgical techniques range from simple suturing to complex reconstructive procedures, and the choice of approach depends on the size, location, and complexity of the fistula. While surgical repair offers high success rates, comprehensive postoperative care is vital to ensure optimal outcomes. Additionally, supportive care, including counseling, social reintegration, and rehabilitation, plays a crucial role in the overall recovery process. Aim of our study consists assiduous understanding and knowledge of vesicovaginal fistula. The awareness and attention of the scientific society and healthcare providers need to be aroused regarding new prospectives, strategies and methods of detection and management of VVF.

Three- instead of two-dimensional evaluation of key parameters alters the choice of the lowest instrumented vertebra in Lenke 1 and 2 AIS patients.

Treatment of AIS, a three-dimensional spinal (3D) deformity, is guided by a two-dimensional (2D) evaluation. Novel 3D approaches that address the 2D limitations have not been adopted in AIS care due to their lengthy and complex 3D reconstruction procedures. This study aims to introduce a simple 3D method that translates the 2D key parameters (Stable vertebra (SV), Lenke lumbar modifier, Neutral vertebra (NV)) into 3D and to quantitively compare these 3D corrected parameters to the 2D assessment. The key parameters of 79 surgically treated Lenke 1 and 2 patients were measured in 2D by two experienced spine surgeons. Next, these key parameters were measured in 3D by indicating relevant landmarks on biplanar radiographs and using the 'true' 3D CSVL which was perpendicular to the pelvic plane. Differences between the 2D and 3D analysis were examined. A 2D-3D mismatch was identified in 33/79 patients (41.8%) for at least one of the key parameters. More specifically, a 2D-3D mismatch was identified in 35.4% of patients for the Sag SV, 22.5% of patients for the SV and 17.7% of patients for the lumbar modifier. No differences in L4 tilt and NV rotation were found. The findings highlight that a 3D evaluation alters the choice of the LIV in Lenke 1 and 2 AIS patients. Although, the true impact of this more precise 3D measurement on preventing poor radiographic outcome needs further investigation, the results are a first step toward establishing a basis for 3D assessments in daily practice.

V03-07 ROBOTIC INFERIOR VENA CAVA GRAFTING AND RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023V03-07 ROBOTIC INFERIOR VENA CAVA GRAFTING AND RECONSTRUCTION Matthew Lee, Aeen Asghar, David Strauss, Naveen Krishnan, and Daniel Eun Matthew LeeMatthew Lee More articles by this author , Aeen AsgharAeen Asghar More articles by this author , David StraussDavid Strauss More articles by this author , Naveen KrishnanNaveen Krishnan More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although oncologic applications of the surgical robot have become commonplace, its true strength is showcased via complex reconstructive procedures, such as central vessel vascular reconstruction. We demonstrate two cases of inferior vena cava (IVC) robotic assisted laparoscopic (RAL) reconstruction using synthetic grafts. METHODS: First, we show a 78-year-old male with cT3b right renal mass undergoing RAL radical nephrectomy and IVC thrombectomy. After interaortocaval dissection, the right renal artery is divided and the left renal vein, suprarenal IVC, and infrarenal IVC are clamped. The mass invaded a 5-centimeter portion of the IVC, necessitating segmental IVC resection. A 6-centimeter PTFE interposition graft was anastomosed to the IVC to re-establish vascular continuity. Next, a 43-year-old female with an OptEaseTM IVC filter that had eroded through the IVC, deviating the right ureter, required IVC reconstruction. The IVC was clamped proximally and distally. A cavotomy was made and the filter was removed piecemeal. After anterior IVC excision, an 8-centimeter segment of PTFE graft was sutured to the defect as an onlay patch graft. RESULTS: IVC cross clamp time was 108 and 132 minutes, respectively. Length of stay was 6 and 5 days, respectively. Neither patient had any vascular based complications and were discharged home. CONCLUSIONS: We demonstrate that RAL management of complex IVC pathologies requiring IVC reconstruction with synthetic grafts may be safe, feasible, and effective. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e247 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Aeen Asghar More articles by this author David Strauss More articles by this author Naveen Krishnan More articles by this author Daniel Eun More articles by this author Expand All Advertisement PDF downloadLoading ...

Suivi à long terme de patients atteints de chondrosarcome de bas grade du squelette appendiculaire traités par curetage prolongé et azote liquide

BackgroundChondrosarcoma is the second most common sarcoma of bone, accounting for about 25% of primary bone tumors. Histological grading is the single most important determinant of local recurrence and metastases, where low-grade chondrosarcoma (grade 1: atypical cartilaginous lesion) is associated with 10 years survival rate 79-100%. There has been always a debate about the need for wide resection in managing low-grade chondrosarcoma, where several reports describe successful management with intralesional curettage and adjuvant therapy, minimizing the need for complex reconstructive procedures and improving the expected outcomes. HypothesisGrade 1 chondrosarcoma of the appendicular skeleton can be successfully treated through extended curettage and liquid nitrogen with favorable oncological and functional outcomes. Patients and methodsWe retrospectively assessed 113 patients with low-grade chondrosarcoma in the appendicular skeleton, who were treated by extended curettage, adjuvant therapy using liquid nitrogen, reconstruction using polymethyl methacrylate and prophylactic fixation. Patients were assessed regarding incidence of recurrence, incidence of non-oncological complications and functional outcome. ResultsThe mean follow up period was 110 months. In three patients (2.7%), local recurrence occurred. Five point three percent of the patients got non-oncological complications that were successfully managed. The mean MSTS score was 95%, with no evidence of distant metastases or disease related mortality. ConclusionGrade 1 chondrosarcoma in the appendicular skeleton can be effectively treated using extended curettage, liquid nitrogen as adjuvant and cement as filler. Prophylactic fixation is required to avoid pathological fractures. When done properly, excellent functional outcome is expected. Level of evidenceIV, case series (retrospective comparative study).

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users

BackgroundRobotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion.MethodsWe set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons’ characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis.ResultsThe 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy.ConclusionRobotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

SHOULD ALL ISOLATED RADIAL STYLOID FRACTURES BE ASSESSED ARTHROSCOPICALLY FOR CONCOMITANT SCAPHOLUNATE LIGAMENT INJURY?

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries.We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries.10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy.We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures.In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae.

A retrospective comparison between laparoscopic and open ureteroneocystostomy for management of benign lower ureteral strictures: An experience in tertiary care centre of Eastern India.

The objective is to discover the etiopathogenesis of benign lower ureteric stricture in Eastern India and compare the outcome of open versus laparoscopic ureteroneocystostomy. Retrospectively 52 patients who underwent laparoscopic (n = 28) or open ureteroneocystostomy (n = 24) for lower ureteral stricture between January 2018and December 2021 were included. The demography, aetiology, radiologic imaging, intraoperative & postoperative outcomes and follow-up data were collected and analysed. The mean duration of follow up was 14.3 months. Lower ureteric stricture were common in females. The most common cause of the stricture was iatrogenic injury (42%). Other causes were tuberculosis, post-endourological surgery, obstructing mega ureter, endometriosis and idiopathic. Laparoscopic surgery had longer mean operative time (228 vs 171 min), less blood loss (166 vs 246 ml), lower VAS score (6.1 vs 7.22) and less need of post-operative analgesia (1.86 vs 2.36 days). The hospital stay (5.36 vs 6.77 days) and post-operative complications (none vs 3) were also significantly lower in laparoscopic group. Open surgery and laparoscopic surgery had success rate of 100% and 96.6% each. Iatrogenic injury are the most common cause of ureteric stricture followed by tuberculosis. Laparoscopic approach is a feasible option in treatment of lower ureteric stricture as it offer comparable outcome to open procedure while offering the advantage of a minimal invasive technique. Stricture secondary to iatrogenic injury poses a different challenge due to presence of hard dense fibrosis. This is a complex reconstructive procedure and has a steep learning curve and demands high level of laparoscopic skill.

Volar adipofascial flap for fingertip defects

Objectives Adipofascial flap is one of the options for finger defect reconstruction. Dorsal finger adipofascial flaps have been reported in the literature, but volar adipofascial flaps are rarely used. In this article, we describe our fingertip reconstruction technique using volar adipofascial flap coverage, followed by skin or amputated part composite grafting. We performed a retrospective analysis of the survival and functional results of 23 flaps in 21 patients. Methods Operational records were retrospectively scanned for cases of volar adipofascial flap application. Patients with a follow-up time of less than 6 months and those younger than 18 years old were excluded. All the patients were evaluated during the final follow-up period. Demographic data, operated fingers, type of skin graft (composite tissue from the amputated part or other donor site), follow-up time, and time to return to work were recorded. The functional results and complaints were assessed. Results Flap or skin graft total necrosis, which required reconstruction using another procedure, was not observed in any case. Only one finger had a PIP flexion contracture of 15 °. All other fingers achieved full extension. Five patients complained of fingertip hypersensitivity in six fingers (%26.1). The mean return to work time was 3.3 months (2-8). Conclusion Volar adipofascial flap combined with skin or composite grafting is a simple choice for fingertip defects. Avoiding PIP flexion contractures is an advantage. Disadvantages include hypersensitivity and a prolonged healing period. This flap can be used in selected patients to avoid more complex reconstruction procedures.

C2SP-Net: Joint Compression and Classification Network for Epilepsy Seizure Prediction.

Recent developments in brain-machine inter-face technology have rendered seizure prediction possible. However, the transmission of a large volume of electro-physiological signals between sensors and processing apparatuses and the related computation become two major bottlenecks for seizure prediction systems due to the constrained bandwidth and limited computational resources, especially for power-critical wearable and implantable medical devices. Although many data compression methods can be adopted to compress the signals to reduce communication bandwidth requirement, they require complex compression and reconstruction procedures before the signal can be used for seizure prediction. In this paper, we propose C2SP-Net, a framework to jointly solve compression, prediction, and reconstruction without extra computation overhead. The framework consists of a plug-and-play in-sensor compression matrix to reduce transmission bandwidth requirements. The compressed signal can be utilized for seizure prediction without additional reconstruction steps. Reconstruction of the original signal can also be carried out in high fidelity. Compression and classification overhead from the energy consumption perspective, prediction accuracy, sensitivity, false prediction rate, and reconstruction quality of the proposed framework are evaluated using various compression ratios. The experimental results illustrate that our proposed framework is energy efficient and outperforms the competitive state-of-the-art baselines by a large margin in prediction accuracy. In particular, our proposed method produces an average loss of 0.6% in prediction accuracy with a compression ratio ranging from 1/2 to 1/16.

Clinical effectiveness of the Ganga Hospital Open Injury Severity Score for limb salvage versus amputation in patients with complex limb injuries : a systematic review and meta-analysis.

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J2023;105-B(1):21-28.

Upper tract urothelial carcinoma in Germany: epidemiological data and surgical treatment trends in a total population analysis from 2006 to 2019

PurposeTo report contemporary epidemiological data and treatment trends for upper tract urothelial carcinoma (UTUC) in Germany over a 14-year period.MethodsWe analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2018/2019. The significance of changes over time was evaluated via regression analysis. Survival outcomes were calculated using the Kaplan–Meier method.ResultsThere was a non-significant increase in the age-standardized incidence rate from 2.5/100,000 in 2006 to 2.9/100.000 in 2018. 13% of patients presented with lymph node metastasis and 7.6% of patients presented with distant metastasis at primary diagnosis. The 5-year overall survival was estimated at 45% and the 10-year overall survival at 32%. Endoscopic biopsies of the renal pelvis and ureter as well as ureteroscopies with excision/destruction of UTUC all increased significantly over the study period. The number of radical nephroureterectomies (RNU) for UTUC steadily increased from 1643 cases in 2006 to 2238 cases in 2019 (p < 0.005) with a shift from open surgery towards minimally invasive surgery. Complex reconstructive procedures like ileal ureter replacement or autotransplantation are rarely performed for urothelial carcinoma of the ureter.ConclusionDiagnostic and therapeutic procedures for UTUC have increased and minimally invasive nephroureterectomy is the predominant approach concerning radical surgery in 2019.

Racial and geographic disparities in reconstructive procedures following melanoma resection.

Melanoma occurs most commonly in non-Hispanic White patients; however, Black and Hispanic patients experience greater morbidity and mortality. This study assesses how race and socioeconomic factors influence rates of reconstructive procedures and hospital-based outcomes in melanoma patients. Data were extracted from the National Inpatient Sample database from the years 2010-2015. Patients with melanoma who underwent a reconstructive procedure were identified. Univariate and multivariate logistic regression analysis was used to identify the relationship between dependent variables and various patient/hospital components for patients undergoing reconstructive procedures. Black and Hispanic patients had a greater length of stay (LOS) than non-Hispanic White patients (OR: 2.252, p=0.0307, and OR: 2.592, p=0.0014), and Hispanic patients were less likely to receive more complex reconstructive procedures (OR: 0.449, p=0.0487). Patients living in rural areas were less likely to receive complex reconstructive procedures than those in both urban teaching and non-teaching hospitals (OR: 3.313, p=0.0135, and OR: 3.505, p=0.0074). Pedicled or rotational flaps were less likely to be performed at medium- or large-sized hospitals (OR: 0.610, p=0.0296, and OR: 0.496, p=0.0002). Race and socioeconomic factors are important predictors of access to complex reconstructive procedures and hospital-based outcomes following extirpation in melanoma patients.

610. NOVEL HYBRID TECHNIQUES FOR DELAYED RECONSTRUCTION OF THE CERVICAL PART OF A LEFT COLON INTERPOSITION: A CASE REPORT

Abstract Conduit necrosis following colon interposition for esophageal replacement is a devastating complication with a high morbidity and mortality rates. Survivors often face a challenging journey of complex reconstructive procedures. A multi-disciplinary approach is paramount to tailor the management according to the patient's anatomy, nutritional and psychological status, conduit alternatives and routes. This case report provides a series of novel reconstructive techniques, each of which could be helpful for esophageal surgeons facing such difficult situation. A 36 years old female, with a history of corrosive ingestion at the age of 5 years, who was subjected to series of regular dilatation since then, presented with a tight stricture not passing a wire. She underwent a subcutaneous isoperistaltic left colon interposition. The postoperative course was complicated with necrosis of the cervical part of the graft with infection of the subcutaneous tunnel. Resection was done with esophagostomy and colostomy in the neck. The patient survived the acute stage, feeding was established through the colostomy opening in the neck. Delayed reconstruction was planned 6 months later. The skin between the two openings in the neck was considered posterior wall of the conduit, and transaxillary pedicled thoracodorsal artery perforator flap (TDAP) was used to reconstruct the anterior wall (1,2). Partial flap loss occurred (3). Debridment and gastrostomy were done. The result was two gaps on both ends of the flap (3). The food regurgitated upwards from the gastrostomy. An antireflux stent was placed inside the flap to bridge the defects and allow oral intake (4). The TDAP-colon side was closed using a local flap from TDAP and skin graft (5,6). The esophageal side was closed primary and covered by a supraclavicular flap (7-12). Management of graft failure should focus on controlling sepsis and nutrition. Attempts should be made to preserve any surviving part of the conduit as long as it doesn’t add to sepsis. A combination of Myocutaneous flaps could be used to replace the cervical part of the conduit as TDAP and supraclavicular flaps. Stent could be used successfully to bridge a failure in a skin flap. Finally, a dedicated team is paramount for a successful outcome.

Long-term follow up of patients with low-grade chondrosarcoma in the appendicular skeleton treated by extended curettage and liquid nitrogen

BackgroundChondrosarcoma is the second most common sarcoma of bone, accounting for about 25% of primary bone tumors. Histological grading is the single most important determinant of local recurrence and metastases, where low-grade chondrosarcoma (grade 1: atypical cartilaginous lesion) is associated with 10 years survival rate 79-100%. There has been always a debate about the need for wide resection in managing low-grade chondrosarcoma, where several reports describe successful management with intra-lesional curettage and adjuvant therapy, minimizing the need for complex reconstructive procedures and improving the expected outcomes. HypothesisGrade 1 chondrosarcoma of the appendicular skeleton can be successfully treated through extended curettage and liquid nitrogen with favorable oncological and functional outcomes. Patients and methodsWe retrospectively assessed 113 patients with low grade chondrosarcoma in the appendicular skeleton, who were treated by extended curettage, adjuvant therapy using liquid nitrogen, reconstruction using polymethyl methacrylate and prophylactic fixation. Patients were assessed regarding incidence of recurrence, incidence of non-oncological complications and functional outcome. ResultsThe mean follow up period was 110 months. In three patients (2.7%), local recurrence occurred. Five point three percent of the patients got non-oncological complications that were successfully managed. The mean MSTS score was 95%, with no evidence of distant metastases or disease related mortality. ConclusionGrade 1 chondrosarcoma in the appendicular skeleton can be effectively treated using extended curettage, liquid nitrogen as adjuvant and cement as filler. Prophylactic fixation is required to avoid pathological fractures. When done properly, excellent functional outcome is expected. Level of evidenceIV, Case series (retrospective comparative study).

NEGATIVE PRESSURE WOUND THERAPY (NPWT): OUR EXPERIENCE USING HOSPITAL WALL SUCTION

Study Design: Prospective case series Delayed wound healing is a signicant concern, particularly in Introduction: complex wounds and the elderly with co-morbidities. It leads to pain, morbidity, prolonged treatment, and requires major reconstructive surgery, which imposes an enormous social and nancial burden. Negative Pressure Wound Therapy (NPWT) was used to cover large wounds, decubitus ulcers, and open fractures that cannot be closed either primarily or secondarily and often require a complex reconstructive procedure to protect the injury. NPWT is an alternative method of wound management, which uses the negative pressure to prepare the wound for spontaneous healing or by lesser reconstructive options. We applied NPWT on pa Materials and Methodology: tients with open fractures, decubitus ulcers, neglected wounds, fasciotomies, and large wounds. Compared to the patented VAC system, ours include pre-sterilized PVA foam, cling drape (Surgiwear TM), nasogastric tube or an infant feeding tube, and a hospital wall suction. There Results: were three cases of soft tissue injury of the foot with wound defect, one case of fasciotomy for compartment syndrome, one case of the decubitus ulcer, one case of open fractures, and three cases of degloving injuries of the foot. In our study, the NPWT was changed every ve days, the average number of NPWT changes was 3-4, length of time NPWT applied before the closure was 14-21 days. The most frequent coverage mode is Split Thickness Skin Graft obviating the need for more complex aps and microvascular reconstructive procedures. Negative Conclusion: pressure therapy stabilizes the wound environment, reduces wound edema/bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis. NPWT appears to be simple and more effective than conventional dressings for managing complex wounds, reducing wound volume, depth, treatment duration, and cost.