Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Christopher Schardt, Angela Schmid, Jens Bodem, Johannes Krisam, Jürgen Hoffmann, Christian Mertens
PurposeBone defects after resective tumor surgeries often require the use of microvascular reanastomized bone grafts for reconstruction. The decision as to which specific flap is most suitable for the particular patient is dependent on various factors. The aspects donor site morbidity and quality of life are rarely taken into account in this connection. The aim of this study was to analyze whether these factors, in the future, should influence the choice of donor site.Material and MethodsIn this study, the donor sites of 46 patients with respect to deep-circumflex iliac artery (DCIA) and fibula flaps were analyzed using subjective and objective parameters. The primary outcome was postoperative pain measured by VAS. Postoperative complication evaluations as well as 2 orthopedic scores were implemented (American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Harris Hip Score) and the patients' quality of life was assessed using the 36-Item Short Form (SF-36) questionnaire to quantify donor site impairment.ResultsPostoperative pain was rated with a mean value of 42.4 mm (SD 34.8) for the DCIA group and 36.9 mm (SD 37.1) for the fibula group (p=0.617). After a mean period of 13.72 months, pain was rated with a mean value of 15.3 mm (SD 21.7) for DCIA and 13.3 mm (SD 22.6mm) for the fibula (p=0.763). Persistent pain, however, was recorded only in 11.11% of DCIA patients and 5.26% of fibula patients. Furthermore pain intensity was higher in the DCIA group. A changed gait pattern was observed in 59.26% of DCIA patients and 21.05% of fibula patients. DCIA patients required walking aids for walking and stair climbing more often. Looking at the results of the 2 orthopedic scores, fibula patients showed slightly better results. Concerning quality of life, patients after reconstructive surgery with DCIA flaps showed slight better results than patients in the fibula group.ConclusionsTaking the results of this study into account, the outcome in terms of pain, morbidity and quality of life did not show a significant superiority of any donor site.



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Patient-specific Biodegradable Implant in Pediatric Craniofacial Surgery

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): H. Essig, D. Lindhorst, T. Gander, P. Schumann, D. Könü, S. Altermatt, M. Rücker
Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver. 3.0.5; Brainlab, Feldkirchen, Germany) to generate a 3D reconstruction. Virtual osteotomies and simulation of the ideal outer contour with reassembled bony segments were performed. Digital planning was transferred with a cutting guide, and an individually manufactured resorbable implant was used for rigid fixation. A resorbable patient-specific implant (Resorb X-PSI) allows precise surgery for FOA in craniosynostosis using a complete digital workflow and should be considered superior to manually bent resorbable plates.



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Patient-specific polymethylmethacrylate prostheses for secondary reconstruction of large calvarial defects: A retrospective feasibility study of a new intraoperative moulding device for cranioplasty

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Manuel Moser, Raphael Schmid, Ralf Schindel, Gerhard Hildebrandt
PurposeThe aim of this study was to review a new template-based technique for intraoperative patient-specific cranioplasty manufacturing (PSCM) with polymethylmethacrylate (PMMA) to cover large calvarial defects.Material and MethodsA polypropylene foil thermoformed on a three-dimensional reprint of the calvarial defect was used as an intraoperative moulding device for PMMA between August 2012 and December 2015. Surgical and radiological data were retrospectively reviewed, and a patient questionnaire was used to assess functional and cosmetic outcome (numeric rating scale, Odom´s criteria).ResultsSeventeen patients (mean age 42.2±14.5 years) received PSCM. Operating time averaged 130±34 min, and the approximate blood loss was 293±185ml. Volumetric analysis revealed a lower implant volume compared to index bone (mean 66.5 vs. 72 cm³, p=0.513), the mean difference in thickness being the lowest in the posterior parietal and pterional (0.4-0.7 mm) and the highest in the anterior-superior frontal area (1.8 mm). Cosmetic satisfaction averaged 9±1.5, with 70.6% of patients judging the overall result as excellent or good and 29.4% as satisfactory. Mean follow-up was 19.5±13.3 months, with an overall complication rate of 17.6%, including 11.8% surgical site infections (SSIs) and one implant removal.ConclusionsIntraoperative PSCM using PMMA moulded on a thermoformed polypropylene foil leads to satisfactory outcomes. It is a safe technique with complication rates comparable but not superior to those of other alloplastic techniques, but the device has considerable production costs.



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Influence of Bone Invasion on Outcomes after Marginal Mandibulectomy in Squamous Cell Carcinoma of the Oral Cavity

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Ivana Petrovic, Pablo H. Montero, Jocelyn C. Migliacci, Frank L. Palmer, Ian Ganly, Snehal G. Patel, Jatin P. Shah
IntroductionMarginal mandibulectomy (MM) is indicated for oral cavity squamous cell carcinomas (OCSCC) that abut or minimally erode the mandible without gross invasion. Successful implementation of MM is predicated on accurate patient selection and appropriate adjuvant treatment based on well-known host and tumor characteristics. The incidence of microscopically diagnosed bone involvement in MM specimens and its implications on outcomes have however not been reported in large contemporary series.PurposeTo report the incidence of bone involvement and analyze its influence on oncologic outcomes in selected patients who underwent MM in treatment of OCSCC.MethodA retrospective cohort study was performed on a consecutive series of previously untreated patients requiring MM, at a tertiary care cancer center between 1985 and 2012 (n=326). The median age was 64 years and 59% were male. The majority of patients (67%) had a primary tumor of the floor of the mouth or lower alveolus, 80% were clinically staged T1-2, and 31% were clinically N+. Postoperative radiation (PORT) was used in 27% and chemoradiation (POCTRT) in 8% of patients who had microscopic bone invasion. The median follow up period was 55 months and endpoints of interest were local and regional recurrence free (LRFS and RRFS) and disease specific (DSS) survival.ResultsMicroscopic bone invasion was present in 15% of patients. (n=49). . Among these cortical invasion was present in 32, medullary in 13 and it was not specified in 4. Eight patients had microscopic positive bone margins. Positive bone margins were associated with medullary bone involvement (p<0.001), floor of mouth and buccal mucosa primary site (p=0.0), and positive soft tissue margins (p=0.05). LRFS and DSS were similar in patients without versus with bone invasion (62.8% vs 79.7% and 76.2% vs 66% respectively, p=NS). LRFS were similar in patients with microscopic positive versus negative bone margins, as long as postoperative adjuvant treatment was administered.ConclusionMicroscopic bone involvement does not adversely influence outcomes but medullary bone involvement does confer a higher risk of positive bone margins. MM and appropriate adjuvant treatment is an effective strategy for treatment of OCSCC in selected patients with primary tumors adherent to or in proximity to the mandible.



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Improving outcome of trauma patients by implementing patient blood management.

Purpose of review: Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. Recent findings: Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients. Summary: In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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An update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine.

Purpose of review: The present review aims to provide an update on the various practical applications of the STOP-Bang questionnaire in anesthesia, surgery, and perioperative medicine. Recent findings: The STOP-Bang questionnaire was originally validated as a screening tool to identify surgical patients who are at high-risk of obstructive sleep apnea (OSA). A recent meta-analysis confirmed that STOP-Bang is validated for use in the sleep clinic, surgical, and general population. Patients with a STOP-Bang score of 0--2 can be classified as low-risk for moderate-to-severe OSA. Those with a score of 5--8 can be classified as high-risk for moderate-to-severe OSA. In patients with a score of 3 or 4, a specific combination of a STOP score at least 2 + BMI more than 35 kg/m2 or STOP score at least 2 + male or STOP score at least 2 + neck circumference more than 40 cm indicates higher risk for moderate-to-severe OSA. Further, patients with a STOP-Bang score at least 3 can be classified as high risk for moderate-to-severe OSA if the serum HCO3- at least 28 mmol/l. STOP-Bang can be used as a novel tool for perioperative risk stratification because it easily identifies patients who are at increased risk of perioperative complications. Summary: STOP-Bang at least 3 was recommended previously to identify the suspected or undiagnosed OSA. To reduce the false positive cases and to improve its specificity, a stepwise stratification is recommended to identify the patients at high risk of moderate-to-severe OSA. Because of its practical application, STOP-Bang is a useful screening tool for patients with suspected or undiagnosed OSA. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Abnormal cell-clearance and accumulation of autophagic vesicles in lymphocytes from patients affected with Ataxia-Teleangiectasia

Publication date: Available online 30 November 2016
Source:Clinical Immunology
Author(s): Roberta D'Assante, Anna Fusco, Loredana Palamaro, Elena Polishchuk, Roman Polishchuk, Gabriella Bianchino, Vitina Grieco, Maria Rosaria Prencipe, Andrea Ballabio, Claudio Pignata




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