Vascularized Muscle Flap Research Articles

The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap – A porcine model

A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.

Creating and Transferring an Innervated, Vascularized Muscle Flap Made from an Elastic, Cellularized Tissue Construct Developed In Situ.

Reanimating facial structures following paralysis and muscle loss is a surgical objective that would benefit from improved options for harvesting appropriately sized muscle flaps. The objective of this study is to apply electrohydrodynamic processing to generate a cellularized, elastic, biocomposite scaffold that could develop and mature as muscle in a prepared donor site in vivo, and then be transferred as a thin muscle flap with a vascular and neural pedicle. First, an effective extracellular matrix (ECM) gel type is selected for the biocomposite scaffold from three types of ECM combined with poly(ester urethane)urea microfibers and evaluated in rat abdominal wall defects. Next, two types of precursor cells (muscle-derived and adipose-derived) are compared in constructs placed in rat hind limb defects for muscle regeneration capacity. Finally, with a construct made from dermal ECM and muscle-derived stem cells, protoflaps are implanted in one hindlimb for development and then microsurgically transferred as a free flap to the contralateral limb where stimulated muscle function is confirmed. This construct generation and in vivo incubation procedure may allow the generation of small-scale muscle flaps appropriate for transfer to the face, offering a new strategy for facial reanimation.

Harnessing the synergy of perfusable muscle flap matrix and adipose-derived stem cells for prevascularization and macrophage polarization to reconstruct volumetric muscle loss.

Muscle flaps must have a strong vascular network to support a large tissue volume and ensure successful engraftment. We developed porcine stomach musculofascial flap matrix (PDSF) comprising extracellular matrix (ECM) and intact vasculature. PDSF had a dominant vascular pedicle, microcirculatory vessels, a nerve network, well-retained 3-dimensional (3D) nanofibrous ECM structures, and no allo- or xenoantigenicity. In-depth proteomic analysis demonstrated that PDSF was composed of core matrisome proteins (e.g., collagens, glycoproteins, proteoglycans, and ECM regulators) that, as shown by Gene Ontology term enrichment analysis, are functionally related to musculofascial biological processes. Moreover, PDSF-human adipose-derived stem cell (hASC) synergy not only induced monocytes towards IL-10-producing M2 macrophage polarization through the enhancement of hASCs' paracrine effect but also promoted the proliferation and interconnection of both human skeletal muscle myoblasts (HSMMs) and human umbilical vein endothelial cells (HUVECs) in static triculture conditions. Furthermore, PDSF was successfully prevascularized through a dynamic perfusion coculture of hASCs and HUVECs, which integrated with PDSF and induced the maturation of vascular networks in vitro. In a xenotransplantation model, PDSF demonstrated myoconductive and immunomodulatory properties associated with the predominance of M2 macrophages and regulatory T cells. In a volumetric muscle loss (VML) model, prevascularized PDSF augmented neovascularization and constructive remodeling, which was characterized by the predominant infiltration of M2 macrophages and significant musculofascial tissue formation. These results indicate that hASCs' integration with PDSF enhances the cells' dual function in immunomodulation and angiogenesis. Owing in part to this PDSF-hASC synergy, our platform shows promise for vascularized muscle flap engineering for VML reconstruction.

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome.

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.

407.9: Treatment of Complex Desmoid Tumours by Intestinal Transplantation

Introduction: Desmoid tumours are rare, locally aggressive tumours which often have an unpredictable and variable clinical course. Although most desmoids (80%) are sporadic, 20% are associated with Familial Adenomatous Polyposis (FAP) which tend to be multi-focal and more aggressive. While the majority of desmoids can be managed by watchful waiting, systemic therapy or radiotherapy, some will require surgical excision. It is recommended in these cases to perform a total resection to reduce the chance of recurrence. In the most extreme cases (multiple segments of bowel, complex fistulating disease, invasion into the abdominal wall, ureteric encasement), the most radical option is to perform a total enterectomy and Intestinal Transplant (ITx). The decision if and when to refer a desmoid patient for ITx can be challenging, particularly the timing and sequence of treatment (simultaneous vs sequential exenteration + delayed listing for ITx). In this study, we present our centre’s experience of managing complex, desmoid tumours with ITx. Method: We performed a retrospective case review of our prospectively collected database between 2007 and 2022. All patients receiving an ITx for desmoids were identified. Results: Between 10/2007 and 03/2022, 126 ITx in 119 patients were performed at our centre. Of these, 14 patients (12%) were for desmoid disease (6 Modified Multivisceral Transplants (MMVT), 5 Isolated ITx and 3 Liver-Small bowel Transplant. Median follow was 43 months (7-104). 9 out of 14 patients are alive (64%) without GI recurrence. None of the patients died from desmoid recurrence. The management of this cohort presented us with several complex technical issues that needed to be overcome such as loss of abdominal domain (6/14), retroperitoneal involvement (6/14), pouch related issues (2/14) and the need for a gastrectomy/duodenectomy due to dysplastic disease (6/14). Loss of abdominal domain and invasion/destruction by the desmoid disease was addressed by using non-vascularised rectus fascia (NVRF), either on its own (4/6) or in combination of vascularized muscle flaps (2/6).Retroperitoneal involvement of the vena cava/iliac vessels and the ureters. Two of these patients required a renal auto-transplantation into the iliac fossa while one patient had a ureteric re-implantation from right to left. The decision to also remove stomach and/or duodenum at the time of ITx depends on the risk of polyp malignancy. Pre-operative polyp surveillance, histology and the Spiegleman score help us to determine the need for a MMVT. Conclusion: Intestinal Transplantation is a viable treatment option in selected patients with extensive desmoid disease. Deciding which patients would benefit from ITx is important to ensure timely referral. Delays in this process can result in additional disease burden such as secondary liver disease or invasion of adjacent structures, requiring further reconstructions.

MP25-20 DEMUSOCALIZED DETRUSOR MUSCLE FLAPS FOR COMPLEX URETHRAL FISTULA

You have accessJournal of UrologyCME1 May 2022MP25-20 DEMUSOCALIZED DETRUSOR MUSCLE FLAPS FOR COMPLEX URETHRAL FISTULA Matthew Loecher, Ramphis Morales-Lopez, and Michael Metro Matthew LoecherMatthew Loecher More articles by this author , Ramphis Morales-LopezRamphis Morales-Lopez More articles by this author , and Michael MetroMichael Metro More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radiation associated rectourethral (RUF) and urosymphyseal fistulas (USF) are complex urologic problems that often require permanent urinary diversion. While reconstruction for RUF and USF have been studied in small case series with good short-term outcomes, little information exists on the optimal approach when reconstruction fails or is not feasible. We present a novel approach to fistula management with subtotal cystectomy with urinary diversion and creation of demucosalized detrusor muscle flaps (DDMF) for pelvic interposition. We propose that this technique optimizes reconstructive principles to improve wound healing and eliminate empty space in a hostile and infected field. METHODS: We performed a retrospective review of eight patients with radiation-associated USF or RUF treated with subtotal cystectomy with DDMFs and ileal conduit performed by a single surgeon between January 2018 and October 2021. Surgical technique and preoperative work up was described (Figure 1). Preoperative data, radiation history and prior interventions were collected. Short-term outcomes and peri-operative complications were recorded (Table 1). RESULTS: All men had been treated for prostate cancer with radiation therapy without evidence of biochemical recurrence. TUR of a BNC was the most common inciting factor. Median age was 76.5 years old (range 71-81). Mean length of stay was 9.5 days. Median follow up was 13.5 months (range 4-24). All USF patients have not had reoccurrence of pelvic sepsis or pubic osteomyelitis at follow up. All RUF patients had been able to re-establish bowel continuity. Thirty-day post-operative complications were all Clavien-Dindo 1 or 2. CONCLUSIONS: DDMFs are a safe and feasible option for patients who fail or are not candidates for definitive reconstruction of RUF or USF. We propose that using vascularized muscle flaps allows for tissue interposition without added morbidity, need for distant muscle flaps or need for plastic surgery consultation. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e436 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Loecher More articles by this author Ramphis Morales-Lopez More articles by this author Michael Metro More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abstract WP261: Encephalomyosynangiosis Improves Angiogenesis And Recovery In Mice After Transient Ischemic Stroke

Background and Purpose: The ability of the brain to self-heal after stroke is limited by inadequate blood supply and acute inflammation. Hence, we hypothesized that improved blood supply via promoting neoangiogenesis will reduce acute inflammation and improve recovery after stroke. Encephalomyosynangiosis (EMS) is a neurosurgical procedure that achieves angiogenesis with low morbidity in patients with moyamoya disease, reducing risk of stroke. EMS has never been studied in ischemic stroke. Here, we developed a novel model of EMS after ischemic stroke induced by middle cerebral artery occlusion model (MCAo) in mice. We demonstrated that this novel EMS procedure can induce angiogenesis and improve recovery after stroke. Methods: After 60 minutes of MCAo, mice were randomized to MCAo or MCAo+EMS groups. After 3-4 hours, EMS was performed. In brief, EMS involves a craniotomy and placement of a vascular temporalis muscle flap on the pial surface of the ischemic brain. Mice were sacrificed at day 7 or 21 after MCAo. Viability of temporalis muscle was measured using a nicotinamide adenine dinucleotide reduced tetrazolium reductase assay. ARY015 Proteome Profiler Mouse Angiogenesis Array (R&D Systems) was used to quantify angiogenic and neuromodulating protein expression. Immunohistochemistry was used to visualize immune infiltration by measuring F4/80 positive macrophages. Results: EMS after ischemic stroke did not increase mortality despite dual invasive surgery. Grafted temporalis muscle remained viable up to 21 days after EMS. We found a significant increase in FGF-acidic (0.677±0.007 vs. 0.585±0.014, p=0.045) and decrease in osteopontin (0.692±0.007 vs. 0.758±0.014, p=0.048) protein levels in the MCAo+EMS group 21 days after stroke, suggesting improved angiogenesis and recovery respectively. Mice in the MCAo+EMS group also showed reduced F4/80+ve macrophage accumulation in the peri-lesional territory of ischemic tissue, suggesting attenuated inflammation after stroke. Conclusions: These proof-of-concept data support that our novel EMS procedure is well-tolerated and may improve angiogenesis and recovery after stroke. EMS after MCAo is a promising new method of improving angiogenesis and recovery after stroke.

Surgical treatment of dumbbell-shaped jugular foramen schwannomas via two-piece lateral suboccipital approach: Report of 26 patients

BackgroundDumbbell-shaped jugular foramen schwannomas (JFS) are rare but challenging for the treatment. Surgical resection is believed to be the optimal therapy; however, postoperative dysfunction of the lower cranial nerves (CNs), tumor residual, cerebrospinal fluid (CSF) leakage, and subcutaneous hydrops are common. The current study's objectives were to describe the optimal surgical strategies for the total removal of dumbbell-shaped JFS, the functional preservation of lower CNs, and the prevention of postoperative CSF leakage. Methods26 consecutive patients with dumbbell-shaped JFS were surgically treated between January 2014 and June 2019. All patients were operated on via two-piece lateral suboccipital approach, vascularized muscle flap was used for the repair of the dural defect after an operation. The clinical information and radiological data of these patients were retrospectively reviewed, and the optimal surgical strategies were further evaluated and discussed. ResultsThe tumor was completely removed in all 26 patients, one patient developed new CN Ⅶ paralysis, and 2 developed new CN IX and Ⅹ paralysis after an operation, all patients were significantly relieved during follow up. None of them developed subcutaneous hydrops and postoperative CSF leakage. No tumor recurrence was observed during a mean follow up of 38.8 (16–69) months. ConclusionsDumbbell-shaped JFS could be safely and completely removed via the two-piece lateral suboccipital approach. Postoperative CSF leakage could be effectively prevented by careful repair of the dural defect in the jugular foramen (JF) and filling the mastoid cavity with a vascularized muscular flap.

Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin

Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P=0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N=36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P=0.02). Other rates of complications were not statistically different between groups. In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Open nasopharyngectomy – maxillary swing approach

Nasopharyngeal carcinoma is treated with definitive radiotherapy +/- chemotherapy depending on the stage of disease. Surgery serves as a means of salvage for persistent or recurrent diseases. Maxillary swing approach offers an anterolateral approach to tumours in the nasopharynx, ipsilateral parapharyngeal space including retropharyngeal lymph nodes and skull base invasion. Tumours abutting on the petrous part of internal carotid artery can be safely removed after identification and protection of the internal carotid artery. Exposed skull base bone and internal carotid artery post tumour extirpation warrant coverage with well vascularized muscle flap such as the vastus lateralis muscle. Attention to details peri-operation and meticulous tissue handling can help to prevent life-threatening complications post operation.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction.

Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Vascularized Muscle Flap to Reduce Wound Breakdown During Flexible Electrode-Mediated Functional Electrical Stimulation After Peripheral Nerve Injury.

The success of devices delivering functional electrical stimulation (FES) has been hindered by complications related to implants including skin breakdown and subsequent wound dehiscence. Our hypothesis was that a vascularized muscle flap along the dorsal surface of an epimysial electrode would prevent skin breakdown during FES therapy to treat atrophy of the gastrocnemius muscle during peripheral nerve injury. Resection of a tibial nerve segment with subsequent electrode implantation on the dorsal surfaces of the gastrocnemius muscle was performed on ten Lewis rats. In five rats, the biceps femoris (BF) muscle was dissected and placed along the dorsal surface of the electrode (Flap group). The other five animals did not undergo flap placement (No Flap group). All animals were treated with daily FES therapy for 2 weeks and degree of immune response and skin breakdown were evaluated. The postoperative course of one animal in the No Flap group was complicated by complete wound dehiscence requiring euthanasia of the animal on postoperative day 4. The remaining 4 No Flap animals showed evidence of ulceration at the implant by postoperative day 7. The 5 animals in the Flap group did not have ulcerative lesions. Excised tissue at postoperative day 14 examined by histology and in vivo Imaging System (IVIS) showed decreased implant-induced inflammation in the Flap group. Expression of specific markers for local foreign body response were also decreased in the Flap group.

Muscle Flap Transposition for the Management of Intrathoracic Fistulas.

Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas. A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed. A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment. Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving. Therapeutic, III.

Surgical management of Boerhaave�s syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients

spontaneous esophageal rupture (Boerhaave's syndrome) is a rare and challenging clinical condition. to evaluate the outcome of different surgical treatments for patients with Boerhaave's syndrome with an early diagnosis (< 24 h) and delayed diagnosis (> 24 h), using a retrospective cohort study in a tertiary referral center. eighty-eight patients with Boerhaave's syndrome who underwent surgical treatment were identified from March 1994 to March 2019 in the First Hospital of Shanxi Medical University. Subsequently, they were retrospectively divided into two groups according to time from symptom onset to diagnosis (group 1, < 24 h, n = 16; group 2, > 24 h, n = 72). Primary suture repair was used in group 1 and reinforcement with a vascular muscle flap was used in group 2, in order to reduce the incidence of fistula. Patients in group 2 were further divided into two subgroups according to reinforcement using diaphragmatic flaps (subgroup 1) or intercostal muscle flaps (subgroup 2). the duration of hospitalization and stay in Intensive Care Unit (ICU) was significantly shorter in group 1 (p = 0.027 and p = 0.001). Group 1 had fewer postoperative esophageal leaks (p = 0.037) compared to group 2. Various aspects were compared in the two subgroups and the differences were not statistically significant (p > 0.05). it is very important to establish an early diagnosis for patients with Boerhaave's syndrome. Early (< 24 h) and primary suture repair is superior to delayed (> 24 h) primary repair, even for those reinforced with vascular muscle flaps. Furthermore, repair reinforcement with different muscle flaps appears to render similar results for patients with delayed diagnosis.

Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures

AimTo report clinical and radiographic results of treatment of patients with complex open tibial pilon fractures. MethodsA retrospective analysis in 14 patients with complex open pilon fractures treated between 2010 and 2015 was conducted. The injuries were graded according to AO Classification and the Gustillo-Anderson system. Routine follow-up was performed at 1, 3, 6, 12 month with an annual evaluation thereafter. All patients were included for the assessment of the rate of infection, wound and fracture-healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 12 months after the injury. The radiological outcome was evaluated through standard XR using the criteria proposed by Burwell and Charnley. ResultsAnalysis were conducted in 12 men and 2 women, with a mean age of 50.4 years (20–77) who were followed up for an average 34 months (range: 9–60 months). All patients had a AO type 43C fracture. There were three Gustilo Type IIIA injuries, seven Type III B and four Type III C. The mean time to fracture healing was 6.3 months. 4 patients underwent definitive treatment with external fixation at the time of the initial irrigation and debridement. 10 patients underwent delayed definitive surgery: in 10 patients ORIF was used. Soft-tissue coverage by vascularized muscle flap was necessary in 4 patients (28%) and was typically performed on the day of definitive fixation. One patient required iliac crest bone-grafting. 4 patients (28%) had a deep infection.6 patients (43%) had a superficial pin infection or cellulitis. 6 patients (43%) presented delayed union. The average AOFAS score was 71.5 (40–95). According to the Burwell-Charnley score, the anatomical reduction of the fracture was obtained in 50% of patients and a good reduction in 86% of cases. 5 patients (35.7%) had loss of joint congruity and evidence of osteoarthritis on radiographs at final follow-up. No patient needed arthrodesis or amputation. ConclusionThe results of our study suggest that open tibial pilon fractures can be safely managed with low rate of complications using intensive debridement, antibiotics, adequate devices and patient-tailored timing of definitive surgical treatment.

Reconstruction of Knee Defects Using Pedicled Gastrocnemius Muscle Flap with Split-Thickness Skin Grafting: A Single Surgeon's Experience with 21 Patients.

Generally, reconstruction of knee defects with exposed bone, joint, tendon, and/or hardware requires a vascularized muscle flap for coverage. Although there are several surgical options for a knee defect reconstruction, the pedicled gastrocnemius muscle still remains the workhorse flap. Although this flap is commonly used for knee defect reconstruction and the technique is described very well, there is an absence of information in the literature detailing the technique of harvesting and insetting of the gastrocnemius flap step by step with illustrations. The purpose of this article is to describe in detail the technique to reconstruct defects of the knee with pedicled gastrocnemius muscle flap as well as to present demographics and surgical results of 21 patients who had knee reconstruction with a pedicled gastrocnemius muscle flap and split-thickness skin grafting.

Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections.

Background:Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging.Methods:Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3).Results:The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred.Conclusions:The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds.

Surgical Treatment of Complications After High-Dose Chemoradiotherapy for Lung Cancer

There are limited published reports on the indications for, and outcomes of, a surgical intervention for complications arising after high-dose chemoradiotherapy (CRT) for locally advanced non-small cell lung cancer (NSCLC). We report on our institutional experience with such cases. Patients who underwent operations for any complication after CRT (≥60 Gy) for NSCLC between 2009 and 2015 were identified. All operations were performed at a tertiary referral center. In the 15 patients identified, the median time between the last day of radiotherapy and first radiologic confirmation of the complication was 8 months (range, 0 to 102 months). Complicated pulmonary cavitation was the most frequent indication for surgical intervention (n= 11 in 9 patients), followed by esophagorespiratory fistula (n= 3), hemorrhage (n= 3), bronchial stenosis (n= 2), esophageal stenosis (n= 1), and bronchiectasis (n= 1). Four patients had more than two complications diagnosed, and 9 patients underwent more than one surgical intervention. Surgical procedures performed included thoracostomy (n= 11 in 9 patients) with seven vascularized muscle flaps used in 6 patients, pulmonary resection (n= 5 in 4 patients) and esophageal resection with gastric tube reconstruction (n= 3). The 30- and 90-day mortality rates were 20% (n= 3) and 27% (n= 4), respectively. Median survival was 19 months (95% confidence interval [CI]: 3.9 to 34.1 months). An Operation is often the only treatment option when irreversible complications arise after high-dose CRT for NSCLC. It is infrequently performed, technically challenging, and associated with high perioperative risk and even death. Therefore, we suggest that such patients should be managed by a multidisciplinary team, including experienced thoracic surgeons.

Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the "first chance is the best chance".

Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula.

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. To our knowledge this is first case in which rectourethral fistula secondary to HIFU was repaired with buccal mucosa graft (BMG) over a harvest bed of gracilis flap. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results. We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the "first chance is the best chance".