Supercharge end-to-side nerve transfer from anterior interosseous nerve to augment intrinsic recovery in high ulnar nerve injuries of varying magnitudes.

BACKGROUND: High ulnar nerve injuries result in intrinsic muscle weakness and are inconvenient for patients. Moreover, conventional surgical techniques often fail to achieve satisfactory motor recovery. A potential reconstructive solution in the form of the supercharge end-to-side (SETS) anterior interosseous nerve (AIN) transfer method has emerged. Therefore, this study aims to compare surgical outcomes of patients with transected and in-continuity high ulnar nerve lesions following SETS AIN transfer. METHODS: Between June 2015 and May 2023, patients with high ulnar palsy in the form of transection injuries or lesion-in-continuity were recruited. The assessment encompassed several objective results, including grip strength, key pinch strength, compound muscle action potential, sensory nerve action potential, and two-point discrimination tests. The muscle power of finger abduction and adduction was also recorded. Additionally, subjective questionnaires were utilized to collect data on patient-reported outcomes. Overall, the patients were followed up for up to 2 years. RESULTS: Patients with transected high ulnar nerve lesions exhibited worse baseline performance than those with lesion-in-continuity, including motor and sensory functions. However, they experienced greater motor improvement but less sensory recovery, resulting in comparable final motor outcomes in both groups. In contrast, the transection group showed worse sensory outcomes. CONCLUSIONS: Our findings suggest that SETS AIN transfer benefits patients with high ulnar nerve palsy, regardless of the lesion type. Nonetheless, improvements may be more pronounced in patients with transected lesions.

Debridement options for the interprofessional team.

ABSTRACT: Debridement is a core component of chronic wound management. Although various debridement methods exist, each carries a unique patient risk level. This article discusses the different normal tissue components that are critical to safe debridement practice, various methods of wound debridement for nurses, and the importance of an interprofessional team and consulting a wound specialist.

Perfusion Dynamics during Secondary Flap Debulking with Liposuction.

BACKGROUND: Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed. METHODS: Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging. RESULTS: Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1. CONCLUSION: Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.

Stack versus Te technique for central slip reconstruction during vascularized toe proximal interphalangeal joint transfer.

BACKGROUND: Significant extension deficit is a common problem after a vascularized toe proximal interphalangeal joint transfer. One of the main causes related to extensor lag is central slip deficiency of the donor toes. In our clinical practice, we performed both the Stack and Te technique to reconstruct central slip function during a joint transfer. The aim of this study was to compare the long-term outcomes of vascularized joint transfers between these two techniques. PATIENTS AND METHODS: From May 2009 to October 2021, 38 digits in 36 patients (28 men and 8 women) underwent free vascularized toe joint transfer requiring central slip reconstruction. Eight and 30 digits were reconstructed with the Stack and Te technique, respectively. RESULTS: The median length of follow-up was 19 months (range, 5 to 78 months). The overall median extension lag was 20±20 degrees and the flexion was 80±20 degrees. There were no significant differences in extension lag (25±29 vs. 20±15 degrees, p = 0.281), flexion (75±10 vs. 85±20 degrees, p = 0.13), and range of motion (53±23 vs. 63±15 degrees, p = 0.076) of the joints between the Stack and Te techniques after the transfers. CONCLUSIONS: From the limited number of cases, both the Stack and Te techniques provided similar outcomes in correcting extension lag in vascularized joint transfers. The Te technique is a simplified and effective method for central slip reconstruction, while caution is advised when using the Stack technique due to potential complications.Clinical question/level of evidence: Therapeutic, IV.

Vascularized Toe Proximal Interphalangeal Joint Transfer in Posttraumatic Fingers: Analysis of Prognostic Factors for Suboptimal Outcomes.

Background: Posttraumatic finger osteoarthritis of the proximal interphalangeal joint (PIPJ) is a difficult problem. Over the past decade, we have reported several methods for improving the outcomes of vascularized toe joint transfer (VJT). In this study, we focused on determining poor prognostic factors which lead to a suboptimal outcome. Methods: A consecutive series of patients with posttraumatic osteoarthritis of the PIPJ who received VJT between January 2008 and January 2021 were enrolled in this study. The senior surgeon (Y.-T.L.) performed the surgery in all cases. In this retrospective study, we reexamine the initial trauma-related soft tissue and bony structure injuries of the recipient finger, to assess the baseline tissue quality before VJT. The injuries were classified into five major categories according to their anatomic region. The functional outcome parameters (including range of motion, percentage of use, and extensor lag of the transferred PIPJ) were collected. Univariate and multivariate linear regression analyses were performed using the generalized estimated equation model to identify the correlation between the injury category involved and functional outcome. Results: A total of 59 digits were enrolled. Our results revealed that the fingers with previous vascular injury that received revascularization procedures had relatively suboptimal functional outcomes. These fingers had a significantly lower percentage of use both before (ß = -0.222, P = 0.006) and after (ß = -0.177, P = 0.006) receiving secondary procedures to improve functional outcome. Conclusions: Patients with prior revascularization surgery were associated with a poor functional outcome after VJT.

An Overview of Clinical Examinations in the Evaluation and Assessment of Arterial and Venous Insufficiency Wounds.

Arterial and venous insufficiency are two major causes of chronic wounds with different etiology, pathophysiology, and clinical manifestations. With recent advancements in clinical examination, clinicians are able to obtain an accurate diagnosis of the underlying disease, which plays an important role in the treatment planning and management of patients. Arterial ulcers are mainly caused by peripheral artery diseases (PADs), which are traditionally examined by physical examination and non-invasive arterial Doppler studies. However, advanced imaging modalities, such as computed tomography angiography (CTA) and indocyanine green (ICG) angiography, have become important studies as part of a comprehensive diagnostic process. On the other hand, chronic wounds caused by venous insufficiency are mainly evaluated by duplex ultrasonography and venography. Several scoring systems, including Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Venous Disability Score, and the Venous Segmental Disease Score (VSDS) are useful in defining disease progression. In this review, we provide a comprehensive overlook of the most widely used and available clinical examinations for arterial and venous insufficiency wounds.

Neurectomy of the Nerve of Henle Associated with Periarterial Sympathectomy for Management of Intractable Raynaud's Phenomenon.

BACKGROUND: In periarterial sympathectomy for intractable Raynaud's phenomenon, the extent of adventitiectomy as well as postoperative outcomes and hand perfusion assessment tools remain debatable. We evaluated the outcome of neurectomy of the nerve of Henle combined with ulnar tunnel release and periarterial adventitiectomy in the treatment of refractory Raynaud's phenomenon using objective measurements and patient-reported outcomes. METHODS: Nineteen patients with 20 affected hands were prospectively enrolled and underwent the proposed procedures from 2015 to 2021. Relevant data, including Michigan Hand Outcomes Questionnaire and 36-Item Short Form health questionnaire scores, were documented for analysis during a 3-year follow-up. RESULTS: The average ingress value of the three measured fingers (index, long, and ring) on indocyanine green angiography increased after surgery (p=0.02). The median number of ulcers decreased (p<0.001) and the median digital skin temperature increased (p<0.001). Questionnaire scores showed improvement in physical aspects, such as overall hand function (p≤0.001), activities of daily living (p=0.001), work performance (p=0.02), pain (p<0.001), physical function (p=0.053), and general health (p=0.048), as well as mental aspects, such as patient satisfaction (p<0.001) and mental health (p=0.001). The average indocyanine green ingress value of the three measured fingers significantly correlated with the patient-reported outcomes, including overall hand function (r=0.46, p=0.04), work performance (r=0.68, p=0.001), physical function (r=0.51, p=0.02), and patient satisfaction (r=0.35, p=0.03). CONCLUSIONS: The proposed surgical procedures provided satisfactory outcomes, both subjectively and objectively, over a follow-up period of up to 3 years. Indocyanine green angiography may provide rapid and quantitative measurements for perioperative hand perfusion assessment.

Quantization of extraoral free flap monitoring for venous congestion with deep learning integrated iOS applications on smartphones: a diagnostic study.

BACKGROUND: Free flap monitoring is essential for postmicrosurgical management and outcomes but traditionally relies on human observers; the process is subjective and qualitative and imposes a heavy burden on staffing. To scientifically monitor and quantify the condition of free flaps in a clinical scenario, we developed and validated a successful clinical transitional deep learning (DL) model integrated application. MATERIAL AND METHODS: Patients from a single microsurgical intensive care unit between 1 April 2021 and 31 March 2022, were retrospectively analyzed for DL model development, validation, clinical transition, and quantification of free flap monitoring. An iOS application that predicted the probability of flap congestion based on computer vision was developed. The application calculated probability distribution that indicates the flap congestion risks. Accuracy, discrimination, and calibration tests were assessed for model performance evaluations. RESULTS: From a total of 1761 photographs of 642 patients, 122 patients were included during the clinical application period. Development (photographs =328), external validation (photographs =512), and clinical application (photographs =921) cohorts were assigned to corresponding time periods. The performance measurements of the DL model indicate a 92.2% training and a 92.3% validation accuracy. The discrimination (area under the receiver operating characteristic curve) was 0.99 (95% CI: 0.98-1.0) during internal validation and 0.98 (95% CI: 0.97-0.99) under external validation. Among clinical application periods, the application demonstrates 95.3% accuracy, 95.2% sensitivity, and 95.3% specificity. The probabilities of flap congestion were significantly higher in the congested group than in the normal group (78.3 (17.1)% versus 13.2 (18.1)%; 0.8%; 95% CI, P <0.001). CONCLUSION: The DL integrated smartphone application can accurately reflect and quantify flap condition; it is a convenient, accurate, and economical device that can improve patient safety and management and assist in monitoring flap physiology.

Debridement: Technical Considerations and Treatment Options for the Interprofessional Team.

GENERAL PURPOSE: To enhance the learner's chronic wound debridement competence as an interprofessional team member. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Differentiate healable, maintenance, and nonhealable wounds to create a holistic debridement treatment plan using the Wound Bed Preparation paradigm.2. Evaluate active debridement options including the potential need for an interprofessional referral or specialized investigations.3. Assess chronic wound debridement options.4. Analyze case studies for appropriate clinical application of debridement modalities.

Debridement is a critical component in the management of both acute and chronic wounds. Six reviewed methods of debridement exist, and specific techniques are more appropriate to match patient needs with available clinical resources. Accurate differentiation between healable, maintenance, and nonhealable wounds is paramount when determining whether a wound would benefit from debridement. Clinical assessment includes review of the patient's underlying medical conditions/ previous surgeries along with the history and progression of the wound. Awareness of the physiologic wound bed preparation components that contribute to the current wound status will direct treatment of the abnormal components. Optimal wound status includes complete healing or reduced abnormal wound-related symptoms or signs. Debridement competency requires an awareness of the six types of debridement, their clinical utility, and appropriate patient selection. Providers need to assess patients' wounds, triage them, and refer them as necessary to an interprofessional setting. For stalled but healable wounds, specialized testing may be necessary when managing patients who would benefit from more invasive or advanced forms of wound care. This article informs providers on the training and experience required for specific debridement techniques depending on the wound etiology.

Reliability of Postoperative Free Flap Monitoring with a Novel Prediction Model Based on Supervised Machine Learning.

BACKGROUND: Postoperative free flap monitoring is a critical part of reconstructive microsurgery. Postoperative clinical assessments rely heavily on specialty-trained staff. Therefore, in regions with limited specialist availability, the feasibility of performing microsurgery is restricted. This study aimed to apply artificial intelligence in postoperative free flap monitoring and validate the ability of machine learning in predicting and differentiating types of postoperative free flap circulation. METHODS: Postoperative data from 176 patients who received free flap surgery were prospectively collected, including free flap photographs and clinical evaluation measures. Flap circulation outcome variables included normal, arterial insufficiency, and venous insufficiency. The Synthetic Minority Oversampling Technique plus Tomek Links (SMOTE-Tomek) was applied for data balance. Data were divided into 80%:20% for model training and validation. Shapley Additive Explanations were used for prediction interpretations of the model. RESULTS: Of 805 total included flaps, 555 (69%) were normal, 97 (12%) had arterial insufficiency, and 153 (19%) had venous insufficiency. The most effective prediction model was developed based on random forest, with an accuracy of 98.4%. Temperature and color differences between the flap and the surrounding skin were the most significant contributing factors to predict a vascular compromised flap. CONCLUSIONS: This study demonstrated the reliability of a machine-learning model in differentiating various types of postoperative flap circulation. This novel technique may reduce the burden of free flap monitoring and encourage the broader use of reconstructive microsurgery in regions with a limited number of staff specialists.

Comparative outcomes between surgical treatment and orthosis splint for mallet finger: a systematic review and meta-analysis.

Mallet finger is a commonly encountered condition in daily practice. However, there is currently no consensus on whether surgical intervention or conservative treatment with orthosis splint is superior. In this systematic review and meta-analysis, we compare the treatment outcomes between surgery and orthosis for bony and tendinous mallet finger. We searched PubMed, Embase, and the Cochrane Library according to the PRISMA guidelines from inception to January 15, 2021. The primary outcome was distal interphalangeal (DIP) joint extension lag angle, and secondary outcomes were DIP joint flexion and range of motion (ROM) angle. A total of 297 studies were initially identified, of which 13 (ten retrospective non-randomized controlled studies (non-RCTs) and three RCTs) were included in the final analysis. The results of this systematic review and meta-analysis showed that there was no high level of evidence supporting the superiority of surgery over orthosis in the treatment of mallet finger. Based on the available evidence, surgical intervention and conservative treatment with splint may offer similar clinical outcomes in both bony and tendinous mallet finger.

Prospective outcome analysis of ulnar tunnel syndrome: Comparing traumatic versus non-traumatic etiologies.

BACKGROUND: Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies. METHODS: Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength. RESULTS: 21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles. CONCLUSIONS: Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.

Comparison of the effectiveness of local anesthesia for the digital block between single-volar subcutaneous and double-dorsal finger injections: a systematic review and meta-analysis of randomized control trials.

Local anesthesia is an effective method to perform digital nerve blocks. In this study, we compare the effectiveness of single-volar subcutaneous and double-dorsal injection through a systematic review and meta-analysis of randomized controlled trials (RCTs). A systematic search of PubMed, Embase, and the Cochrane Library from inception to 7 April 2021 was performed. RCTs with the effects of single-volar subcutaneous and double-dorsal injection were eligible. Meta-analysis was performed using random effect models with pooled standardized mean differences (SMDs) and 95% confidence intervals (CI). RoB 2.0 and GRADE of Recommendation Assessment, Development, and Evaluation criteria were applied for evaluating the bias. A total of 2484 studies were initially identified, with 11 eligible RCTs finally included in the meta-analysis (1363 patients). The pooled data of nine studies showed single-volar injection had a statistically significantly lower pain score (pooled SMD: 0.20, 95% CI, 0.01 to 0.39, p = 0.041, I2 = 58%, N = 1187) and higher patient preference but invalid anesthesia at the dorsal proximal digit. No significant differences were observed in the onset of anesthesia, adjacent digit invalid numbness, distal phalanx invalid anesthesia, additional injection rate, and adverse effects. In conclusion, this meta-analysis of RCTs showed that the single-volar injection was associated with a lower pain sensation during injection and higher patient satisfaction with a reduced anesthetic effect over the proximal dorsal phalanx. Further high-quality RCTs with a higher number of cases are needed to validate our results.

The impact of depression on survival of head and neck cancer patients: A population-based cohort study.

Background: Depression is common among patients with head and neck cancer, thereby affecting their survival rate. However, whether close monitoring of depression affects the survival outcomes of these patients is unknown. Therefore, this study aimed to determine whether depression treatment continuity after the diagnosis of cancer affects the survival of these patients. Methods: A total of 55,069 patients diagnosed with head and neck cancer in the Cancer Registration System database in Taiwan were enrolled. This cohort was followed from January 1, 2007 to December 31, 2017. Furthermore, the patients were divided into four groups, namely, "no depression," "pre-cancer only," "post-cancer only," and "both before and after cancer," on the basis of the diagnosis of depression and the duration of the follow-up period in the psychiatric clinic. Further, the Cox proportional hazard model was applied to estimate the hazard of death for the four groups. Results: A total of 6,345 (11.52%) patients were diagnosed with depression in this cohort. The "pre-cancer only" group had a lower overall survival (HR = 1.18; 95% CI = 1.11-1.25) compared with the "no depression" group. Moreover, the "post-cancer only" group had better overall survival (HR = 0.88; 95% CI = 0.83-0.94) compared with the "no depression" group, especially in advanced-stage patients. Patients who were diagnosed with depression before cancer and had continuous depression treatments after the cancer diagnosis had better overall survival (HR = 0.78; 95% CI = 0.71-0.86) compared with patients who had treatment interruptions. Conclusion: Patients with pre-cancer depression had poorer survival outcomes, especially those who did not receive psychiatric clinic visits after their cancer diagnosis. Nonetheless, in patients with advanced-stage cancer, depression treatment may improve overall survival.

The Effect of Narrow-Band Ultraviolet B Irradiation on the Vascularized Composite Allotransplantation Rat Model.

INTRODUCTION: Vascularized composite allotransplantation (VCA) allows functional and esthetic reconstruction for patients with complex anatomical defects. However, acute and chronic graft rejections are significant obstacles to VCA. Ultraviolet light is an oncogenic environmental hazard. However, ultraviolet B (UVB) has an immunomodulation effect. Therefore, this study aims to elucidate the impact of UVB irradiation on the VCA rat model. METHODS: The rat vascularized bone marrow allotransplantation model was used. A vascularized bone marrow from a Brown Norway rat (RT1Ac) was transplanted into a Lewis rat (RT1Ab). The allograft and surrounding abdominal skin were exposed to narrow-band ultraviolet B (NB-UVB) (311 nm) radiation with an energy of 1350 mJ/cm2 3 times a week until the end of the study period. There were 5 study groups: syngeneic transplantation (group 1), allogeneic transplantation (group 2), allogenic transplantation-NB-UVB (group 3), allogenic transplantation-antilymphocyte serum (ALS)-tacrolimus (group 4), and allogenic transplantation-antilymphocyte serum-tacrolimus-NB-UVB (group 5). RESULTS: Group 5 had decreased graft survival compared with group 4. In the donor cell chimerism analysis, donor cell chimerism decreased significantly after UVB irradiation and was unresponsive to the administered immunosuppressants. After UVB irradiation, the CD8 T-cell ratio was increased, and the regulatory T-cell ratio was decreased. CONCLUSIONS: The preliminary data showed that NB-UVB irradiation of the VCA rat model may decrease graft survival. However, further studies are needed to elucidate the possible mechanisms of this phenomenon.

Implantable Immunosuppressant Delivery to Prevent Rejection in Transplantation.

An innovative immunosuppressant with a minimally invasive delivery system has emerged in the biomedical field. The application of biodegradable and biocompatible polymer forms, such as hydrogels, scaffolds, microspheres, and nanoparticles, in transplant recipients to control the release of immunosuppressants can minimize the risk of developing unfavorable conditions. In this review, we summarized several studies that have used implantable immunosuppressant delivery to release therapeutic agents to prolong allograft survival. We also compared their applications, efficacy, efficiency, and safety/side effects with conventional therapeutic-agent administration. Finally, challenges and the future prospective were discussed. Collectively, this review will help relevant readers understand the different approaches to prevent transplant rejection in a new era of therapeutic agent delivery.

End-to-Side Anterior Interosseous Nerve Transfer: A Valuable Alternative for Traumatic High Ulnar Nerve Palsy.

BACKGROUND: The prognosis of high ulnar nerve injury is poor despite nerve repair or grafting. Anterior interosseous nerve (AIN) transfers provide a satisfactory recovery. However, the efficacy of end-to-side (ETS) AIN transfer and optimal timing in Sunderland grade IV/V of high ulnar nerve injury is lacking. OBJECTIVE: The goals were to compare the outcomes of high ulnar nerve injury managed with ETS AIN transfers with those managed with conventional procedures (nerve repair or graft only) and identify differences between early and delayed transfers. METHODS: Patients with isolated high ulnar nerve injury (Sunderland grade IV/V) from 2010 to 2017 were recruited. Patients with conventional treatments and AIN transfers were designated as the control and AIN groups, respectively. Early transfer was defined as the AIN transfer performed within 8 weeks postinjury. Outcomes were measured and analyzed by the British Medical Research Council (BMRC) score, grip strength, and pinch strength. RESULTS: A total of 24 patients with high ulnar nerve injury (Sunderland grade IV/V) were included. There were 11 and 13 patients in the control and AIN groups, respectively. In univariate analysis, both early and delayed AIN transfers demonstrated significantly better motor recovery among BMRC score and strength of grip and pinch at 12 months (P < 0.05). No statistical significance was found between early and delayed transfer. In multivariate analysis, both early and delayed transfers were regarded as strong and independent factors for motor recovery of ulnar nerve. Compared with the control, early [odds ratio (OR), 1.83; P < 0.001] and delayed (OR, 1.59; P < 0.001) transfers showed significant improvement with regard to BMRC scores. The pinch strength in early (OR, 31.68; P < 0.001) and delayed (OR, 26.45; P < 0.001) transfers was also significantly better. CONCLUSION: The ETS AIN transfer, in either early or delayed fashion, significantly improved intrinsic motor recovery in high ulnar nerve injuries classified as Sunderland grade IV/V. The early transfer group demonstrated a trend toward better functional recovery with less downtime.

Suprafascial dissection of the pedicled groin flap: A safe and practical approach to flap harvest.

BACKGROUND: The groin flap has been relied upon for more than 4 decades and is well suited for reconstruction of the mutilated hand. Classic groin flap harvest is subfascial and includes the superficial circumflex iliac artery (SCIA). SCIA perforator flaps have shown that one perforator is sufficient to supply a large flap without breaching fascia. Accordingly, we routinely preserve the fascia and rely wholly on the superficial branch of the SCIA, sparing the deep branch. We aim to investigate the safety of suprafascial flap elevation and encourage a paradigm shift in reconstruction with groin flap transfer. METHODS: Between 2008 and 2013, 77 hand injuries were treated with pedicled groin flap transfers. According to surgeons' preference, 49 flaps were elevated with conventional technique ("subfascial") and 28 were harvested with suprafascial approach ("fascia sparing"). Demographic data including flap size, operative time, and outcome were reviewed in both approaches and compared. RESULTS: Suprafascial flaps were taken as large as 32 × 12 cm2 and subfascial flaps large as 30 × 10 cm2 (p = 0.08). Operative time was 268.2 ± 104.7 minutes in the suprafascial group and 227.4 ± 89.0 in the subfascial group (p = 0.14). One suprafascial flap (3.6%) had partial necrosis compared to four subfascial flaps (8.2%) (p = 0.65). All patients were followed for a minimum of six months. All the wounds finally healed without further flap reconstruction, and all the patients were back to the normal life with activities. CONCLUSION: Suprafascial dissection is safe and does not adversely influence outcomes. Thinner flaps are expected to facilitate flap insetting and reduce revisionary debulking surgery. LEVEL OF EVIDENCE: III (Therapeutic).

Predictors of pathological complete response to neoadjuvant chemoradiotherapy for esophageal squamous cell carcinoma.

BACKGROUNDS: In this study, we evaluated the factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma (ESCC). METHODS: Pre-nCRT parameters in ESCC patients treated between 1999 and 2006 were analyzed to identify predictors of pCR. All patients received 5-fluorouracil/cisplatin-based chemotherapy and external beam radiation followed by scheduled esophagectomy. Variables were analyzed using univariate and multivariate analyses with pCR as the dependent variable. Estimated pCR rate was calculated with a regression model. RESULTS: Fifty-nine (20.9%) of 282 patients achieved pCR. Univariate analysis identified four patient factors (age, smoking status, drinking history and hypertension), one pre-nCRT parameter (tumor length) as significant predictors of pCR (all P <0.05). On multivariate analysis, tumor length ≤3 cm (favorable, odds ratio (OR): 4.85, P = 0.001), patient age >55 years (favorable, OR: 1.95, P = 0.035), and being a non-smoker (favorable, OR: 3.6, P = 0.003) were independent predictors of pCR. The estimated pCR rates based on a logistic regression including those three predictors were 71%, 35 to approximately 58%, 19 to approximately 38%, and 12% for patients with 3, 2, 1 and 0 predictors, respectively. CONCLUSION: Age, smoking habit and tumor length were important pCR predictors. These factors may be used to predict outcomes for ESCC patients receiving nCRT, to develop risk-adapted treatment strategies, and to select patients who could participate in trials on new therapies.