Successful Salvage Research Articles

Comparison of Clinical Outcomes in Locally Advanced Distal Rectal Cancer Patients with Complete Clinical Response: Total Mesorectal Excision versus Nonoperative Management

Abstract Background: Over the past few decades, nonoperative management (NOM) has become increasingly prevalent as an effort to preserve organs and improve functional outcomes compared to surgery. Objectives: This study aims to compare the clinical outcomes of patients with locally advanced distal rectal cancer (LADRC) following neoadjuvant treatment with either total mesorectal excision (TME) or NOM. Design: The study was conducted retrospectively. Patients and Methods: The study was conducted at two comprehensive cancer centers between January 1, 2014, and October 31, 2019. The study included all LADRC patients with clinical complete response (cCR) following neoadjuvant treatment, and who agreed to NOM or had a pathology report concluding that they had achieved pathologic complete response (pCR) following TME. Main Outcomes and Measurements: We evaluated patients for the presence of local regrowth or recurrence (LR), distant metastases (DM), and survival. Sample Size: A total of 462 individuals were identified from the database of the centers. Among them, 137 (31.8%) were confirmed to have achieved cCR. Results: Out of 137 patients with cCR, 67 patients were treated with NOM and 70 patients underwent TME, with 69 of them achieving pCR. In terms of baseline characteristics and tumor location, the patients in the NOM group (n = 67) did not differ from those in the pCR group (n = 69) (P > 0.05). Surveillance of the 67 patients in the NOM group revealed that 10 (15%) developed local regrowth and required salvage surgery. As a result of salvage surgery, 65 patients (97%) maintained pelvic control. Although there was no evidence of pelvic recurrence in the pCR group, three patients (4.3%) underwent metastasectomy for DM. In the NOM group, DM was observed in two (20%) out of ten patients after salvage surgery for local regrowth, whereas no DM was detected in NOM patients without local regrowth. In the NOM group, DM was significantly associated with local regrowth compared to those who did not develop pelvic regrowth (20% vs. 0%; P < 0.05). It was observed that the pCR group had improved disease-free survival rates (95.7% vs. 85.1%, P = 0.034); however, there was no difference in the overall survival rates (100% vs. 98.5%, P = 0.248). Conclusion: Compared with the traditional trimodal treatment strategy, NOM is a safe and promising treatment option for selected LADRC patients with an acceptable rate of pelvic control and overall survival. Consequently, close endoscopic and radiologic monitoring is essential to maximize the likelihood of an early detection of recurrence and a successful salvage surgery. Limitations: Due to its retrospective nature, this study has limitations primarily related to data collection from patients’ records and databases after the completion of follow-up. Conflict of Interest: The authors have no conflict of interest to declare.

Intraoperative Renal Artery Thrombosis of the Transplanted Kidney Secondary to Intimal Injury

Vascular complications after renal transplantation are rare, however, they are serious surgical complications. Intimal tears in the renal arteries can result from iatrogenic injuries. These injuries can occur due to crushing injuries of the intima secondary to the use of improper vascular clamps, mishandling of the vessels, and use of traumatic infusion/perfusion needles or devices. It is important to recognize these intimal injuries so that corrective measures can be undertaken immediately and avoid vascular complications. We report a case of renal artery thrombosis secondary to intimal injury leading to intraoperative poor blood flow across the anastomosis which was promptly recognized and corrected leading to successful salvage of the transplanted kidney.

Ortho-oncoplastic surgery in foot and ankle: A narrative overview on reconstruction of soft-tissue defects after oncologic resections.

Malignant tumors of the foot are rare, and treatment strategies are challenging considering the complex anatomy of this area. In recent years, dramatic advances in technology and collaborations between different specialties (such as orthopedic, oncology, radiology, plastic, and vascular surgery) significantly changed the approach to complex malignant tumors without resorting to limb removal. The combination of the strengths of both orthopedic surgery and plastic surgery constitutes the modern definition of "orthoplasty." The aim of this review article is to provide treatment strategies that are available for reconstruction of foot and ankle in limb-salvage surgery after tumor resection, with a specific focus on microsurgical techniques in plastic surgery. We conducted a comprehensive search for relevant papers across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with small and large soft tissue defects. Indications, pros and cons, and technique tips are discussed for each type of reconstructive technique. The search was done using literature of the past 30 years (from 1990 to date), resulting in about 725 articles describing over 2000 cases. Cutaneous flaps included lateral supramalleolar flap, medial plantar flap, reverse sural neurocutaneous island flap, medial leg flap, and lateral leg flap. Free flaps included anterolateral thigh flap, radial forearm flap, latissimus dorsi flap, gracilis muscle flap, lateral arm flap, and rectus abdominis flap. The orthoplastic approach in musculoskeletal oncology is a collaborative model of orthopedic and plastic surgeons working together, resulting in a higher rate of successful limb salvage in patients at risk for amputation. Protocols, biologic substitutes, and surgical techniques are largely improved in the last decades increasing the possibility of functional reconstruction. Microsurgical strategies represent the new frontiers in these demanding reconstructions.

Comparing outcomes and cost in surgery versus watch & wait surveillance of patients with rectal cancer post neoadjuvant long course chemoradiotherapy.

Watch and wait (W&W) in complete clinical responders after neoadjuvant chemoradiotherapy has increasingly robust data supporting its oncological safety. Recently, studies have assessed the real-world costs of this strategy compared to surgical resection. Our aim was to compare our oncological safety and costs associated with operative and surveillance strategies to international literature. Data were retrospectively collected and analysed via electronic health records from March 2014 to March 2021 in Christchurch, New Zealand. Two cohorts were created based on intention to treat. All hospital events were recorded and costed, as well as oncologic outcomes. Our primary endpoints were the cumulative cost of both strategies, 3-year survival rate, and disease-free survival. Forty-eight patients were identified who had rectal cancers resected (OT) with a yPT0N0 pathology, and 42 who were on the wait-and-watch (W&W) audit after having a clinical complete response. After exclusions, we identified 38 OT and 23 W&W patients; the W&W group were more co-morbid (P = 0.05), had worse functional status (P = 0.008), higher BMI (P = 0.34) and more favourable clinical tumour staging (P = 0.01). The operative treatment (OT) group (n = 38) had more acute admissions (34% versus 13% in W&W, P = 0.08, OR 0.29). There was a 35.7% (n = 8 of 23) local recurrence in W&W and none in the OT group (P ≤ 0.001), with successful salvage in the W&W with local recurrence in 71.5% (n = 5 of 7). Three-year distant metastasis-free rate was 97.3% in the OT group and 90.9% in W&W (p = 0.05). Overall survival was 100% (W&W) and 94.7% (OT); (P = 0.019). Care in the OT group cost more than W&W, accounting for local regrowth management; $NZ70,759.56 versus $NZ47,905.52 (P = 0.014). This study found better oncological outcomes in the OT group, whilst the W&W group had reduced morbidity and acute bed days. The cost of wait and watch was approximately two-thirds that of operative treatment, even accounting for salvage procedures for local regrowth.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study.

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Catheter salvage from central line-related bloodstream infections in pediatric intestinal failure.

Patients with intestinal failure require central venous access which puts them at risk for central line-associated bloodstream infections (CLABSI). Maintaining vascular patency is critical for this population to receive nutrition support. When CLABSIs occur line salvage can help maintain vascular access. The aim of this study is to assess factors associated with safe and successful central venous catheter salvage. Retrospective cohort study of patients with intestinal failure at two tertiary care institutions between 2012 and 2020. The study examined the rates of attempted salvage, factors associated with successful salvage, and complications associated with salvage attempts. Over the study period, 76 patients with intestinal failure were include while central venous access was in place. There were a total of 94 CLABSIs. Salvage was more likely to be attempted when patients were under the direct care of an intestinal rehabilitation service (95% vs. 68%, p = 0.04). The overall successful salvage rate was 91.6% (n = 77). Gram-positive, Gram-negative, and polymicrobial infections had successful salvage rates of 97%, 92%, and 94% respectively. The successful salvage rate for fungal infections was 40%. There was no difference in 30-day complication rates for hospital readmission, intensive care unit admission, and death between patients who underwent salvage attempt and those who did not. Central line salvage can be safely attempted for many infections in patients with intestinal failure, leading to vascular access preservation.

Salvaging mangled upper limbs with early soft tissue cover with flaps- A case series

Mutilating upper limb injuries present complex challenges to both patients and surgeons, necessitating prompt and effective management strategies to achieve favorable outcomes. This retrospective study examines the cases of five consecutive patients with mangled upper limbs resulting from blunt trauma, evaluating demographics, injury mechanisms, injury patterns, and 60-day limb salvage outcomes. Among 2128 admissions between January and December 2022, five patients were identified with mangled upper limbs and open fractures, with an average age of 40.2 years and a notable male predominance (80%). The dominant hand was affected in 60% of cases, primarily due to blunt high-velocity road traffic accidents. The mean Mangled Extremity Severity Score (MESS) was 7.2, and the Ganga Hospital Open Injury Score averaged 16, indicating substantial injury severity without limb ischemia or compartment syndrome. All patients underwent definitive surgery within 48 hours, with various soft tissue reconstruction techniques employed, including free flaps, pedicle flaps, and local muscle mobilization, along with nerve grafting procedures. At the 60-day follow-up, successful limb salvage was achieved in all cases, with no instances of surgical site infection and excellent acceptance of skin grafted areas exceeding 95%. The findings underscore the importance of timely surgical intervention and comprehensive soft tissue coverage in achieving successful limb salvage outcomes in patients with mutilating upper limb injuries, emphasizing the critical role of early intervention and multidisciplinary collaboration.

IDF23-0419 Successful limb salvage of diabetic foot osteomyelitis using Induced membrane (masquelet) technique

IDF23-0419 Successful limb salvage of diabetic foot osteomyelitis using Induced membrane (masquelet) technique

A nomogram for predicting risk factors of testicular salvage after testicular torsion in children.

This study aimed to establish a nomogram for predicting the probability of testicular salvage after testicular torsion in children. We retrospectively collected data of children with testicular torsion who were treated at Shenzhen Children's Hospital between September 2005 and August 2022. Of the training cohort, 113 patients who underwent orchiectomy and five with testicular atrophy after orchiopexy were included in the failed testicular salvage group. Additionally, 37 patients who underwent orchiopexy without postoperative testicular atrophy were included in the successful testicular salvage group. The predictive factors affecting testicular salvage were determined using univariate and multivariate logistic regression analyses; a nomogram was constructed. The nomogram was verified using data from the validation group. Using multivariate logistic regression analysis, the independent risk factors of testicular salvage after testicular torsion were symptom duration (p = 0.034), intratesticular blood flow (p = 0.003), spermatic cord torsion degree (p = 0.037), and monocyte count (odds ratio: 0.012, p = 0.036). A nomogram was established based on these four risk factors. In the training cohort, the area under the receiver operating characteristic curve was 0.969. The area under the receiver operating characteristic curve of the verification cohort was 0.965, indicating good discrimination ability of the nomogram. Increased symptom duration without intratesticular blood flow increased the monocyte count and spermatic cord torsion degree and decreased the success rate of testicular salvage. This prediction model could obtain the corresponding probability of testicular salvage according to the clinical characteristics of different patients with testicular torsion, providing reference for clinicians and parents.

P891 Comparative Effectiveness and Safety of Infliximab and Tacrolimus in the Treatment of Acute Severe Ulcerative Colitis

Abstract Background Acute severe ulcerative colitis (ASUC) affects approximately 20% of patients with ulcerative colitis (UC). Patients failing initial corticosteroid therapy receive salvage therapy with either infliximab (IFX) or calcineurin inhibitors, cyclosporine (CYS) or tacrolimus (TAC). We aimed to compare the effectiveness and safety of IFX and the oral calcineurin inhibitor, TAC, in this setting. Methods This retrospective cohort study included consecutive patients with ASUC, based on the Truelove and Witts criteria, admitted to Tel Aviv Medical Center between 2017 and 2022 and treated with salvage therapy. Demographic, clinical, and laboratory data were retrieved. The primary endpoint was successful salvage therapy defined as clinical response resulting in discharge without colectomy. Secondary endpoints included the colectomy rates at 90 days and the safety profile of the treatments. Results During the study period 96 patients with ASUC were admitted to our center. Of these, 40 patients received salvage therapy – 21 patients received IFX and 16 received TAC and were included in the analysis; 3 patients received CYS and were excluded from the study. Demographic data are detailed in Table 1. Disease duration was significantly longer in patients receiving TAC (mean (±SD) 9.7 years (±7.1) vs 4.5 (±5.9), p=0.04). In addition, patients receiving TAC had significantly greater prior exposure to advanced therapies (14 (87.5%) vs 6 (28.6%), p<0.001) and 12 (75%) patients had previous exposure to IFX. Baseline markers of disease severity including disease extent, hemoglobin, C-reactive protein (CRP), albumin and body mass index (BMI) were similar between the treatment groups (Table 1). Therapeutic success was similar between treatment groups (IFX: 18 (86%) vs TAC: 15 (94%), p=0.62). The 90-day colectomy rate (IFX: 4 (19%) vs TAC: 2 (12.5%), p=0.68), CRP upon discharge (median (IQR) IFX: 15 mg/L (3.3-27) vs TAC: 11 mg/L (5.4-25, p=0.64) and length of hospitalization (mean (±SD) IFX: 23.5 days (±19.46) vs TAC: 17.56 days (±5), p=0.19) were similar between the groups. Safety profiles were similar between the treatment groups with mild electrolyte disturbances treated conservatively in both groups and no observed infections, deaths or other adverse events. Conclusion This real world, retrospective study shows that IFX and TAC have similar effectiveness and safety in the setting of ASUC. In this study, patients receiving TAC had significantly longer disease duration and advanced therapy exposure than those receiving IFX and still maintained excellent effectiveness highlighting TAC’s value in this setting.

Early Ultrasound Surveillance of Newly-Created Hemodialysis Arteriovenous Fistula

IntroductionWe assess if ultrasound surveillance of newly-created arteriovenous fistulas (AVFs) can predict non-maturation sufficiently reliably to justify randomised controlled trial (RCT) evaluation of ultrasound-directed salvage intervention. MethodsConsenting adults underwent blinded fortnightly ultrasound scanning of their AVF after creation, with scan characteristics that predicted AVF non-maturation identified by logistic regression modelling. ResultsOf 333 AVFs created, 65.8% matured by 10 weeks. Serial scanning revealed that maturation occurred rapidly, whereas consistently lower fistula flow rates and venous diameters were observed in those that did not mature. Wrist and elbow AVF non-maturation could be optimally modelled from the week four ultrasound parameters alone, but with only moderate positive predictive values (wrist, 60.6% (95% CI 43.9 – 77.3); elbow, 66.7% (48.9 - 84.4)). Moreover, 40 (70.2%) of the 57 AVFs that thrombosed by week 10 had already failed by the week 4 scan, thus limiting the potential of salvage procedures initiated by that scan’s findings to alter overall maturation rates.Modelling of the early ultrasound characteristics could also predict primary patency failure at 6 months, but that model performed poorly at predicting assisted primary failure (those AVFs thatfailed despite a salvage attempt), partly because patency of at-risk AVFs was maintained by successful salvage performed without recourse to the early scan data. ConclusionsEarly ultrasound surveillance may predict fistula maturation, but is likely, at best, to result in only very modest improvements in fistula patency. Power calculations suggest that an impractically large number of participants (>1700) would be required for formal RCT evaluation.

Outcomes of Aortoiliac Occlusive Disease Treated by Aorto-femoro-popliteal and Distal Bypass Surgeries: A Prospective Cohort Study

Introduction: Aortoiliac occlusive disease can contribute to lower extremity ischaemic symptoms requiring intervention. Though proximal aorto-femoral bypass surgery has been the mainstay of intervention, the delayed healing in many patients necessitates exploration of other techniques, including sequential revascularisation. Aim: To estimate the outcomes of aortoiliac occlusive disease treated by aorto-femoro-popliteal and distal bypass surgeries. Materials and Methods: A prospective cohort study was conducted to determine the treatment outcomes of 25 patients with aortoiliac occlusive disease visiting a tertiary care centre of Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India from October 2012 to December 2014. Data regarding the aetiology of the disease, co-morbidities including substance use, degree of disease involvement, and treatment modalities were collected. Data was analysed by Statistical Package for Social Sciences (SPSS) software version 22.0. The Chi-square test was used to compare outcomes with different treatment modalities, and a p-value <0.05 was considered statistically significant. Results: The mean age of the study participants was 58.3±2 years (range 40 to 70 years). The study noted that the most common aetiology for aortoiliac occlusive disease was atherosclerosis in 18 (72%) cases. The most common associated co-morbidity was smoking in 18 (72%) cases. Abnormal profunda patency was noted in 15 (60%) cases and synthetic Polytetrafluoroethylene (PTFE) was used in 80% of sequential bypass cases. A significantly higher proportion (86.7% vs 30%) of people treated by the sequential procedure achieved relief from claudication pain (p-value<0.05). The complication noted after the proximal bypass was pseudoaneurysm (20%), and the only complication noted after the sequential bypass was graft thrombosis (13.33%). The mean Ankle-brachial Index (ABI) score and ulcer healing time were also significantly higher in the sequential bypass procedure (p-value<0.05). Conclusion: Sequential bypass offers better advantages than proximal bypass for treating aortoiliac occlusive disease. It was found to be a safe and effective method for successful limb salvage, ensuring successful limb revascularisation and sufficient outflow to maintain graft patency.

Retinoblastoma and its adverse events experienced

Background: Retinoblastoma management has seen a paradigm shift with intra-arterial chemotherapy (IAC). Using IAC as primary management in this paediatric cancer is becoming more widespread in developing countries such as Malaysia. Considerable evidence shows that IAC has a more beneficial globe salvage rate thanintravenous chemotherapy (IVC).
 Case presentation: This case report describes a successful globe salvage in Group D retinoblastoma with primary IAC and the complications experienced with this mode of treatment, especially the vascular events seen which could possibly contribute to persistent poor vision despite a completely regressed tumour.
 Conclusion: Despite the remarkable tumour regression and globe preservation, the patient’s vision did not improve in the treated eye. We wish to explore the possibilities resulting in those complications and methods to reduce them in the future.

Long-Term Treatment Outcomes of Hypopharyngeal Cancer Using Different Surgical Modalities

Background and Objectives In the present study, we evaluated the treatment results of hypopharyngeal squamous cell carcinoma (HPSCC) patients and analyzed the occurrence of secondary primary malignancies. Treatments were based on two different surgical modalities (conventional pharyngo-laryngectomy vs. transoral surgery). In addition, prognostic factors of the patients were evaluated.Subjects and Method We analyzed medical data of 232 patients diagnosed with HPSCC and underwent surgery at our hospital from January 2006 to December 2019.Results The 5-year recurrence-free survival was 67.2% for the stage I-II group and 64.9% for the stage III-IV group. The 5-year disease-specific survival was 78.2% for the stage I-II group and 54.5% for the stage III-IV group. N classification was significantly correlated with disease relapse and patient mortality. Patient age, sex, perineural invasion, extranodal extension, initial tumor stage, and early recurrence (within 6 months) were significantly associated with successful salvage treatment. The two surgical modalities did not yield different oncological outcomes. Secondary primary malignancies occurred most frequently in the esophagus, with no observed inferior survival rate in patients with second malignancies.Conclusion The 5-year survival rate for HPSCC patients who received surgical treatment was 78% for stage I-II and 54% for stage III-IV. While no difference in oncological outcome was observed based on surgical modality, the transoral surgery group showed better functional outcomes.

Long term-control via successful salvage therapy with cytoreductive surgery, chemotherapy, and radiotherapy for recurrence with intraperitoneal carcinomatosis of synchronous advanced ovarian and endometrial cancer: a case report

Long term-control via successful salvage therapy with cytoreductive surgery, chemotherapy, and radiotherapy for recurrence with intraperitoneal carcinomatosis of synchronous advanced ovarian and endometrial cancer: a case report

Aqueous Humor Liquid Biopsy as a Companion Diagnostic for Retinoblastoma: Implications for Diagnosis, Prognosis, and Therapeutic Options: Five Years of Progress

To define the prospective use of the aqueous humor (AH) as a molecular diagnostic and prognostic liquid biopsy for retinoblastoma (RB). This is a prospective, observational study wherein an AH liquid biopsy is performed at diagnosis and longitudinally through therapy for patients with RB. Tumor-derived cell-free DNA is isolated and sequenced for single nucleotide variant analysis of the RB1 gene and detection of somatic copy number alterations (SCNAs). The SCNAs are used to determine tumor fraction (TFx). Specific SCNAs, including 6p gain and focal MycN gain, along with TFx, are prospectively correlated with intraocular tumor relapse, response to therapy, and globe salvage. A total of 26 eyes of 21 patients were included with AH taken at diagnosis. Successful ocular salvage was achieved in 19 of 26 (73.1%) eyes. Mutational analysis of 26 AH samples identified 23 pathogenic RB1 variants and 2 focal RB1 deletions; variant allele fraction ranged from 30.5% to 100% (median 93.2%). At diagnosis, SCNAs were detectable in 17 of 26 (65.4%) AH samples. Eyes with 6p gain and/or focal MycN gain had significantly greater odds of poor therapeutic outcomes (odds ratio = 6.75, 95% CI = 1.06-42.84, P = .04). Higher AH TFx was observed in eyes with vitreal progression (TFx = 46.0% ± 40.4) than regression (22.0 ± 29.1; difference: -24.0; P = .049). Establishing an AH liquid biopsy for RB is aimed at addressing (1) our inability to biopsy tumor tissue and (2) the lack of molecular biomarkers for intraocular prognosis. Current management decisions for RB are made based solely on clinical features without objective molecular testing. This prognostic study shows great promise for using AH as a companion diagnostic. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

A case of Barrett’s esophageal adenocarcinoma and severe scoliosis with successful salvage esophagectomy after definitive chemoradiotherapy

BackgroundSevere scoliosis can cause reflux esophagitis, and is a risk factor for Barrett's adenocarcinoma of the esophagus. Severe scoliosis is associated with respiratory dysfunction, impaired operative tolerance, and anatomical difficulty in surgical manipulation, and is, therefore, considered a high surgical risk. In this report, we describe the case of a young patient with Barrett's esophageal adenocarcinoma with severe scoliosis who underwent salvage surgery after radical chemoradiotherapy.Case presentationThe patient was a 39-year-old male. Although he had severe scoliosis and paraplegia of both lower limbs since childhood, he was independent in activities of daily living. His previous doctor, who diagnosed the esophageal cancer, determined that surgery was not indicated due to the coexistence of severe scoliosis, so he underwent chemoradiotherapy with curative intent. After chemoradiotherapy, the patient was referred to our hospital for a second opinion because of a tumor remnant. After various additional examinations, thoracoscopic and laparoscopic subtotal esophagectomy for esophageal cancer was performed, along with ante-thoracic route reconstruction using a narrow gastric tube. Although the patient had symptoms associated with postoperative reflux, he recovered well overall and was discharged home about 4 weeks after surgery.ConclusionsWe report the case of an esophageal cancer patient with severe scoliosis at high surgical risk who underwent successful minimally invasive esophagectomy.

Enhanced recovery for acute open lower limb fracture ‘fix and flap’

IntroductionEnhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following ‘fix & flap’, return to theatre, rate of successful flap salvage, flap failure and deep infection rates. MethodsAn observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. Results161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. ConclusionIn isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

A Simple Technique Using Peri-Prosthetic Irrigation Improves Implant Salvage Rates in Immediate Implant-Based Breast Reconstruction.

Background and objectives: Implant-related complications leading to implant loss contribute to major morbidity in immediate breast reconstruction (IBR). Various techniques have been advocated to improve rates of reconstruction salvage. The objective of our study was to assess if a peri-prosthetic irrigation system was an effective adjunct to the conventional wash-out technique in improving reconstruction salvage rates. Methods: The study included patients who had immediate implant-based breast reconstruction from January 2015 to November 2020. The conventional technique of reconstruction salvage, using debridement, wash-out, and implant/expander exchange with systemic use of antibiotics, was performed for patients undergoing exploration for infection until May 2019. A simple technique using a continuous peri-prosthetic irrigation system with vancomycin (1 g/L normal saline over 24 h) for 2 days was added as an adjunct to the conventional technique. Treatment details and clinical outcomes were compared between the groups. The study was approved by the Clinical Governance department. Results: During the study period, 335 patients underwent IBR. A total of 65 patients (19.4%) returned to the theatre due to post-operative complications, of which 45 (13.4%) were due to infection. A conventional technique was used in 38 (84.4%) patients, and peri-prosthetic irrigation was used as an adjunct in 7 patients (15.6%). A total of 16 (42.1%) in the conventional group and all 7 (100%) in the irrigation group had successful reconstruction salvage. No patients had complications due to antibiotic irrigation. Conclusions: The peri-prosthetic irrigation system is a simple, safe, and effective adjunct to conventional techniques in improving reconstruction salvage in IBR.

Safety and efficacy of mechanical aspiration thrombectomy for patients with acute lower extremity ischemia

ObjectiveAcute limb ischemia (ALI) is associated with high rates of amputation and consequent morbidity and mortality. The objective of this study is to report on the safety and efficacy of aspiration thrombectomy using the Indigo Aspiration System in patients with lower extremity (LE) ALI. MethodsThe STRIDE study was an international, multicenter, prospective, study that enrolled 119 participants presenting with LE-ALI. Patients were treated firstline with mechanical thrombectomy using the Indigo Aspiration System, before stenting or angioplasty, or other therapies as determined by treating physician. The primary end point was target limb salvage at 30 days after the procedure. Secondary end points within 30 days included technical success, defined as core laboratory-adjudicated Thrombolysis in Myocardial Infarction (TIMI) 2/3 flow rate immediately after the procedure, changes in modified Society for Vascular Surgery runoff score, improvement of Rutherford classification compared with before the procedure, patency, rate of device-related serious adverse events, and major periprocedural bleeding. Secondary end points that will be evaluated at 12 months include target limb salvage and mortality. ResultsOf the 119 participants enrolled at 16 sites, the mean age was 66.3 years (46.2% female). At baseline (n = 119), ischemic severity was classified as Rutherford I in 10.9%, Rutherford IIa in 54.6%, and Rutherford IIb in 34.5%. The mean target thrombus length was 125.7 ± 124.7 mm. Before the procedure, 93.0% (of patients 107/115) had no flow (TIMI 0) through the target lesion. The target limb salvage rate at 30 days was 98.2% (109/111). The rate of periprocedural major bleed was 4.2% (5/119) and device-related serious adverse events was 0.8% (1/119). Restoration of flow (TIMI 2/3) was achieved in 96.3% of patients (105/109) immediately after the procedure. The median improvement in the modified Society for Vascular Surgery runoff score (before vs after the procedure) was 6.0 (interquartile range, 0.0-11.0). Rutherford classifications also improved after discharge in 86.5% of patients (83/96), as compared with preprocedural scores. Patency at 30 days was achieved in 89.4% of patients (101/113). ConclusionsIn the STRIDE (A Study of Patients with Lower Extremity Acute Limb Ischemia to Remove Thrombus with the Indigo Aspiration System) study, aspiration thrombectomy with the Indigo System provided a safe and effective endovascular treatment for patients with LE-ALI, resulting in a high rate (98.2%) of successful limb salvage at 30 days, with few periprocedural complications.