Assuntos
Índice de Massa Corporal , Mamoplastia , Mama , Neoplasias da Mama , Humanos , Mastectomia , Estudos Retrospectivos , Transplante AutólogoRESUMO
With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
Assuntos
Quilotórax/cirurgia , Microcirurgia/métodos , Ducto Torácico/cirurgia , Veias/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Lactente , Masculino , Cuidados Pós-Operatórios/métodos , Vênulas/cirurgiaRESUMO
BACKGROUND: Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. METHODS: A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. RESULTS: A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. CONCLUSIONS: Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Fraturas Expostas/cirurgia , Retalhos de Tecido Biológico/transplante , Traumatismos da Perna/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Lesões dos Tecidos Moles/cirurgia , Cicatrização/fisiologia , Doença Aguda , Adulto , Análise de Variância , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Sobrevivência de Enxerto , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Retalho Miocutâneo/irrigação sanguínea , Retalho Miocutâneo/transplante , Estudos Retrospectivos , Medição de Risco , Transplante de Pele/métodos , Lesões dos Tecidos Moles/diagnóstico , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Weight gain is common in breast cancer patients and increases the risk of recurrence and mortality. The authors assessed the impact of autologous breast reconstruction on body mass index patterns after diagnosis in mastectomy patients. METHODS: Women undergoing therapeutic mastectomy at the authors' institution from 2008 to 2010 were identified. Patients undergoing no breast reconstruction or autologous breast reconstruction were propensity-matched by age at diagnosis, baseline obesity, mastectomy laterality, and adjuvant therapies. Multivariable regression was used to estimate covariate associations with percentage body mass index change and percentage body mass index change greater than 5.0 percent at 1 to 4 years after diagnosis. RESULTS: Of 524 total patients, 80 propensity-matched pairs were identified. In multivariable regression, women undergoing immediate autologous breast reconstruction had reduced body mass index changes after diagnosis, compared with nonreconstruction patients, at 1 year (ß = -5.25 percent; p < 0.01), 2 years (ß = -8.78 percent; p < 0.01), and 3 years (ß = -7.21 percent; p < 0.01). After 4 years, all autologous reconstruction was predictive of reduced body mass index changes (ß = -3.54 percent; p = 0.02). Higher body mass index increases were observed among women who were leaner at diagnosis (p < 0.01 at 1 year) and received chemotherapy (p = 0.02 at 3 years; p = 0.04 at 4 years). CONCLUSIONS: Women undergoing autologous breast reconstruction gained less weight after diagnosis than nonreconstruction patients. Normal baseline body mass index and chemotherapy were predictive of greater body mass index increases. These findings may guide targeted weight management strategies in high-risk patients to maximize survival rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Idoso , Índice de Massa Corporal , Neoplasias da Mama/complicações , Feminino , Humanos , Mastectomia/métodos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Obesidade/complicações , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Retalhos Cirúrgicos , Magreza/complicações , Transplante Autólogo/métodos , Aumento de Peso/fisiologia , Redução de Peso/fisiologiaRESUMO
BACKGROUND: Breast augmentation with subglandular versus subpectoral implants may differentially impact the early detection of breast cancer and treatment recommendations. The authors assessed the impact of prior augmentation on the diagnosis and management of breast cancer in women undergoing mastectomy. METHODS: Breast cancer diagnosis and management were retrospectively analyzed in all women with prior augmentation undergoing therapeutic mastectomy at the authors' institution from 1993 to 2014. Comparison was made to all women with no prior augmentation undergoing mastectomy in 2010. Subanalyses were performed according to prior implant placement. RESULTS: A total of 260 women with (n = 89) and without (n = 171) prior augmentation underwent mastectomy for 95 and 179 breast cancers, respectively. Prior implant placement was subglandular (n = 27) or subpectoral (n = 63) (For five breasts, the placement was unknown). Breast cancer stage at diagnosis (p = 0.19) and detection method (p = 0.48) did not differ for women with and without prior augmentation. Compared to subpectoral augmentation, subglandular augmentation was associated with the diagnosis of invasive breast cancer rather than ductal carcinoma in situ (p = 0.01) and detection by self-palpation rather than screening mammography (p = 0.03). Immediate two-stage implant reconstruction was the preferred reconstructive method in women with augmentation (p < 0.01). CONCLUSIONS: Breast cancer stage at diagnosis was similar for women with and without prior augmentation. Among women with augmentation, however, subglandular implants were associated with more advanced breast tumors commonly detected on palpation rather than mammography. Increased vigilance in breast cancer screening is recommended among women with subglandular augmentation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Implante Mamário/efeitos adversos , Neoplasias da Mama/etiologia , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Implante Mamário/métodos , Implantes de Mama/efeitos adversos , Neoplasias da Mama/patologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Mamoplastia/efeitos adversos , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/fisiopatologia , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/transplante , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis. METHODS: All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors. RESULTS: A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 10/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 10/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 10/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 10/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 10/liter; OR, 3.82; p = 0.002). CONCLUSIONS: Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.