Superior Medial-Based Breast Reduction with Inverted T Incision: A Precise Description of Our Refined Preoperative Marking and Operative Technique.

The purpose of this paper was to compile a thoroughly elaborated step-by-step guide for the preoperative marking and operative technique for superior medial pedicle inverted T breast reduction based on our long experience and technical refinements. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does the breast reconstruction method have an impact on time delay to adjuvant chemotherapy - A comparison between autologous and expander/implant breast reconstruction.

Introduction: This study aims to analyze whether autologous breast reconstruction as compared to expander/implant reconstruction has a higher risk of postoperative wound healing problems (WHPs) and thus potentially delays chemotherapy start. Methods: Between January 2012 and December 2019, a total of 64 women with NSME/SSME and autologous (Group1, n = 33) or expander/implant reconstruction (Group2, n = 31) and adjuvant chemotherapy were enrolled in this study conducted at Innsbruck Medical University Hospital. Immediate postoperative WHPs in each group were compared, and the time from operation to initiation of chemotherapy was analyzed. If the start of chemotherapy was postponed for more than six weeks postoperatively due to WHP, it was defined as delayed. Statistical analysis was performed with SPSS and Fisher's exact test. Results: More postoperative WHP occurred in Group 1 than in Group 2 (51.6% vs. 9.7%, p < 0.001). Due to WHP, chemotherapy start was delayed for more than six weeks postoperatively in 30.3% of Group 1 patients and 3.2% of Group 2 patients. Only small differences in age (Group 1: 47±1 vs. Group 2: 46±2 years) and BMI (Group 1: 24.3 ± 0.6 vs. Group 2: 23.3 ± 0.7 kg/m2) were found. Conclusion: Our study shows a far smaller risk for postoperative WHP and delay of chemotherapy start in the expander/implant group in comparison with the autologous group. In some selected patients with high urgency for adjuvant chemotherapy, a bridging operation by means of expander reconstruction prior to chemotherapy could be an oncologically safe pathway.

Free Flap Outcome in Irradiated Recipient Sites: A Systematic Review and Meta-analysis.

The impact of previous radiotherapy on free flap outcome is still a subject of debate. Clinical investigations have come to divergent conclusions and the true effect of radiotherapy (XRT) on flap survival is not definitely known. Most studies investigating the factor often have their methodological limitations such as lack of statistical power as a consequence of the overall low failure rates together with few irradiated cases. This study will attempt to address the question whether previous radiotherapy is associated with a significantly higher incidence of flap failure or not. Methods: A systematic review and meta-analysis were conducted in concordance with the PRISMA protocol using the PubMed database. Fixed-effect and random-effect models were applied to obtain the odds ratio of total flap failure and partial flap failure between radiation and nonradiation groups. Statistical heterogeneity and publication bias were assessed and forest plots and funnel plots were constructed for graphic illustration. Results: A total of 43 studies were included for qualitative and quantitative analysis involving 18,776 flaps in 17,532 patients. Patients with preoperative XRT were significantly associated with an increased risk for total (odds ratio fixed = 1.675, 95% confidence interval [CI] = 1.405-1.996, P < 0.001) and partial free flap failure (odds ratio fixed = 2.161, 95% CI = 1.472-2.172, P < 0.001). Conclusion: The study suggests that preoperative radiotherapy is associated with an increased risk for total and partial free flap failure. Further studies are needed to investigate the effect of total XRT dose and time after radiation on free flap outcome.

A Modified Rhomboid Flap for Medial Canthal Reconstruction.

The reconstruction of medial canthal defects is often challenging in achieving continuity of color and texture, obtaining adequate tissue for large defects, and the reproduction of natural external appearance with inconspicuous scars. We describe a technique for reconstruction of the medial canthal area, using a modified rhomboid flap. METHODS: The technique is based on the use of a modified rhomboid flap for medial canthal defects-superiorly based on the root of the nose for defects mostly above the medial canthal tendon, inferiorly based on the cheek for defects mostly below the medial canthal tendon, and in cases of large defects, using a combination of the two flaps. We present a case series of five patients successfully reconstructed with the mentioned technique after resection of medial canthal basal cell carcinoma. RESULTS: Of the five patients with a mean age of 76.2 years (range 62-84 years), reconstruction was performed in three patients with a superiorly based rhomboid flap, in one patient with an inferiorly based rhomboid flap, and in another patient with a large defect using a combination of the two flaps. Mean follow-up was 374.4 days (range 30-1247 days). All patients achieved a complete primary closure with no further surgery and satisfactory cosmetic and functional results. CONCLUSION: The modified rhomboid flap is a simple and reliable technique for all defects of the medial canthal area.

Influence of Incision Site on Postoperative Outcome in Skin-/Nipple-Sparing Mastectomy: Is There a Difference between Radial and Inframammary Incision?

BACKGROUND: The aim of this study was to determine whether there is a difference in results between the radial and the inframammary approach in nipple-/skin-sparing mastectomy and immediate reconstruction. METHODS: The patients were divided into two groups (group 1: radial incision; group 2: inframammary fold incision [IMF]), each consisting of two subgroups for direct-to-implant reconstruction (1a, 2a) and expander reconstruction (1b, 2b). The patients were operated on between March 2012 and May 2017. Preoperative tumor parameters, reconstruction parameters, postoperative tumor parameters, and immediate and late complications were assessed. Postoperative photographs were evaluated by the patients and 8 plastic surgeons by means of grading (1-5) and the visual analog scale (VAS; 1-10). RESULTS: Enrolled in this study were 28 patients, namely, 7 patients in each subgroup. The median age was 46 years, and the median follow-up period was 40 months. No immediate complications occurred. Three patients had late complications, but there was no case of evident capsular fibrosis. Twenty-seven patients (96.42%) evaluated the postoperative result as excellent/good. The postoperative evaluation by the plastic surgeons was excellent/good for a median of 18 patients (64.28%). Group 1 showed a median VAS score of 7.63 (expander group: 7.50; direct-to-implant group: 7.75); the median VAS score for group 2 was 8.25 (expander group: 8.75; direct-to-implant group: 7.50). CONCLUSIONS: Our study shows good results for implant breast reconstruction in both groups, with minimally better results for the IMF group. In the direct-to-implant subgroups, the radial group showed slightly better results.

Necrotizing fasciitis of the lower extremity caused by perforated sigmoid diverticulitis-a case report.

Diverticulosis of the sigmoid colon is a common condition and occurs more often in elderly patients. A well-known complication is infection or even perforation which often requires surgery. Necrotizing fasciitis as a complication of perforated diverticulitis is very rare. Here, we present a case of a covered perforated diverticulitis in an immunosuppressed patient leading to life-threatening necrotizing fasciitis requiring extracorporeal membrane oxygenation. Either hematogenous or local dissemination via the inguinal canal seemed the most probable mechanism of leg infection leading to hip articulation.

Long-term quality-of-life improvement in gastric banding patients from body-contouring surgery.

Following my prior study of long-term results after laparoscopic gastric banding concerning operative outcome and complications involving the gastric band itself, I now focus on long-term quality-of-life improvement in the same study group after body-contouring surgery. As determined from our electronic patient data system, 72 patients from the former study group subsequently sought body-contouring surgery at our hospital after successful weight loss. Patients were enrolled in a telephone interview and asked about their expectations and body image before and after postbariatric aesthetic surgery and how it altered their well-being in addition to the weight loss achieved with the gastric band. All patients undergoing postbariatric aesthetic surgery felt extremely uneasy with the hanging skin resulting from weight reduction. Patients cannot imagine the degree of dissatisfaction they will experience from the sagging skin that comes with weight loss. Hardly any patient expected fewer scars than he ultimately had after body-contouring surgery and reported an extreme improvement in body image. Gastric banding should not be performed without informing patients about the need for postbariatric body-contouring surgery, because most patients not forewarned suffer greatly from their body image after weight loss.

Long-term follow-up evaluation of revisional gastric bypass after failed adjustable gastric banding.

BACKGROUND: Disappointing long-term results, frequent band failure, and high rates of band-related complications increasingly necessitate revisional surgery after adjustable gastric banding. Laparoscopic conversion to gastric bypass has been recommended as the procedure of choice. This single-center retrospective study aimed to evaluate the long-term results of revisional gastric bypass after failed adjustable gastric banding. METHODS: The study included 108 consecutive patients who underwent laparoscopic conversion of gastric banding to gastric bypass from 2002 to 2012. Indications for surgery, operative data, weight development, morbidity, and mortality were analyzed. The median follow-up period was 3.4 years (maximum, 10 years). RESULTS: The most common indications for band removal were band migration, insufficient weight loss, and pouch dilation. The median interval between gastric banding and gastric bypass was 6.6 years. In 52 % of the cases, band removal and gastric bypass surgery were performed simultaneously as a single-stage laparoscopic procedure. The early postoperative morbidity rate was 10.2 %. The body mass index before gastric banding (43.3 kg/m(2)) decreased significantly to 37.9 kg/m(2) before gastric bypass and to 28.8 kg/m(2) 5 years after gastric bypass. CONCLUSIONS: This is the first report on the long-term outcome after conversion of failed adjustable gastric banding to gastric bypass. Findings have shown revisional gastric bypass to be a feasible bariatric procedure particularly for patients with insufficient weight loss that guarantees a constant and long-lasting weight loss.

Long-term results and complications following adjustable gastric banding.

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 +/- 6 kg/m(2). BMI after 1, 5, 7, 9, and 10 years was 33 +/- 6, 30 +/- 6, 31 +/- 6, 32 +/- 7, and 31 +/- 7 kg/m(2), respectively. Mean excess weight loss after 1 year was 57.1 +/- 23.0% and after 5, 7, 9, and 10 years 73.2 +/- 29.6%, 65.9 +/- 29.3%, 61.8 +/- 32.8%, and 64.0 +/- 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.

Surgical treatment of intrahepatic cholangiocarcinoma--a single center experience.

This study aimed to evaluate outcome after liver resection for intrahepatic cholangiocarcinoma (ICC). In a 72-month period a total of 25 patients operated on for ICC were followed-up with postoperatively. Eleven right hemihepatectomies (8 extended), seven left hemihepatectomies (3 extended), one segmental resection, two bisegmentectomies (II + III), and four nonanatomical resections were performed. Median observation period was 2.7 (range: 0.2-6.9) years. Analysis focused on age, gender, tumor-size, operating time, histologic resection margin, Tumor-Node-Metastasis-stage, reoperations, postoperative complications, tumor recurrence, survival rate and a putative relation between p53 accumulation, ki67 index, MUC1 positivity, and prognosis. Mean tumor size was 6.49 +/- 3.93 cm. Eighteen patients (72%) underwent lymph node dissection. Major postoperative complications occurred in 10 patients. Seventeen patients (68%) showed tumor recurrence. Mean time to tumor recurrence was 6.7 (5.7-15.4) months. We found no correlation between p53 accumulation/ki67 index counts/Mucin 1 cell surface associated antibody (MUC1) positivity and ICC prognosis. A total of 13 patients died (52%) including one early and 12 late deaths. Mean time from surgery to death was 14.6 (7.4-30.9) months. Survival rate at 1 year was 84 per cent, at 3 years 57 per cent, and at 5 years 45 per cent. In our review only a small number of these 25 patients are indeed cured.

Weight loss and quality of life after gastric band removal or deflation.

BACKGROUND: The study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding. METHODS: A total of 41 patients (93% female, mean age 34.1 (SD 10.5) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group 1, n = 26) and those who later underwent a second bariatric operation (group 2, n = 15). We evaluated weight gain after band removal/during the time between band removal and second bariatric operation. RESULTS: Of our patients, 31 (76%) suffered a complication (18 late pouch dilatations, six band infections, five band migrations, and two band leaks) requiring band removal. Ten patients wanted their band removed (six) or emptied (four). Mean time after band removal, when patients had neither a band nor a second bariatric operation, was 2.84 (SD 2.3) years. Five (12.2%) patients maintained their weight, four of whom experienced a learning effect; all others gained weight. Mean body mass index for both groups after the period without a band was 36.7 (SD 8.0) kg/m(2) (vs 29.4 (SD 7.0) at removal), and excess weight loss was 33.2% (SD 39.2; vs 69.8% (SD 32.9) at removal). Of our patients, 73% would not agree to gastric banding again. According to the bariatric analysis and reporting outcome system, long-term outcome of patients following band removal was a "failure" in 66% of patients. CONCLUSIONS: Long-term outcome following band removal is unsatisfactory in many patients. Nevertheless, a minority of patients was able to maintain its weight loss.

Unusual differential diagnosis of upper abdominal pain.

We here present an interesting unusual case of upper abdominal pain. The patient was a 38-year-old man, who was admitted to our hospital complaining of right upper quadrant pain caused by a toothpick that perforated the anterior gastric wall and penetrated segment I of the liver. After endoscopic removal and an initially uneventful course, computed tomography revealed a perigastric abscess that was treated by repeated gastroscopic rinsing via an endoscopically placed catheter. After another three uneventful weeks, a liver abscess with minor tendency to constrict the portal vein was diagnosed, and a segment I liver resection together with abscess drainage was performed. The peculiarity of this case is the rarity of toothpick ingestion and gastric perforation in a young and healthy white Caucasian followed by development of a liver abscess after primary uneventful endoscopic removal. In light of this case, gastric perforation due to ingested foreign bodies such as toothpicks can be considered a rare cause of upper abdominal pain.

Disappointing mid-term results after laparoscopic gastric banding in young patients.

BACKGROUND: When gastric banding was introduced as a bariatric operation about 12 years previously, its early results were promising, with a low complication rate. Only a few long-term studies on this subject have been published. This study was performed to assess our results with laparoscopic gastric banding in young patients after

Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile?

BACKGROUND: The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopically assisted left-sided colon resection for the assessment of anastomosis. MATERIALS AND METHODS: All consecutive laparoscopically assisted left-sided colon resections performed at our department between May 2001 and February 2006 were included in this study. After colon resection and reanastomosis, an intraoperative colonoscopy was performed to detect anastomosis risk. RESULTS: A total of 122 patients were enrolled in this study. In 73 patients (59.84%), the anastomosis was checked via colonoscopy (the study group, (SG), whereas the control group (CG) consisted of 49 (40.16%) patients without colonoscopy. Of the 122 patients, 65 (53.28%) underwent a laparoscopically assisted sigmoid resection, 45 (36.89%) a laparoscopically assisted sigmoid rectum resection, 4 (3.28%) a laparoscopically assisted anterior rectum resection, and 8 (6.56%) a laparoscopically assisted left hemicolectomy. In the study group, 5 (6.85%) anastomotic leakages were intraoperatively detected and oversewn. A total of 6 (4.92%) anastomotic leakages occurred in the early postoperative period (SG: 4 [5.47%] vs. CG: 2 [4.08%]; P = 0.541). CONCLUSIONS: Intraoperative evaluation of anastomosis prevents early anastomotic insufficiency because intraoperative identification of leaks allows for repair during surgery. Nevertheless, a certain rate of anastomotic dehiscence occurs in every kind of colon resection. The sometimes increased rate of dehiscence in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.

Impaired anal sphincter function in professional cyclists.

BACKGROUND: The purpose of our study was to assess anal function in professional mountain bikers, as an increasing number of cycling enthusiasts report functional and morphological problems in the anal region. We tried to find out if constant saddle vibration suffered by professional cyclists could lead to defecation disorders. METHODS: 19 professional male mountain bikers took part in this study. The findings were compared with those of a control group (CG) of healthy volunteers who rode bikes less frequently. Both groups underwent rectal examination and anorectal manometry. Rectal sensation, rectal compliance and the anorectal inhibitory reflex were also assessed. Information on anal pain, blood on the toilet tissue, history of hemorrhoids, anal fissure, abscess formation and problems with defecation was collected by questionnaire and local examination was carried out. RESULTS: Sphincter resting pressures (89 +/- 27 mmHg vs CG: 69 +/- 16 mmHg), squeeze pressures (137 +/- 36 mmHg vs CG: 96 +/- 19 mmHg) and sphincter volumes (resting vector volume: 513 +/- 277 cc vs CG 273 +/- 170 cc, squeeze vector volume: 1389 +/- 867 cc vs CG: 490 +/- 219 cc) were significantly higher in the professional mountain bikers. Values reflecting rectal sensation (sensory threshold: 51 +/- 32 ml vs CG: 46 +/- 12 ml) were not significantly different between the groups. CONCLUSION: Proctological problems are very common in professional mountain bikers. Permanent microtrauma through constant saddle vibration may lead to chronic inflammation and anal fissure resulting in anal pain and therefore high sphincter pressure. Muscle hypertrophy as a consequence may lead to defecation disorders.

Laparoscopic resection of a giant liver hemangioma.

We present a case report of hepatic resection performed laparoscopically for a giant symptomatic hemangioma. The patient was a 50-year-old woman who was diagnosed with a giant hemangioma 20 cm in diameter. As in the case of our patient, laparoscopic resection of hepatic hemangiomas can be performed successfully, even when dealing with giant hemangiomas. However, a thorough preoperative assessment and a structured approach, in our case including preoperative embolization, is crucial for success.

It is not always appendicitis.

BACKGROUND: Patients who are suspected of having acute appendicitis usually undergo surgery in order to avoid life-threatening complications such as perforation and peritonitis. However, acute appendicitis is difficult to distinguish from other sources of right-sided abdominal pain. The clinical picture is almost indistinguishable from appendiceal diverticulitis, which is a rare entity and remains a difficult diagnostic problem. PATIENTS AND METHODS: We describe the case of a 39-year-old male with perforated appendiceal diverticulitis. The patient was admitted to our surgical unit with acute appendicitis-like symptoms and underwent surgery with a diagnosis of suspected acute appendicitis. RESULTS: The patient was found to have perforated appendiceal diverticulitis and standard appendectomy with abdominal lavage was carried out. DISCUSSION: Most patients presenting with acute right-sided peritonitic pain are diagnosed and managed as cases of acute appendicitis. Acute pain in the lower right side of the abdomen caused by appendiceal diverticulitis is very rare and clinically indistinguishable from acute appendicitis. Inflammatory complications of appendiceal diverticula mimic acute appendicitis. CONCLUSION: Every surgeon should be aware of the possibility of diverticulitis of the appendix in the operating room, even if this does not change the operative management. As diverticula of the cecum can be found as solitary lesions, as multiple lesions confined to the right colon, or as part of a generalized disease of the entire colon, postoperative barium enema examination may be useful.

Is it necessary to deflate the adjustable gastric band for subsequent operations?

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is an effective method in the treatment of morbid obesity. However, it is unknown, whether deflating the gastric band before operations under general anesthesia is necessary to avoid complications such as nausea, vomiting, respiratory complications, and weight regain. METHODS: Between January 1996 and June 2001, we performed LAGB on 408 patients at the University Hospital of Innsbruck. Of these patients, we identified 68 (16.7%) patients who were to undergo subsequent unrelated general, reconstructive, vascular, or orthopedic procedures. These patients were prospectively randomized into two groups: group 1 (n = 32) preoperative deflation of the adjustable band system and group 2 (n = 36) without preoperative deflation of the adjustable band system. RESULTS: There were no anesthetic or perioperative band-related complications in either group 1 or group 2. There were two reoperations necessary due to surgical complications unrelated to the gastric band. CONCLUSIONS: Operations after adjustable gastric banding can be safely performed without deflating the adjustable system.