Evaluating Operative Times for Intraoperative Conversion of Axillary Node Biopsy to Axillary Lymph Node Dissection with Immediate Lymphatic Reconstruction.

BACKGROUND: Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning. METHODS: A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded. RESULTS: There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001). CONCLUSION: Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Quantification of Lymphangiogenesis in the Murine Lymphedema Tail Model Using Intravital Microscopy.

Background: Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel therapeutics. Intravital microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous nonviral vector gene delivery using a chip with nanochannel poration in a rapid (<100 ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics in the live mice model. Methods and Results: The murine tail model of lymphedema was utilized. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: TNTpCMV6 group receives pCMV6 (expression vector backbone alone) (n = 6); TNTProx1 group receives pCMV6-Prox1 (n = 6). Lymphatic vessels (fluorescein isothiocyanate [FITC]-dextran stained) and lymphatic branch points (indicating lymphangiogenesis) were analyzed with the confocal/multiphoton microscope. The experimental group TNTProx1 exhibited reduced postsurgical tail lymphedema and increased lymphatic distribution compared to TNTpCMV6 group. More lymphatic branching points (>3-fold) were observed at the TNT site in TNTProx1 group. Conclusions: This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. IVM can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.

Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.

The Lymphedematous Limb as a Donor Site for Breast Fat Grafting.

Breast cancer-related lymphedema results in chronic upper limb swelling with subcutaneous deposition of fluid and fibroadipose tissue. Morbidity includes psychosocial distress, infection, and difficulty using the extremity. Operative management includes excisional procedures such as suction-assisted lipectomy to reduce abnormal subcutaneous fibroadipose tissue to improve limb volume. Patients who have had postmastectomy breast reconstruction often benefit from fat grafting. This report introduces the concept of fat grafting the breast using the lymphedematous arm as a donor site. This technique improves the volume of the limb by removing the excess subcutaneous adipose, and at the same time reconstructs the breast without adding a donor site not related to the breast cancer-related lymphedema.

Trends in Immediate Lymphatic Reconstruction.

Background and objective Immediate lymphatic reconstruction (ILR) is emerging as a useful adjunct after axillary lymph node dissection (ALND), leading to a decrease in lymphedema rates from 30 to 3-13% in breast cancer patients. ILR requires coordination between two surgical specialties for oncologic ALND and microsurgical axillary lymphatic anastomosis. This study aimed to assess the trends in the frequency of ILR performed after ALND at our institution. Methods This study involved a retrospective review of breast cancer patients undergoing ALND with and without ILR at our institution (2017-2022). Data on patient demographics, tumor characteristics, and treatments received were gathered and analyzed. Results A total of 316 patients underwent ALND at our institution and 30.7% (97/316) of them received ILR. There was no significant difference in clinical breast cancer stages between patients who underwent ALND with or without ILR (p>0.05). Neoadjuvant chemotherapy was given to 51.1% (112/219) of patients with ALND only compared to 60.8% (59/97) of patients who underwent ALND with ILR (p=0.09). All patients received adjuvant radiation therapy. ILR was performed after ALND in 4.2% (2/47) in 2017, 25.8% (3/58) in 2018, 17.6% (12/68) in 2019, 35% (21/60) in 2020, 56.9% (41/72) in 2021, and 54.5% (6/11) in 2022. When comparing the first year of the ILR program with the last year of the study period, the odds ratio of receiving ILR after ALND was 1.8 (p=0.04). Conclusions The frequency of performing ILR after ALND in breast cancer patients at our institution witnessed a substantial increase during the study period. The implementation of an established ILR program at an institution can increase procedure uptake accompanied by continued growth in utilization.

Topical tissue nanotransfection of Prox1 is effective in the prophylactic management of lymphedema.

Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.

Prophylactic Absorbable Antibiotic Beads for High-risk, Implant-based Prepectoral Reconstruction.

Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) (P < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.

Risk of Ipsilateral Deep Vein Thrombosis After Kidney Transplantation: A Retrospective Study.

OBJECTIVE: To investigate the incidence and characteristics of deep vein thrombosis (DVT) in kidney transplantation recipients and analyze whether the anatomical side of DVT was associated with the side of the transplanted organ. METHODS: A single-center retrospective medical record review of patients who received a kidney transplant between January 2004 and July 2019 and who subsequently developed DVT. Only patients who received unilateral kidney transplants were included in the study. Patients who underwent concomitant pancreatic transplants, bilateral kidney transplants, or repeat procedures were excluded. RESULTS: Of the 2449 kidney transplants performed during the study period, 1482 were included in the analysis (948 men [64%]; mean age 61 years). Of 606 duplex ultrasound tests, 115 results confirmed the presence of DVT. The incidence of symptomatic DVT was 4.7%. The most common time of DVT diagnosis was within four weeks after transplantation. Type 2 diabetes, heart failure, acute myocardial infarction, sepsis, chronic obstructive pulmonary disease/abnormal pulmonary function, and being confined to bed were associated with DVT after kidney transplant (all P < 0.05). Patients with ultrasound-confirmed DVT had higher mean Caprini scores than patients with negative duplex ultrasounds (P < 0.5). Approximately 53% of transplant patients with ultrasound-confirmed DVT had a 1:1 correlation of transplant side to the side of DVT. Cohen kappa statistic 0.03 indicated no correlation between the side of DVT and the side of transplant. CONCLUSIONS: The incidence of DVT after kidney transplant was lower than the incidence reported in the literature. Being confined to a bed may be a risk factor for DVT after transplant surgery. Kidney transplant recipients who had a positive duplex ultrasound had higher Caprini risk assessment scores than transplant recipients who had negative duplex ultrasounds. There was no correlation between the side of the DVT and the side of the transplant.

Perioperative Coronavirus Vaccination-Timing and Implications: A Guidance Document.

EXECUTIVE SUMMARY: Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.