Subcutaneous Tunnel Research Articles

Single-incision endoscope-assisted breast-conserving surgery and sentinel lymph node biopsy: prospective SINA-BCS cohort study.

The current consensus on surgical treatment for early breast cancer is to ensure oncological safety during surgery while preserving functions and aesthetics1–3. Minimally invasive endoscopic surgery has become widely used in modern surgery4–6. Endoscope-assisted surgery allows incision concealment and scar minimization, thereby optimizing aesthetic outcomes and patient satisfaction7–10. The shortcomings of endoscope-assisted surgery are, however, also prominent, including limited working space, increased surgical difficulty11, prolonged operating time, need for additional laparoscopic instruments, and increased costs9,10,12. This study describes single-incision, non-lipolytic, endoscope-assisted breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB), the SINA-BCS technique, and compares its perioperative outcomes and cosmetic properties with those of conventional BCS and SLNB (C-BCS). This single-centre prospective cohort study evaluated the efficacy and benefits of SINA-BCS in patients with breast cancer. The study was approved by ChiECRCT (ChiECRCT20200410) and registered at Chictr.org.cn (ChiCTR2100043403). Written informed consent was obtained from all patients. Women aged 20–80 years with pathologically diagnosed cTis–2 N0 breast cancer, who were treated at the West China Hospital of Sichuan University from July 2020 to September 2022, were included. The decision to perform either SINA-BCS or C-BCS was made jointly by the patients and surgeons. Lumpectomy procedures were the same for SINA-BCS and C-BCS. Dual tracers with radioisotope and blue dye were used for SNLB. The operating space of the axilla was established using a non-liposuction method. A subcutaneous tunnel was gradually created through the lumpectomy incision, and expanded by subcutaneous dissociation of the breast tissue toward the axilla. SLNB of SINA-BCS was performed by means of polar diathermy scissors and ultrasonic scalpels, using the working space established through the subcutaneous tunnel and a specifically designed retractor system (Fig. 1). The radionucleotide probe was also inserted through the same incision to detect hot nodes. For C-BCS, an additional 3–4cm axillary incision was made for SLNB (Fig. S1).

Pronator quadratus musculo-osseous free flap for wide hard palatal defect reconstruction: An anatomical study

Wide hard palate defects include congenital and acquired defects that are six square centimeters or larger in size. Obturator prostheses and autologous soft tissue transfers have been used to reconstruct palatal defects. This study aims to repair wide, hard palatal defects by using a pronator quadratus musculo-osseous free flap to achieve subtotal reconstruction. Seventeen formalin-fixed cadavers were dissected. Free musculo-osseous pronator quadratus flaps were prepared after a 12 cm curvilinear volar skin incision. Standard 30 × 23 mm (690 ± 52.12 mm2) hard palate defects were made by chisels and saws. A subcutaneous tunnel was created between the mandibular edge cross point of the facial vessels and the retromolar trigone through the subcutaneous to the superficial musculoaponeurotic system by dissection. Area measurements of the pedicle and palate defects were performed by the ImageJ program (National Institutes of Health, Bethesda, MD, USA) on drawings over an acetate layer of materials. Mandibular distances of gonion-facial vessel cross point (a), gonion-gnathion (m), and facial vessels’ cross point-retromolar entrance point (h) were measured. Ratios of h/m and a/m were calculated. The mean pronator quadratus area was 2349.39 ± 444.05 mm2, and the arterial pedicle pronator quadratus diameter was 2.32 ± 0.34 mm. The mean pedicle length of the pronator quadratus was 117.13 ± 8.10 mm. Study results showed that musculo-osseous pronator quadratus flaps’ bone and muscle parts perfectly fit on the defects in all cadavers. Pronator quadratus musculo-osseous flap is a feasible surgical option for wide, hard palatal defect reconstruction strategies.

ASSESSING DEGREE OF EXTERNAL DISLOCATION OF EPIDURAL CATHETER IN CLINICAL PRACTICE IN TRAUMA PATIENTS

For the purpose of the study, we selected 73 patients who underwent combined two-level spinal-epidural anesthesia with a catheter in the subcutaneous tunnel during operations for lower limbs fractures. All patients underwent postoperative epidural analgesia. We applied a method for assessing the degree of external dislocation of the epidural catheter and an algorithm of actions when a dislocation of the epidural catheter is detected. When changing the fixing aseptic sticker, the degree of epidural catheter dislocation was assessed, and if a pronounced dislocation was detected, additional measures were taken to enhance the fixation of epidural catheter. In 14 cases, we used additional fixation devices “Epi-Fix”, which was associated with the threat of falling out of the epidural catheter with a pronounced degree of dislocation. Additional fixation in this case helped to avoid prolapse and ensure continuation of anesthesia. However, in two cases, the epidural catheter was removed because the dislocation corresponded to the 6th degree of the proposed scale, and its continued use was useless. Thus, the use of the scale we developed enables to monitor and assess the risk of worsening anesthesia and catheter migration or prolapse. Further tactics in relation to prolonged anesthesia depend on an objective assessment of the position of the catheter.

Utilização de flap de omento para indução da cicatrização de enxertos cutâneos

ABSTRACT The objective of this study was to assess healing induction of free skin grafts following transposition of omental flap through a subcutaneous tunnel to the recipient bed. Macroscopic and microscopic evaluations were performed. Nineteen piglets were used. Two surgical wounds were created of each subject. The graft removed from the left side (LS) was placed on the right side (RS) without the omental flap in the graft-bed (control group-CG). On the LS, an omental flap was placed between the graft removed from the RS and the recipient bed (omentum group-OG). Macroscopic evaluations showed edema, which gradually decreased on both groups. Suture dehiscence was highest at day 10 compared to other days in both groups. The CG had a higher incidence of unvitalized tissue compared to OG, although no difference was found among days of postoperative evaluation. The presence of unvitalized tissue was seen on 32% on OG and 53% on CG. Microscopic evaluations revealed higher collagenization, reepithelization, keratinization and less swelling in the OG compared to CG. In conclusion, mesh skin grafts evolved satisfactorily in swine even in newly created bedding without granulation tissue, but with appropriate vascularization. The omentum flap provided better macroscopic and microscopic outcomes regarding graft integration.

Subcutaneous tunneling of epidural catheter in four easy steps - A novel technique.

Subcutaneous tunneling of epidural catheter in four easy steps - A novel technique.

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.

Subcutaneous tunnelling versus conventional insertion of peripherally inserted central catheters in hospitalized patients (TUNNEL-PICC): a study protocol for a randomized controlled trial

BackgroundPeripherally inserted central catheters (PICCs) are now widely used in modern medicine, and associated complications have also increased. Central line-associated bloodstream infection (CLABSI) is the most serious complication because it can cause extended hospital stays and increase costs. Furthermore, it can contribute to dire consequences for critically ill patients. Subcutaneous tunnelling for central venous catheters is an accepted method to reduce the risk of CLABSI. However, it is not generally adopted for PICC placement in most hospitals because its safety and efficacy have not been thoroughly evaluated.MethodsIn this multi-institutional, prospective, non-blinded pragmatic randomized controlled trial, 1694 patients treated at five referral hospitals will be assigned to one of two parallel arms (conventional and tunnelled PICC groups) using computer-generated stratified randomization. The conventional group will undergo PICC placement by routine practice. In the tunnelled PICC (tPICC) group, additional subcutaneous tunnelling will be applied. Patients will be followed until PICC removal or the end of this study. The primary endpoint is whether subcutaneous tunnelling reduced the rate of CLABSI compared to the conventional method. The secondary endpoints are technical success rates, complications including exit-site bleeding or infection, and the procedure time between the groups.DiscussionSubcutaneous tunnelling is a widely used method to reduce catheter-associated infection. However, it has not been thoroughly applied for PICC. A randomized trial is needed to objectively assess the effects of the subcutaneous tunnel in PICC placement. This TUNNEL-PICC trial will provide evidence for the effectiveness of subcutaneous tunnelling in decreasing the risk of CLABSI.Trial registrationClinical Research Information Service (CRiS) KCT0005521

Lower Trapezius Myocutaneous Propeller Flap Based on Dorsal Scapular Artery.

The pedicled lower trapezius myocutaneous flap is generally transferred to the recipient site through a subcutaneous tunnel, and a portion of the flap buried in the tunnel needs to be de-epithelialized. Thus, considerable amount of normal skin is sacrificed, and the redundant tissue buried in the tunnel can cause bulging deformity. We believe that transferring the lower trapezius myocutaneous flap in a propeller fashion can avoid the aforementioned issues. A retrospective review was performed on all lower trapezius myocutaneous propeller flap reconstructions by a single surgeon from July 2013 to March 2021. Data on patient demographics, diagnosis, features of the defect, characteristics of the flap, and the outcome were collected and analyzed. Thirty-three lower trapezius myocutaneous propeller flaps were used to reconstruct soft tissue defects in the head, neck, and back. The etiologies were malignancy, trauma, postburn scar contracture, and congenital melanocytic nevus. The mean skin paddle dimensions were 29.0 cm in length (range, 13-45 cm) and 10.9 cm in width (range, 6-15 cm). The donor sites were closed primarily in 30 patients, closed using a skin graft in 1 patient, and covered with the second flap in 2 patients. Venous congestion occurred in the distal portion of 4 flaps and partial necrosis in the distal 6 cm of 1 flap. The average follow-up time was 17.5 months (range, 1-56 months). The normal contour of the back was preserved without bulging deformity. No patient developed a winged scapula or a decrease in shoulder elevation. The lower trapezius myocutaneous propeller flap may be an option for reconstruction of soft tissue defects of the head, neck, and back with less waste of normal tissue and bulging deformity.

35097 Characterization of B cell dynamics in hidradenitis suppurativa: Evidence for antigen-driven pathophysiology

Hidradenitis suppurativa (HS) is a high-morbidity, chronic inflammatory skin disorder that affects an estimated 1% of adults in developed countries and is disproportionately prevalent among African Americans and women. Lesions in HS primarily affect intertriginous sites and present as painful inflammatory nodules, subcutaneous abscesses, and scarring subcutaneous tunnels. Histologically, these lesions are rich in inflammatory infiltrate including T cells, neutrophils, macrophages, dendritic cells, B cells and plasma cells. While the role of B cells and their late differentiation partner, plasma cells, are unclear in HS, emerging evidence has suggested a link between these cells, disease progression, and treatment response. Here, we further characterize B cells in HS using single cell RNA-seq (scRNA-seq) and bacteriophage immunoprecipitation sequencing (PhIP-seq) to identify local and global alterations to B cell and plasma cell populations in HS. Using published bulk RNA-seq data from HS lesions and control skin, we extracted CDR3 sequences using MiXCR software. Diversity analysis demonstrated an increase in clonotypes in HS skin compared with control skin (P < .05). Further analysis of clonal populations in HS skin using D50 diversity index revealed selective clonal expansions (P < .01). To understand whether B cell axis alterations in HS were limited to the lesion, we assayed serum from 10 HS patients and 14 controls using PhIP-seq. HS patients possessed serum autoreactivity to a set of four autoantigens compared with controls, including type I collagen (P < .01 for each). Together, these studies provide evidence for local and global alteration to B cell populations in an antigen-specific manner in HS.

Tunneled Uncuffed Pigtail Drainage Catheter Placement in Patients with Refractory Ascites or Pleural Effusion: A Single-Center Experience.

No evidence exists to support the use of tunneled non-cuffed pigtail drainage catheters in patients with refractory ascites or pleural effusion. The purpose of this study was to determine the feasibility of non-cuffed tunneled pigtail drainage catheters in patients with refractory ascites or pleural effusions. Between October 5, 2020 and May 25, 2021, 34 pigtail catheters were implanted in 27 patients (17 males, 10 females; average age: 65.66 ± 12.04years) under either ultrasound or computed-tomography guidance (19 catheters for ascites, 15 catheters for pleural effusion). Twenty-eight catheters (82.35%) were implanted for malignant etiologies, and 6 catheters (17.65%) were implanted for benign etiologies. The catheters (size: 8-14 French) were implanted through a subcutaneous tunnel. Complication rate and factors related to complications were analyzed. Catheter lifetime was analyzed with Kaplan-Meier method. Patency ranged from 3 to 211days. None of the patients experienced a major complication (e.g., peritonitis and empyema). Meanwhile, 8 minor complications were observed including 3 catheter occlusion, 3 ascites leakage, 1 peri-catheter local skin infection, 1 peri-catheter local skin reaction. None of the etiologies were related to the catheter complications. However, the 8-F catheter was associated with a significantly higher complication rate (odds = 5.5, p = 0.044). The estimated mean [CI] dwelling time of a catheter was 59.18 [32.97, 85.39] days. Image-guided insertion of tunneled peritoneal or pleural pigtail external drainage catheters achieved with a 100% technical success rate and resulted in an acceptable complication rate and catheter lifetime for the management of refractory ascites or pleural effusion.

Closed Suction Drain Placement Using a Carroll Tendon Retriever.

The technique used for closed suction drain placement in plastic surgery is dependent on surgeon preference and experience. Drains assist in preventing accumulation of inflammatory seroma fluid, but they also present a possible nidus for infection, which is particularly concerning in implant-based breast reconstruction. Murray et al.1 retrospectively reviewed 200 cases of breast reconstruction with tissue expander placement and found that subcutaneous tunneling is one factor that may defend against infection by means of in vivo protection of the prosthesis from the drain. This clinical practice is echoed in the neurosurgery literature, where several studies have shown that long subcutaneous tunneling decreases the incidence of surgical site infection in neurosurgical procedures.2,3 Yoshida et al.4 recently described a method of drain placement into the breast pocket utilizing a liposuction cannula. While their method is innovative and effective, we would like to propose another technique with the similar advantage of using readily available operating room instruments but that is simpler and more ergonomic. The method utilizes a Carroll tendon retriever, commonly referred to as a tendon passer by plastic and hand surgeons, to place a tunneled closed-suction drain for implant-based breast reconstruction through a long subcutaneous plane with minimal disruption and stress to surrounding tissues. We begin by selecting a drain insertion site lateral to the breast pocket at the level of the inframammary fold to allow for at least 5 cm of subcutaneous tunneling. This location permits the scar to be hidden by a bra. After creating a stab incision, the surgeon inserts a Carroll tendon retriever with jaws closed and advances it manually with gentle, constant pressure through the subcutaneous plane into the breast pocket. The jaws are then opened to grasp the external end of the drain and draw it out from the upper outer breast pocket through the tunnel. The drain is secured with nonabsorbable suture and dressed with a sterile adhesive dressing. [See Video (online), which demonstrates the use of a Carroll tendon retriever to facilitate drain placement into a breast pocket.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates the use of a Carroll tendon retriever to place a drain tube into a breast pocket.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_acjzm5ek"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The Carroll tendon retriever has several advantages over other common methods of placing tunneled drains. This technique facilitates atraumatic creation of a long subcutaneous tunnel. In contrast to either a tonsil or a hemostat, both of which have a shank that splays widely toward the handle in the tissue, the Carroll tendon retriever has a static, narrow body that forms a uniform-sized tunnel. Its blunt tip makes it a safer alternative to using a trocar for drain placement. Lastly, the Carroll tendon retriever is well known to plastic and hand surgeons and is reusable and reasonably inexpensive. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No direct funding was provided for this study.

Catheter Lock Anchor Technique for Placement of Retrogradely Tunneled Implantable Ports

Abstract Purpose Groshong valved catheters require retrograde tunneling and a port chamber needs to be attached to the catheter after trimming. During this process, working space constraints are generally faced by operators. We describe a novel technique to improve the comfort of the operator while working in a constrained space. Materials and Methods The port catheter with the distal valve is retrogradely tunneled and trimmed. Thread from absorbable surgical suture is used to anchor the catheter lock. Anchored catheter lock is comfortably pushed over the catheter into the subcutaneous tunnel without it being migrated proximally. Once the port chamber is attached to the catheter, the catheter lock is retrieved back and moved to the locking position. We retrospectively analyzed implantable ports for smoothness of curves and outcomes in terms of catheter days. Results Technical success was achieved in all patients. There were no periprocedural complications. Clinical success was achieved in 27/29 cases. Early port removal was done due to infection in one patient and for nonhealing of the wound in one patient. Conclusion The catheter lock anchor is a safe and useful technique for the placement of valved ports. A satisfactory catheter-nut angle can be achieved with this technique.

A New Procedure for Guidewire Exchange of Tunneled Hemodialysis Catheters in Chronic Hemodialysis Patients: A Pilot Study

Introduction: Different techniques of guidewire exchange of tunneled catheters for hemodialysis (HD) have been reported. This study was carried out to assess the feasibility of a new procedure in chronic HD patients who needed catheter exchange because of mechanical dysfunction. Methods: The guidewire exchange method was based on the creation of a new exit site and a new subcutaneous tunnel while using the same venous insertion site. This was a retrospective study of exchanged tunneled catheters because of mechanical complications in patients on chronic HD between June 1, 2015, and December 31, 2019. The feasibility of the procedure was defined by successful exchange and catheter patency at 6 months. Catheter survival and immediate complications were reported. Results: A total of 49 procedures were performed in 34 HD patients. There was no catheter insertion failure. At 6 months, 6 catheters have lost their patency because of a mechanical complication. Thus, the success rate of the procedure was 43/49 (87.8%). Catheter survival censored on death, transplantation, or vascular access creation was 97.8% at 90 days, 86.2% at 180 days, and 74.5% at 1 year. The median catheter survival was 10.2 months. Among the 49 procedures, there were 9 hematomas at the insertion site that did not require surgical intervention. Discussion/Conlusion: Our study shows that guidewire exchange of a tunneled HD catheter by creating a new exit site and a new subcutaneous tunnel by using the same venous access is a newer method in chronic HD patients. This procedure should not be used in patients with coagulation issues. Additional studies are needed to compare the different methods of HD catheter exchange.

Brachiobasilic Fistulas Superficialization with Minimal Incisions: A New Approach by Very Good Outcomes

Background: Failure of cannulation due to the unavailability of deep veins is one of the complicated problems for chronic hemodialysis patients. By using superficialization, the veins with larger caliber and intact intima will be available for continuing the dialysis process. Brachio-Basilic superficialization with Minimal Incision (BBMI) is a proposed method that its patency and results are explored in the current study.&#x0D; Methods: Thirty hemodialysis patients with two-step superficialization indication were evaluated. For BBMI, first by using sonography, basilic vein pathway was marked and with three small incisions matured basilic vein explored and transected near pervious anastomosis and transposed from new subcutaneous tunneling and re-anastomosed the vein. In a definitive time period up to 6 months, the study variables were evaluated.&#x0D; Results: There were 11 females and 19 males. The minimum and maximum ages were 29 and 92. Technical success was 100%. After passing several successful dialysis sessions from the superficialized vein, 2 patients (6.7%) encountered unsuccessful cannulation due to thrombosis, and one of thrombosis events was due to hypotension. These cases were whom with the shortest interruption between surgery and dialysis initiation (18 and 25 days; mean±SD=28.63 ±7.36 days). There were no cases of infection and pseudoaneurysm. Furthermore, 1 case (3%) experienced wound dehiscence that managed using proper wound care.&#x0D; Conclusion: BBMI could be utilized safely with a high patency. This method has the lowest complications. The minimal side effects are affected by predisposing factors that should be clarified precisely in future studies and by gathering more evidence.

Perineal perforator switch flap for three-dimensional vulvovaginal reconstruction

Vulvovaginal reconstruction is challenging. In this study, we evaluated the outcomes of vulvovaginal reconstruction with "perineal perforator switch flap" (PPSF) and compared it with other conventional flaps. In addition, the long-term esthetic results were compared with the perineal perforator propeller flap (PPPF), which we previously used. We retrospectively reviewed the clinical data of 16 patients (27 flaps) who underwent vulvovaginal reconstruction with PPSF. After tumor resection, perineal perforators close to the genitofemoral sulcus were identified. The flap was designed as an island with the perforator at the center. The flap was elevated while preserving the soft tissue surrounding the pedicle, and transferred to the defect via the subcutaneous tunnel without pedicle skeletonization. All flaps survived and no major surgical complications were observed. The total follow-up period was 16.13±3.38 months. The mean operation time was 79.38±19.65 min, and the initiation of walking and the length of hospitalization were 1.69 ± 0.79 and 5.69 ± 0.79 days, respectively. Perineal function was well preserved. Comparison of esthetic results with PPPF showed that PPSF showed better results in symmetrical and labial shape (2.29 ± 0.73 vs. 3.13 ± 0.81; p=0.015, 2.43 ± 1.02 vs. 3.25 ± 0.68; p=0.031, respectively), and in total score. (10.29 ± 2.16 vs. 12.31 ± 1.82; p=0.017). PPSF was technically simple and significantly reduced the duration of operation and the overall recovery time. PPSF also prevented delay in radiation. Therefore, PPSF is a promising method for vulvovaginal reconstruction.

Does a small-diameter rod-type tunneler reduce postoperative swelling? An evaluation using a canine arteriovenous graft model.

Sheath-type tunnelers are frequently used to create vascular access using vascular grafts. However, during vascular access creation, tunnelers damage the surrounding tissues, consequently causing problems, such as swelling, failure to heal, and infection. This study evaluated a novel rod-type tunneler that was designed to prevent tunneler-related tissue damage and its sequelae. We developed a small-diameter rod-type tunneler that reduces injuries during subcutaneous tunnel creation. The rod diameter of this tunneler is smaller than the vascular graft diameter being implanted. It has a structure in which a vascular graft is implanted at a target site by grasping and pulling the vascular graft. Three dogs were used in the experiment, and arteriovenous grafts were created using a rod-type and a sheath-type tunneler on the left and right thighs, respectively, with a different type of commercially available graft used in each dog. The edema of the tissues surrounding the vascular graft was measured at 11 sites by ultrasonography at prespecified intervals. Compared with implantation using a sheath-type tunneler, when the self-sealing Rapidax II was implanted using the small-diameter rod-type tunneler, the postimplantation edema (degree of change) decreased by 28-53% and 80-247% in the peri-vascular-graft area and within the loop, respectively. The MAXIFLO and SEALPTFE did not significantly reduce postoperative edema but exhibited a tendency for improved postimplantation tissue healing. The reduced-diameter rod-type tunneler may be a useful device for vascular graft implantation.

Point-of-care ultrasound in peritoneal dialysis catheter-related infection: An observational study

Point-of-care ultrasound aims to enhance physical examination findings with real-time information from the ultrasound. Peritoneal dialysis catheter-related infections are a frequent complication of peritoneal dialysis and a major predisposing factor to peritonitis. The diagnosis of peritoneal dialysis catheter-related infections is made with physical examination, but physical findings usually lack sensitivity or specificity. This is a single-center observational study that aimed to evaluate the accuracy of point-of-care ultrasound for the diagnosis of peritoneal dialysis catheter-related infections. Sixteen peritoneal dialysis patients with peritoneal dialysis catheter-related infections clinical suspicion were enrolled in this study, as well as nine controls. Peritoneal dialysis catheter-related infection was defined as a purulent discharge with or without inflammatory signs in the peritoneal dialysis catheter exit-site or subcutaneous tunnel, and a positive microbiological culture collected from the exit-site. Point-of-care ultrasound was considered positive when an anechoic collection in relation to the external cuff or catheter tunnel was identified. Physical examination findings were coded using the Exit-site Scoring System. A total of 13 peritoneal dialysis catheter-related infections were diagnosed. The mean Exit-site Scoring System score for the suspected cases of peritoneal dialysis catheter-related infections was 2,82 ± 1,22, and the most commonly encountered sign was purulent discharge. All of the cases of peritoneal dialysis catheter-related infections had a positive point-of-care ultrasound. In contrast, none of the controls had a positive point-of-care ultrasound (p &lt; 0,001). The area under the receiver operating characteristic curve of physical examination for the diagnosis of peritoneal dialysis catheter-related infections was 0,6 (95% CI 0,37-0,84). In contrast, point-of-care ultrasound had an AUROC of 0,91 (95% CI: 0,73-1) for the diagnosis of peritoneal dialysis catheter-related infections. Nephrologist-performed point-of-care ultrasound is feasible and superior to physical examination for the diagnosis of peritoneal dialysis catheter-related infections.

A New Modified Bipedicle Scrotal Skin Flap Technique for the Reconstruction of Penile Skin in Patients with Paraffin-Induced Sclerosing Lipogranuloma of the Penis.

We introduce a new modified penile skin reconstruction technique to treat paraffin-induced sclerosing lipogranuloma of the penis. From 2017 to 2020, 49 patients underwent the procedure. Complete removal of the lipogranuloma-involved penile skin was performed. A subcutaneous tunnel was then created between a horizontal scrotal incision and a proximal penile circumferential incision. The denuded penis was pulled through the tunnel, and a subcoronal and longitudinal dorsal penile suture line was made. An inverted V-shaped incision was made on the scrotum on the ventral side of the penis, followed by longitudinal closure. Outcomes and complications of the procedure were retrospectively studied. The long-term effect of surgery on sexual function and overall satisfaction was measured using a patient-reported questionnaire, which was completed by 30 patients. The overall complication rate was 26.5%. Clavien-Dindo grade 1, 2, 3a, 3b, 4 and 5 complications occurred in the postoperative period 5, 0, 8, 1, 0 and 0 times, respectively, in 13 patients. Surgery was successful in 27 (90%) patients according to the patient-reported questionnaire. Erectile dysfunction, pain/tension during erection, premature ejaculation and penile lymphedema were observed in 2, 3, 1 and 1 patients, respectively. All patients reported sexual intercourse ability. The type of penile skin reconstruction after the removal of sclerosing lipogranuloma of the penis is controversial. The reconstruction technique presented herein is an effective single-stage treatment option with a high success rate in patients with sclerosing lipogranuloma of the penis with intact scrotal skin.

Translated article] Versatility of Tunneled Island Flaps for the Reconstruction of Facial Defects

Background and objectiveTunneled island flaps that transfer skin from a site adjacent to the wound are an effective way to reconstruct defects. These flaps provide good aesthetic and functional results and can be completed during a single surgical session, thus reducing complications. The procedure consists of taking an island of skin about the size of the surgical defect and moving it through a subcutaneous tunnel to cover the wound. We aimed to exemplify the use of these flaps in different regions of the face. Material and methodsRetrospective descriptive study of 12 cases in which tunneled island flaps were used after removal of malignant tumors in different facial regions. ResultsThe tumors, all of which were basal cell carcinomas, were removed by means of conventional surgery from 9 patients and Mohs micrographic surgery from 3 patients. Histology demonstrated tumor-free margins after excision in all cases. None of the tumors recurred during a mean follow-up period of 25 months. All complications were minor and transient. There were 3 cases of trapdoor effect and 2 each of postsurgical bleeding, transient superficial flap necrosis, and slight protrusion of the pedicle. The final cosmetic and functional outcome was satisfactory in all cases. ConclusionsTunneled island flaps are particularly useful for repairing defects in the center of the face, where several anatomical structures converge. These flaps, which use donor skin that is similar to skin in the receptor site, can be used to close large defects in one-step procedures with only slight alteration of the facial architecture.

Ten-year experience with laparoscopic pedicled omental flap for cerebral revascularization in patients with Moyamoya disease

BackgroundThe omental flap has numerous extraperitoneal applications in reconstruction and revascularization given its favorable immunologic and angiogenic properties. In patients with Moyamoya disease, cerebral revascularization using a pedicled omental flap has proven to be a viable option following direct revascularization procedures. Historically, harvesting omentum involved laparotomy with the associated risk of complications; herein we describe outcomes from a 10-year experience of laparoscopic harvesting of pedicled omental flap for cerebral revascularization in Moyamoya patients. MethodsA retrospective chart review was performed of all patients with Moyamoya disease who underwent laparoscopic omental cerebral transposition between 2011 and 2021. Intraoperative and postoperative complications, length of stay (LOS), and outcomes at follow-up were analyzed. ResultsTwenty-one patients underwent the procedure during the study period. Three intraoperative complications occurred (one segmental transverse colectomy for mesenteric injury, one converted to omental free flap, and one requiring micro anastomosis). Average overall LOS was 6 ± 6 days, with 3 ± 3.5 days in the ICU (mean±SD). Following discharge, complications included epigastric incisional hernia at the graft fascial exit site, recurrent neck pain at subcutaneous tunneling site, and partial scalp necrosis. One patient required subsequent direct bypass seven months after the initial procedure owing to the progression of the disease. All other patients had partial or complete resolution of symptoms. ConclusionOur retrospective observational study indicates that laparoscopic pedicled omental flap mobilization and transposition is a safe and effective method of indirect cerebral revascularization in patients with Moyamoya disease. Level of evidenceN/A.