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Journal of Plastic Surgery and Hand... Dec 2023In this report, we describe a super microsurgical technique that enables rapid and accurate anastomosis while adjusting for caliber differences when anastomosing a...
In this report, we describe a super microsurgical technique that enables rapid and accurate anastomosis while adjusting for caliber differences when anastomosing a small-caliber lymphatic vessel and a vein with a larger caliber, which is frequently encountered in surgeries such as lymphaticovenous anastomosis (LVA). The suture size adjustment technique was performed in 30 anastomoses of lymphatic vessels and veins, whose diameter of lymph duct was at least two times smaller than that of the vein. The type of lymphedema, caliber of lymphatic vessels and veins anastomosed, caliber ratio, vein wall thickness, modified caliber ratio after vein wall thickness subtracted, presence of additional anastomosis, and anastomosis time were examined. On average, the lymphatic vessels had a diameter of 0.61 mm, while the veins were 1.43 mm in diameter. The mean caliber ratio of vein to lymphatic vessel was 2.3, while the modified caliber ratio of vein-to-lymphatic vessel was 1.5 on average. The average venous wall thickness was 0.51. The average anastomosis time was 9.1 min and no additional anastomosis due to leakage was necessary in any case. We successfully performed an anastomosis of lymphatic vessels and veins with different calibers, which can maintain long-term patency while adjusting the caliber difference and suppressing leakage at the anastomosis site. Finally, the caliber of the vein is commonly larger than that of the lymphatic vessel to be anastomosed in many cases of LVA surgery, indicating that the proposed anastomosis method could be of therapeutic use in many cases.
Topics: Humans; Veins; Lymphedema; Lymphatic Vessels; Anastomosis, Surgical; Lymphography; Microsurgery
PubMed: 38130209
DOI: 10.2340/jphs.v58.18384 -
Annals of Translational Medicine Feb 2024Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications,... (Review)
Review
BACKGROUND AND OBJECTIVE
Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications, especially for living donor liver transplantation. The application of microsurgical techniques for hepatic artery reconstruction has greatly reduced the risk of hepatic artery thrombosis. In this narrative review, we discuss the technical considerations and challenges faced in microsurgical reconstruction of hepatic artery in liver transplantation.
METHODS
PubMed, Web of Science, and Google Scholar were searched for keywords relating to "liver transplantation", "microsurgery", "living donor liver transplantation", "deceased donor liver transplantation", "hepatic artery", "hepatic artery thrombosis", "hepatic artery reconstruction" and "microsurgical anastomosis". Relevant articles pertaining to the technical considerations and challenges of microsurgery in liver transplantation were included.
KEY CONTENT AND FINDINGS
The conditions of liver transplantation pose unique challenges to the microsurgeon. Nonetheless, there are described strategies that can overcome these conditions, as well as technical details that may improve the outcomes of hepatic artery reconstruction. These strategies start from proper positioning of the patient, conscientious selection of donor and recipient hepatic vessels, and minimizing movements during critical microsurgical anastomosis. Technical details include techniques to overcome vessel delamination, size mismatch, poor quality vessels, and short vessel stump. This review also explores the outcomes of microsurgical hepatic arterial reconstruction.
CONCLUSIONS
There are various strategies to mitigate the challenges of microsurgery in liver transplant. Microsurgery improves the outcome of liver transplantation. Microsurgeons will continue to be a priceless resource that all liver transplant teams should have.
PubMed: 38304899
DOI: 10.21037/atm-23-519 -
Journal of Neurological Surgery Reports Oct 2023Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The...
Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The objective of this study was to describe clinical characteristics and outcomes in patients undergoing repeat surgery for VS. All adult (≥ 18 years) patients undergoing VS resection between 2003 and 2022 at our institution were retrospectively reviewed to identify patients who underwent repeat surgery of an ipsilateral VS following prior gross-total (GTR) or subtotal resection. Patient, radiographic, and clinical characteristics were reviewed. Primary outcomes were postoperative tumor volume, extent of resection, postoperative cranial nerve deficits, and time to further tumor progression. Of 102 patients undergoing VS resection, 6 (5.9%) had undergone repeat surgery. Median (range) follow-up was 20 (5-117) months. Three patients were female. Median age was 56 (36-60) years. Median pre- and postoperative tumor volumes were 8.2 (1.8-28.2) cm and 0.4 (0-3.8) cm . GTR was achieved in two patients. Four patients had higher House-Brackmann scores at last follow-up, but none had tumor progression. In this small cohort of patients, repeat resection of recurrent or progressive VS can effectively reduce tumor volume with acceptable perioperative outcomes.
PubMed: 37900579
DOI: 10.1055/s-0043-1776124 -
Annals of Translational Medicine Feb 2024Mastectomies have a significant socio-psychological impact, motivating patients to undergo breast reconstruction. Initially, silicone implants were used to reconstruct... (Review)
Review
BACKGROUND AND OBJECTIVE
Mastectomies have a significant socio-psychological impact, motivating patients to undergo breast reconstruction. Initially, silicone implants were used to reconstruct the breast. However, breast implants have been the subject of successive crises throughout the years. Indeed, rupture, silicone bleeding, and capsular contracture remain topical. In 2019, the BIOCELL textured breast implants was banned and recalled due to the discovery of the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). More recently, the breast implant illness has been depicted in the media. To cope with these issues and to respond to some patients' expectations for a natural reconstruction, plastic surgeons have developed autogenous solutions for breast reconstruction. Since Taylor's research on angiosomes, the development of the microsurgery and more recently fat grafting, autogenous breast reconstruction has known a tremendous expansion. Autologous breast reconstruction allows a more natural feeling and texture. This narrative review aims to provide to the readers a comprehensive and updated evidence-based overview of state of the art about autologous breast reconstruction after total mastectomy.
METHODS
We conducted a narrative review of the literature searching for papers published between January 2010 and December 2022. The MeSH terms with different combinations were used to identify articles for inclusion. After screening article titles and abstracts independently by three authors, 66 papers were included in this review.
KEY CONTENT AND FINDINGS
In this review, the authors describe and discuss the different autogenous techniques in breast reconstruction.
CONCLUSIONS
Autologous reconstructions provide very satisfactory, durable, and reliable results with relatively low complication rates. Deep inferior epigastric perforator (DIEP) flaps, latissimus dorsi flaps and autologous fat grafting are the most common type of autogenous breast reconstructions.
PubMed: 38304895
DOI: 10.21037/atm-23-1471 -
Annals of Translational Medicine Oct 2023The hand is the highly specialized distal construct of the upper limb with complex and intricate anatomy. Soft tissue defects can compromise this and result in... (Review)
Review
BACKGROUND AND OBJECTIVE
The hand is the highly specialized distal construct of the upper limb with complex and intricate anatomy. Soft tissue defects can compromise this and result in significant functional impairment. Choosing the optimal reconstructive modality is essential for the best functional recovery. The objective of this narrative review was to provide a treatment algorithm for soft tissue defects in the hand.
METHODS
Relevant literature for the topic was searched from PubMed and Cochrane Database from year 1953 up till end of November 2022. Specified searches for randomized controlled trials, systematic reviews and reviews were performed.
KEY CONTENT AND FINDINGS
There are no randomized controlled trials published on this topic. There are six systematic reviews or meta-analyses published. Most of the literature still comprises on expert opinion and case reports with few previously proposed algorithms. Defect features, size, location and depth, patient related factors and available resources are the main determinants of the treatment strategy. In the hand, there are reasonable locoregional coverage options, but microsurgical options should be a routine alternative of the treatment repertoire. In the thumb and fingers, the reconstruction depends remarkably on injury extent.
CONCLUSIONS
Patient factors, surgical expertise, etiology, severity and goal of reconstruction will invariably have influence on the ultimate reconstruction performed, and algorithms may significantly help the surgical planning.
PubMed: 37970605
DOI: 10.21037/atm-23-201 -
Acta Cirurgica Brasileira 2023To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models.
PURPOSE
To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models.
METHODS
The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL).
RESULTS
There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%.
CONCLUSIONS
The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.
Topics: Humans; Internship and Residency; Microsurgery; Urology; Clinical Competence; Anastomosis, Surgical; Simulation Training
PubMed: 38055400
DOI: 10.1590/acb386523 -
Lasers in Medical Science Sep 2023The choice between radiotherapy (RT) and CO laser surgery (CO-LS) for early glottic cancer remains controversial. We systematically examined electronic databases in... (Meta-Analysis)
Meta-Analysis Review
The choice between radiotherapy (RT) and CO laser surgery (CO-LS) for early glottic cancer remains controversial. We systematically examined electronic databases in order to identify prospective trials comparing patients who had undergone CO-LS or RT to treat early glottic cancer. Eleven studies involving 1053 patients were included. In the selected literature, the parameter setting of CO laser equipment can be summarized as wavelength 10.6 µm, superpulsed mode, continuous setting, power tailored on target structures (1-3 W for subtle resections and 4-15 W for cutting a larger tumor), and approximately 2080-3900 W/cm of laser energy. Using RevMan 5.3, we estimated pooled odds ratios (ORs) for dichotomous variables and pooled mean differences (MDs) for continuous variables, along with associated 95% confidence intervals (CIs). The heterogeneity in the treatment variables was measured using Higgins' inconsistency test and expressed as I values. The continuous variables were then depicted as histograms developed using PlotDigitizer 2.6.8. Compared to patients treated with CO-LS, those treated with RT had better jitter (MD 1.27%, 95% CI 1.21 ~ 1.32, P < 0.001), and high scores on the "Grade (MD 6.54, 95% CI 5.31 ~ 7.76, P < 0.001), Breathiness (MD 9.08, 95% CI 4.02 ~ 14.13, P < 0.001), Asthenia (MD 2.13, 95% CI 0.29 ~ 3.98, P = 0.02), and Strain (MD 3.32, 95% CI 0.57 ~ 6.07, P = 0.02)" scale. Patients treated with CO-LS had worse local control rates (OR 3.14, 95% CI 1.52 ~ 6.48, P = 0.002) while lower incidence of second primary tumor (OR 0.30, 95% CI 0.15 ~ 0.61, P < 0.001). It is hoped that retrospective analysis can provide suggestions for early glottis patients to choose personalized treatment.
Topics: Humans; Carbon Dioxide; Treatment Outcome; Retrospective Studies; Microsurgery; Laryngeal Neoplasms; Prospective Studies; Laser Therapy; Glottis; Tongue Neoplasms
PubMed: 37758965
DOI: 10.1007/s10103-023-03890-3 -
Life (Basel, Switzerland) Jan 2024This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The... (Review)
Review
This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The objective was to balance the prevention of thrombotic complications commonly leading to flap failure, with the risk of increased bleeding complications associated with anticoagulant use. A meticulous PubMed literature search following Evidence-Based-Practice principles yielded 79 relevant articles, including both clinical and animal studies. The full-texts were carefully reviewed and evaluated by the modified Coleman methodology score. Clinical studies revealed diverse perioperative regimens, primarily based on aspirin, heparin, and dextran. Meta-analyses demonstrated similar flap loss rates with heparin or aspirin. High doses of dalteparin or heparin, however, correlated with higher flap loss rates than low dose administration. Use of dextran is not recommended due to severe systemic complications. In animal studies, systemic heparin administration showed predominantly favorable results, while topical application and intraluminal irrigation consistently exhibited significant benefits in flap survival. The insights from this conducted systematic review serve as a foundational pillar towards the establishment of evidence-based guidelines for anticoagulation in microsurgery. An average Coleman score of 55 (maximum 103), indicating low overall study quality, however, emphasizes the need for large multi-institutional, randomized-clinical trials as the next vital step.
PubMed: 38255697
DOI: 10.3390/life14010082 -
Plastic and Reconstructive Surgery.... Feb 2024Starting an academic microsurgery practice is a daunting task for plastic surgery graduates. Despite this, academic practice provides many advantages as a starting point...
Starting an academic microsurgery practice is a daunting task for plastic surgery graduates. Despite this, academic practice provides many advantages as a starting point for a career. Microsurgical faculty can make use of several unique benefits within an academic center. These include vast resources of clinical and basic science departments, communications and public affairs divisions, and quality improvement teams. Building a multi-disciplinary microsurgery practice with specific focus will jumpstart research questions and outcome data. Using residents and students to their full potential is both rewarding and efficient as a microsurgeon. Finally, peer faculty in an academic environment provide a stimulating resource for growth and assistance when needed. This special topic provides insight into starting a microsurgery practice for any resident considering a career in academics.
PubMed: 38317654
DOI: 10.1097/GOX.0000000000005571 -
Journal of Investigative Surgery : the... Dec 2023To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal neuroendocrine tumor (RNET) patients. This article will provide reliable evidence for surgeons in regards to clinical decision-making.
METHODS
Systematic literature retrieval was performed in Pubmed, Embase and Cochrane database from 2013/4/30 to 2023/4/30. Methodology validation was performed by using the Newcastle-Ottawa Scale (NOS). Data-analysis was conducted by using the Review manager version 5.3 software.
RESULTS
A total of three retrospective studies were included in our meta-analysis. All eligible studies were considered to be high quality. By comparing baseline characteristics between TEM and ESD, patients in the TEM group seemed to be characterized by a larger tumor size and lower tumor level, even though no statistical significance was found. Clear statistical significance favoring TEM was identified in terms of R0 resection rate, procedure time and hospital stay. No statistical significance was found in terms of recurrence rate, adverse events rate and additional treatment rate.
CONCLUSIONS
Compared with ESD, TEM was a more effective treatment modality for early RNET patients; it was associated with a relatively higher R0 resection rate and a similar degree of safety. However, the relatively higher cost and complicated manipulation restricted the promotion of TEM. Surgeons should opt for TEM as a primary treatment in patients with a larger tumor size and deeper degree of tumorous infiltration if the financial condition and hospital facility permit.
Topics: Humans; Transanal Endoscopic Microsurgery; Endoscopic Mucosal Resection; Neuroendocrine Tumors; Retrospective Studies; Rectal Neoplasms
PubMed: 37970828
DOI: 10.1080/08941939.2023.2278191