Immediate Bilateral Breast Reconstruction with Unilateral Deep Superior Epigastric Artery and Superficial Circumflex Iliac Artery Flaps.

Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.

Paraumbilical perforator flap for soft tissue reconstruction of the forearm.

Numerous flaps exist for coverage of injuries to the upper extremity, ranging from local, to regional, to free tissue transfer. The choice of flap is dependent on a variety of factors, including patient, functional needs, and depth of injury. The paraumbilical perforator (PUP) flap for upper extremity coverage can offer the benefits and versatility of pedicled and free flaps while avoiding some of the donor-site morbidity and risks of free tissue transfer. We report the indications and management of two clinical cases that exemplify PUP flap application. Technical points of flap harvest, inset, timing of pedicle division, and pertinent anatomy are discussed.

Design and experimental evaluation of an anti-leak feeding tube.

BACKGROUND: Enteral feeding via gastrostomy or jejunostomy tube is often required to adequately treat patients with cancer, gastrointestinal disorders, and cerebral vascular accident. Although sufficient to provide adequate caloric intake, the present design of a gastrostomy tube is inadequate. Leakage of gastric contents onto the skin is commonplace prompting emergency department visits and skin damage that requires costly nonoperative and operative intervention. We introduce a new gastrostomy tube design and prototype that inhibits leakage by using an adjustable external retaining member, which compresses against the feeding tube shaft thereby preventing dynamic friction. METHODS: A conventional external retaining member of a 22 French gastrostomy tube was tested against a novel compression-fitting external retaining member. Each gastrostomy tube was clamped to a scale and the external retaining member moved to slide along the tubing at a constant rate, and the applied frictional force was recorded. Thirty repetitions were performed. RESULTS: The experimental prototype generated ×2.5-3 the frictional force preventing tube excursion. Mean (standard deviation) forces were 18 (3) versus 46 (4) ounces (n = 10, P = 2.57E-13) and 15 (4) versus 48 (4) ounces (n = 10, P = 1.90E-13) for conventional and experimental designs, respectively. Simulated in situ environment mean forces were 19 (3) versus 39 (3) ounces (n = 10, P = 3.30E-11) for conventional and experimental designs, respectively. CONCLUSIONS: The experimental design created an increased static frictional force that inhibited the movement of the external retaining member against the gastrostomy tube. Clinical implementation is the next step to evaluate for reduced feeding tube morbidity and healthcare expenses by preventing leakage of gastric contents.

Feasibility of omitting cortical renorrhaphy during robot-assisted partial nephrectomy: a matched analysis.

BACKGROUND AND PURPOSE: To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes. PATIENTS AND METHODS: Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression. RESULTS: No differences were seen between renorrhaphy and nonrenorrhaphy in sex (P=0.53), age (P=0.14), body mass index (P=0.08), Charlson score (P=0.44), tumor diameter (P=0.55), nephrometry score (P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin (P=0.21). Warm ischemia time was less for the nonrenorrhaphy group (P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy (P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm(3) for renorrhaphy and 9 cm(3) for nonrenorrhaphy (P=0.003). In a multivariable model, both cortical renorrhaphy (P=0.004) and tumor diameter (P=0.004) were predictors of %volume loss. CONCLUSION: Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy.

Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida.

Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the American Academy of Pediatrics led to significant changes in circumcisions in Florida with a shift to nonneonatal procedures as a result of costs. We sought to study the prevalence and financial implications of nonneonatal circumcisions in Florida. A retrospective population study was performed using the Florida Agency for Health Care Administration outpatient procedure database. We queried for patients 0 to 17 years of age undergoing circumcision between 2003 and 2008. Demographics, charges, and insurance status were analyzed. From 2003 to 2008, 31,741 outpatient circumcisions were performed. Publicly funded circumcisions accounted for 17,537 charging the state $6,263 on average for each circumcision at an expense of $111.8 million for the 5-year time period analyzed. Publicly funded circumcision procedures increased more than sixfold (P < 0.0001) than those covered by private insurance. Black circumcision procedures increased 77.3 per cent, whereas white circumcisions increased 28.7 per cent. There has been a significant increase in the number of nonneonatal circumcisions performed. This has resulted in an increase in economic health care. Public funding of neonatal circumcision could result in significant cost savings and avoid potential complications of general anesthesia.

Amyand's hernia: a rare inguinal hernia.

Inguinal hernia repair is commonplace in general surgery practice and an estimated 700 000 are performed each year in the USA. The presence of the vermiform appendix contained in the hernia sac, or an Amyand's hernia, is exceedingly rare, occurring in 1% of inguinal hernia patients. We report the intra-operative findings of a standard inguinal hernia repair and discuss the management of the four types of Amyand's hernia.

Multi-dye theranostic nanoparticle platform for bioimaging and cancer therapy.

BACKGROUND: Theranostic nanomaterials composed of fluorescent and photothermal agents can both image and provide a method of disease treatment in clinical oncology. For in vivo use, the near-infrared (NIR) window has been the focus of the majority of studies, because of greater light penetration due to lower absorption and scatter of biological components. Therefore, having both fluorescent and photothermal agents with optical properties in the NIR provides the best chance of improved theranostic capabilities utilizing nanotechnology. METHODS: We developed nonplasmonic multi-dye theranostic silica nanoparticles (MDT-NPs), combining NIR fluorescence visualization and photothermal therapy within a single nanoconstruct comprised of molecular components. A modified NIR fluorescent heptamethine cyanine dye was covalently incorporated into a mesoporous silica matrix and a hydrophobic metallo-naphthalocyanine dye with large molar absorptivity was loaded into the pores of these fluorescent particles. The imaging and therapeutic capabilities of these nanoparticles were demonstrated in vivo using a direct tumor injection model. RESULTS: The fluorescent nanoparticles are bright probes (300-fold enhancement in quantum yield versus free dye) that have a large Stokes shift (>110 nm). Incorporation of the naphthalocyanine dye and exposure to NIR laser excitation results in a temperature increase of the surrounding environment of the MDT-NPs. Tumors injected with these NPs are easily visible with NIR imaging and produce significantly elevated levels of tumor necrosis (95%) upon photothermal ablation compared with controls, as evaluated by bioluminescence and histological analysis. CONCLUSION: MDT-NPs are novel, multifunctional nanomaterials that have optical properties dependent upon the unique incorporation of NIR fluorescent and NIR photothermal dyes within a mesoporous silica platform.

Microbial barriers.

Barrier wound therapy is commonplace in the health care environment and functions to limit bacterial colonization and infection in both acute wounds and recalcitrant chronic wounds. This article reviews the nature of acute and chronic wounds and their available adjunctive barrier therapies.

Nanoparticle delivery for metastatic breast cancer.

Breast cancer represents a major ongoing public health problem as the most common non-cutaneous malignancy among U.S. women. While significant progress has been made in improving loco-regional treatments for breast cancer, relatively little progress has been made in diagnosing and treating patients with metastatic breast cancer. At present there are limited curative options for patients with breast cancer metastatic beyond regional nodes. Emerging nanotechnologies promise new approaches to early detection and treatment of metastatic breast cancer. Fulfilling the promise of nanotechnologies for patients with metastatic breast cancer will require delivery of nanomaterials to sites of metastatic disease. Future translational approaches will rely on an ever increasing understanding of the biology of breast cancer subtypes and their metastases. These important concepts will be highlighted and elucidated in this manuscript.

Evaluation of breast tumor margins in vivo with intraoperative photoacoustic imaging.

The use of photoacoustic effect is a promising approach for biomedical imaging in living tissues. Photoacoustic tomography (PAT) has been demonstrated to image breast cancer, brain vasculature, arthritis and seizure focus owing to its rich optical contrast and high resolution in a single imaging modality. Here we report a microelectromechanical systems (MEMS)-based intraoperative PAT (iPAT) technique, and demonstrate its ability to accurately map tumors in three-dimension and to inspect the completeness of tumor resection during surgery in a tumor-bearing mouse model. The MEMS imaging probe is small and has the potential to be conveniently used to guide surgical resection of tumors in the breast.

Nanoparticle delivery for metastatic breast cancer.

Breast cancer represents a major ongoing public health problem as the most common non-cutaneous malignancy among U.S. women. While significant progress has been made in improving loco-regional treatments for breast cancer, relatively little progress has been made in diagnosing and treating patients with metastatic breast cancer. At present there are limited curative options for patients with breast cancer metastatic beyond regional nodes. Emerging nanotechnologies promise new approaches to early detection and treatment of metastatic breast cancer. Fulfilling the promise of nanotechnologies for patients with metastatic breast cancer will require delivery of nanomaterials to sites of metastatic disease. Future translational approaches will rely on an ever increasing understanding of the biology of breast cancer subtypes and their metastases. These important concepts will be highlighted and elucidated in this manuscript.

Fractionated photothermal antitumor therapy with multidye nanoparticles.

PURPOSE: Photothermal therapy is an emerging cancer treatment paradigm which involves highly localized heating and killing of tumor cells, due to the presence of nanomaterials that can strongly absorb near-infrared (NIR) light. In addition to having deep penetration depths in tissue, NIR light is innocuous to normal cells. Little is known currently about the fate of nanomaterials post photothermal ablation and the implications thereof. The purpose of this investigation was to define the intratumoral fate of nanoparticles (NPs) after photothermal therapy in vivo and characterize the use of novel multidye theranostic NPs (MDT-NPs) for fractionated photothermal antitumor therapy. METHODS: The photothermal and fluorescent properties of MDT-NPs were first characterized. To investigate the fate of nanomaterials following photothermal ablation in vivo, novel MDT-NPs and a murine mammary tumor model were used. Intratumoral injection of MDT-NPs and real-time fluorescence imaging before and after fractionated photothermal therapy was performed to study the intratumoral fate of MDT-NPs. Gross tumor and histological changes were made comparing MDT-NP treated and control tumor-bearing mice. RESULTS: The dual dye-loaded mesoporous NPs (ie, MDT-NPs; circa 100 nm) retained both their NIR absorbing and NIR fluorescent capabilities after photoactivation. In vivo MDT-NPs remained localized in the intratumoral position after photothermal ablation. With fractionated photothermal therapy, there was significant treatment effect observed macroscopically (P = 0.026) in experimental tumor-bearing mice compared to control treated tumor-bearing mice. CONCLUSION: Fractionated photothermal therapy for cancer represents a new therapeutic paradigm enabled by the application of novel functional nanomaterials. MDT-NPs may advance clinical treatment of cancer by enabling fractionated real-time image guided photothermal therapy.

Tumor endothelial marker 8 expression in triple-negative breast cancer.

BACKGROUND/AIM: Tumor endothelial marker 8 (TEM8) is a tumor endothelial-associated antigen that is having an increasingly recognized role in tumor biology. The expression of TEM8 in triple-negative breast cancer (TNBC) has not yet been characterized. MATERIALS AND METHODS: We hypothesize that TEM8 is overexpressed in TNBC and in metastatic TNBC in lymph nodes (LN) compared to normal breast tissue and normal lymphatic tissue, respectively. We studied expression of TEM8 in cases of primary (n=17) and metastatic (n=2) TNBC using immunohistochemical analyses. RESULTS: All cases demonstrated increased expression of TEM8 in tumor tissue compared to non-cancerous breast tissue. TEM8 was expressed at a higher level in the stroma adjacent to the TNBC in all cases, with focal immunoreactive areas within the tumor. TEM8 was not expressed in normal lymphoid tissue, but showed expression at sites of LN metastases. CONCLUSION: TEM8 would appear to represent a new biologic target for designing novel diagnostic or therapeutic approaches for TNBC.

The promise of nanotechnology for solving clinical problems in breast cancer.

Approaches for breast cancer treatment are invasive, disfiguring, have significant side-effects, and are not always curative. Nanotechnology is an emerging area which is focused on engineering of materials <100 × 10(-9) m. There is significant promise for advancing nanotechnology to improve breast cancer diagnosis and treatment including non-invasive therapy, monitoring response to therapy, advanced imaging, treatment of metastatic disease, and improved nodal staging. Current approaches and important future directions are discussed.

Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions.

BACKGROUND: Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy. METHODS: The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008. RESULTS: Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (∼30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year. CONCLUSIONS: The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs.

The 'Gator' Mouse Suit for early bioluminescent metastatic breast cancer detection and nanomaterial signal enhancement during live animal imaging.

UNLABELLED: Optical imaging is a cornerstone of modern oncologic research. The aim of this study is to determine the value of a new tool to enhance bioluminescent and fluorescent sensitivity for facilitating very-low-level signal detection in vivo. EXPERIMENTAL: For bioluminescent imaging experiments, a luciferase expressing breast cancer cell line with metastatic phenotype was implanted orthotopically into the mammary fat pad of mice. For fluorescent imaging experiments, near-infrared (NIR) nanoparticles were injected intratumorally and subcutaneously into mice. Images were compared in mice with and without application of the 'Gator' Mouse Suit (GMS). RESULTS: The GMS was associated with early detection and quantification of metastatic bioluminescent very-low-level signal not possible with conventional imaging strategies. Similarly, NIR nanoparticles that were undetectable in locations beyond the primary injection site could be visualized and their very-low-level signal quantifiable with the aid of the GMS. CONCLUSION: The GMS is a device which has tremendous potential for facilitating the development of bioluminescent models and fluorescent nanomaterials for translational oncologic applications.