Citations

IntroductionManagement after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap.MethodsThis is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed.ResultsBetween 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8–14.5 hours), average length of ICU stay was 3 days (range, 2–15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1–20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss.ConclusionsOverall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.

Background Patients with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort. It is unknown how transcatheter aortic valve replacement ( TAVR ) compares with surgical aortic valve replacement in this group of patients, which was the objective of this study. Methods and Results We retrospectively reviewed all patients with severe aortic stenosis who underwent either TAVR or surgical aortic valve replacement at our institution with a history of mediastinal radiation (n=55 per group). End points were echocardiographic and clinical outcomes in‐hospital, at 30 days, and at 1 year. Inverse propensity weighting analysis was used to account for intergroup baseline differences. TAVR patients had a higher STS score than surgical aortic valve replacement patients (5.1% [3.2, 7.7] versus 1.6% [0.8, 2.6], P <0.001) and more often ( P <0.01 for all) a history of atrial fibrillation (45.5% versus 12.7%), chronic lung disease (47.3% versus 7.3%), peripheral arterial disease (38.2% versus 7.3%), heart failure (58.2% versus 18.2%), and pacemaker therapy (23.6% versus 1.8%). Postoperative atrial fibrillation was less frequent (1.8% versus 27.3%; P <0.001) and hospital stay was shorter in TAVR patients (4.0 [2.0, 5.0] versus 6.0 [5.0, 8.0] days; P <0.001). The ratio of observed‐to‐expected 30‐day mortality was lower after TAVR as was 30‐day mortality in inverse propensity weighting–adjusted Kaplan–Meier analyses. Conclusions In patients with severe aortic stenosis and a history of chest radiation therapy, TAVR performs better than predicted along with less adjusted 30‐day all‐cause mortality, postoperative atrial fibrillation, and shorter hospitalization compared with surgical aortic valve replacement. These data support further studies on the preferred role of TAVR in this unique patient population.

Abstract Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

Background Optimal management of patients with severe mitral stenosis ( MS ) and low transmitral gradient is incompletely understood. Methods and Results We examined 101 consecutive patients with severe rheumatic MS (mitral valve area ≤1.5 cm 2 ) who underwent balloon valvuloplasty. Low gradient was defined as mean transmitral gradient <10 mm Hg and low flow as stroke volume index ≤35 mL/m 2 by echocardiography. Symptoms and mortality data were collected. Systolic, diastolic, and arterial function were characterized by measuring left ventricular (LV) end‐systolic elastance, LV stiffness constant (β), diastolic capacitance (predicted LV end‐diastolic volume at a common LV filling pressure of 30 mm Hg), and effective arterial elastance. Low gradient (<10 mm Hg) was present in 55 patients, including low flow/low gradient in 11 and normal flow/low gradient in 44 patients, and high gradient was present in 46 patients. Participants with low‐flow/low‐gradient (LG) MS were older with higher rates of atrial fibrillation (64%) and subvalvular thickening, higher afterload, and decreased LV compliance with lower ejection fraction (57±10% versus 65±4% versus 63±6%, P =0.002) but similar end‐systolic elastance compared with patients with normal‐flow/ LG and high‐gradient MS . The normal‐flow/ LG group had larger mitral valve area and lower left atrial pressure by catheterization, as well as favorable long‐term outcomes compared with the low‐flow/ LG and high‐gradient MS group. A total of 40% of patients with LG MS had no symptomatic benefit from valvuloplasty compared with 18% of patients with high‐gradient MS ( P =0.02). Conclusions Presence of low gradient in patients with severe MS was associated with lesser symptomatic benefit from valvuloplasty. In the subset with low stroke volume index, this may be related to independent ventricular‐vascular uncoupling, decreased LV compliance, and high prevalence of atrial fibrillation in addition to intrinsic MS .

AbstractBackgroundTreatment of hemodynamically significant mitral annular calcification (MAC) using transcatheter approaches is in the early learning phase. The occurrence of paravalvular leak (PVL) following transcatheter mitral valve in MAC is common.AimsTo report the initial experience and techniques of percutaneous PVL closure after transcatheter valve in MAC.MethodsThis series includes five consecutive patients who underwent percutaneous PVL closure following transcatheter balloon expandable SAPIEN S3 valve in MAC.ResultsMean patient age was 73.6 ± 5.4 years (4 [80%] female), with average Society of Thoracic Surgeons score of 8.1 ± 2.8%. Three patients had a single PVL defect while two patients had two defects; all were located at the commissural sites. Closure was performed primarily for heart failure in four patients and hemolytic anemia in one patient. Transfemoral transseptal antegrade approach and Amplatz Vascular Plug (AVP)‐II occluders were utilized in all patients. Procedure success was achieved in three patients. One patient developed significant occluder related leaflet impingement and subsequent severe prosthetic mitral regurgitation requiring a second transcatheter mitral valve in valve implantation. The procedure was aborted in one patient due to difficulty crossing PVL defect after balloon post‐dilatation of SAPIEN prosthesis with 10 mL of additional volume. There was no in hospital or 30 day mortality or the need for emergent surgery.ConclusionEarly experience with percutaneous PVL closure of SAPIEN valve in MAC demonstrated feasibility of this approach. Careful procedure planning and monitoring for SAPIEN prosthesis leaflet impingement and frame instability is of utmost importance to increase the chances of procedural success.

Background: Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle. Methods: Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted. Results: An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it. Conclusions: The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

BackgroundThe medial thigh is a well‐hidden area. The two most common flaps from this area are the transverse upper gracilis (TUG) and profunda artery perforator (PAP) flaps. Herein, we explored the applications of combined TUGPAP flap to reconstruct large and complex defects in different regions.MethodsBetween November 2015 and May 2017, 28 patients who underwent reconstruction and extensive soft tissue coverage with the TUGPAP flap for the breasts, head and neck, and pelvi‐perineal regions were included. The defects size ranged from 22 to 29 × 6–8 cm. All flaps were based on the two pedicles: the medial circumflex femoral artery for TUG flap and the profunda artery perforator for PAP flap. They were each anastomosed to a set of recipient vessels. A “Y”‐shaped interposition vein graft (YVG) was used if only one recipient artery was available.ResultsThe harvested skin paddle had dimensions ranged from 20 to 30 × 6–9 cm and all flaps survived completely. Postoperative complications included one case each of donor and recipient site seroma, and one case of wound dehiscence. They were all successfully managed conservatively. During an average follow‐up period of 12.7 months, one patient reported permanent paresthesia in the donor site and another developed hypertrophic scar. All patients were able to resume daily activity without major concerns.ConclusionThe combined TUGPAP flap is a safe, effective, and a good alternative to the common workhorse flaps as it offers the potential for a large skin paddle and decent soft tissue volume with low donor site morbidity in a well‐concealed area.

AbstractIntroductionMicrosurgical reconstruction of complex head and neck defects often requires reliable tissue in multiple spatial configurations to achieve good functional and aesthetic outcomes. In addition to robust perforators, flap inset and wound closure require great caution to minimize complications especially in the presence of trismus with limited space for inset. This report describes the technique and results of our staged approach to flap inset which increases the chance of total flap survival in complex head and neck reconstructions.MethodsFrom February 2010 to August 2016, a total of 53 patients were identified via a retrospective chart review. Patients who were suspected to have a high risk of vascular compromise and subsequently underwent complex head and neck reconstruction with staged inset of anterolateral thigh (ALT) flaps were included. The flap was inset only partially at the recipient site initially with fewer sutures. At a second stage, after neovascularization from surrounding tissue was established, the flap was partially elevated, divided and mobilized on its own pedicle for definitive inset.ResultsFifty‐one patients had complete survival of flaps and had uneventful postoperative course. Six cases required immediate re‐exploration to release wound tension or reposition the pedicle. Of these, 4 flaps were salvaged, 2 failed due to small perforators despite anastomosis revision. The flap survival rate was 96.2% and the average time between 2 stages was 24 days (range, 21–28).ConclusionStaged flap inset can improve free flap survival in complex head and neck reconstructions.