Microvascular nose reconstruction after extended tumor resection.

<b>Introduction:</b> The nose is the central and probably the most important organ of the face. In view of the three-dimensional shape and variety of tissues, reconstructive surgery after tumor resection in this anatomical region requires the surgeon's knowledge of anatomy. <br><b>Materials and Method:</b> In the years 2010-2019, 48 patients were treated in the Oncological and Reconstructive Surgery Clinic for extended nasal tumors, which required the use of free microvascular flaps after resection for functional and aesthetic supply of anatomical structures of the nose. <br><b>Results:</b> In 48 patients, a total of 92 free microvascular flaps were used for nasal reconstruction including: radial forearm free flap in 24 patients, radial forearm free flap with radial bone in 14 patients, auricular free flap in 16 patients, radial forearm free flap in combination with auricle free flap in 7 patients, double auricular free flap in 6 patients, radial forearm free flap in combination with double auricular free flap in 4 patients. Total necrosis of the free flap was noted in 4 cases, partial in 6 patients. <br><b>Conclusions:</b> The presented surgical techniques using microvascular free flaps constitute a recognized method of treatment and should be used in everyday surgeon practice. The results demonstrated in this article allow to obtain optimal functional and aesthetic effects.

Virtual surgical planning and cone beam computed tomography in reconstruction of head and neck tumors - pilot study.

<b>Introduction:</b> The aim of the study was to prove that a combination of visual surgical planning (VSP) and cone beam computed tomography (CBCT) is an optimal technique in fibular free flap reconstructions after complex tumor resections in the head and neck region and that it leads to better functional and aesthetic outcomes. <br><b>Material and method:</b> Six patients (3 females, 3 males) with head and neck tumors were included in the study. The region concerned midface in 2 cases and mandible in 4 patients. On the basis of computed tomography of the head, fibular free flap (FFF) reconstruction was planned with the VSP technique. The 3D-printed models were prepared. At the beginning of the operation and a few minutes after the reconstruction, an xCAT CBCT by XORAN was performed. Minor corrections of the angles of the reconstructed bony parts were made where needed. The time of the operation was assessed for each case. Functional and cosmetic results were evaluated in a 1-year follow-up. <br><b>Results:</b> The mean time of operation was 6 hours and 48 minutes, which was approximately 1hour and 40 minutes less than standard reconstructive surgery. Functional recovery was achieved in all patients. Aesthetic result was unsatisfactory for 2 patients due to insufficient soft tissue masses of FFF. <br><b>Conclusions:</b> The authors claim that intraoperative CBCT imaging, regardless of the cost, improves the accuracy of aesthetic outcome of reconstructive surgeries based on VSP, especially in the region of the midface and the mandible. Further studies on a higher number of subjects are required.

First Complex Allotransplantation of Neck Organs: Larynx, Trachea, Pharynx, Esophagus, Thyroid, Parathyroid Glands, and Anterior Cervical Wall: A Case Report.

OBJECTIVE: Evaluate the possibility of performing a complex vascular allotransplant of all neck organs including skin. SUMMARY BACKGROUND DATA: There are 2 previous attempts described in the literature, none of them being that complex. The first one is nonfunctional due to chronic rejection, the second one is viable yet considerably limited in complexity (no parathyroids, no skin). METHODS: The allotransplantation was performed simultaneously on 2 adjacent operating rooms, using microsurgical techniques. RESULTS: The patient's voice, breathing through mouth, swallowing, and endocrinal functions have been fully restored. CONCLUSIONS: Achieved results show clearly that such operations performed in selected patients can nearly fully restore functional and aesthetic effects in 1 single procedure.

Treatment Outcome and Prognostic Factors for Malignant Skin Melanoma Treated with Radical Surgery.

AIM: To assess the treatment outcome in patients with malignant skin melanoma and prognostic factors for distant metastases (DM), disease-free survival (DFS) and overall survival (OS). MATERIALS AND METHODS: A retrospective analysis was conducted on 113 patients with malignant skin melanoma (60 females, 53 males, average age-55 years) who were treated surgically. Primary treatment consisted of local excision. In 12 cases, it was accompanied by lymph node excision. In 93 (82%) cases, radicalization was necessary, which was either local only (19 cases) or accompanied by lymph node surgery/biopsy (74 cases). Possible prognostic factors such as Clark's stage and Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases (pN+), gender, tumor location and primary excision margins were considered. RESULTS: In 51 (45%) cases, treatment failure occurred. The 5-year DM rate was 47%, the 5-year DFS was 38%, and the 5-year OS was 56%. In the univariate analysis, the important factors with respect to at least one endpoint included Clark's stage, Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases, gender and primary tumor localization. The presence of metastasic nodes was the most important prognostic factor, with a 5-year DM rates of 30% for pN(-) and 76% for pN(+) and a 5-year DFS and OS of 56% and 76% for pN(-) and 13% and 24% for pN(+), respectively. The average tumor dimension was independently significant for DFS and OS, with 5-year rates of 69% and 80% for ≤1 cm, 28% and 53% for 1-2 cm, and 18% and 30% for >2 cm, respectively. Tumor location was also significant for DM and OS, with 5-year rates of 69% vs 33% and 41% vs 66% for trunk vs other locations, respectively. CONCLUSIONS: The natural course of a malignant skin melanoma treated radically is disadvantageous, with unsuccessful outcome in nearly half of the cases. Common clinical factors, such as Clark's tumor stage, Breslow's depth of invasion and the presence of metastatic nodes, have high prognostic significance. The size and location of the primary lesion may be considered independent prognostic factors. The most important negative prognostic factor is the presence of metastatic regional lymph nodes. Only one quarter of patients with metastases in lymph nodes survive 5 years from primary surgery.

A novel peritoneum derived vascular prosthesis formed on a latex catheter in an SDF-1 chemokine enriched environment: a pilot study.

INTRODUCTION: Although saphenous vein grafts are widely used conduits for coronary artery bypass graft surgery, their clinical value remains limited due to high failure rates. The aim of the study was to evaluate feasibility, safety, and biocompatibility of peritoneal derived vascular grafts (PDVG) formed on a silicone-coated, latex, Foley catheter in a stromal cell-derived factor (SDF-1)- enriched environment. METHODS: Foley catheters were implanted into the parietal wall of 8 sheep. After 21 days the peritoneal cavity was re-opened and the newly formed tissue fragments were harvested. The animals were randomly assigned into: (1) study group in which conduits were incubated in a solution containing SDF-1, (2) control group without SDF-1 incubation. Left carotid arteries were accessed and "end-to-side" anastomoses were performed. Biological materials for histological examination were taken at 4, 7, 10, and 14 days. RESULTS AND CONCLUSIONS: The study proved safety, feasibility, and biocompatibility of PDVG formed on the basis of a silicone-coated, latex catheter in an SDF-1 chemokine-enriched environment. These biological grafts effectively integrated with the native high-pressure arterial environment in an ovine model and provided favorable vascular profile. The potential clinical value of this technology needs to be further elucidated in long-term preclinical and clinical studies.

The use of a pedunculated, extended latissimus dorsi flap in primary and secondary breast reconstruction procedures--case report.

The extended latissimus dorsi flap (LD) is used in breast reconstruction since the 70's. LD flap is often used in corrective surgery in cases of unsatisfactory cosmetic results after breast-conserving therapy. In our department LD flap has several uses. In addition to free microvascular flaps - which applies in breast reconstructive surgery is routine, there are clinical situations where the use of pedicled LD flap is justified. The main indications for its use are: the inability to apply microvascular flap, the general condition (diabetes, advanced atherosclerosis), smoking, previous surgery of abdominal wall, abdominal obesity, patient preferences. Approximately 30% of patients after breast reconstruction require corrective procedures. Group which uses extended LD flap account for 24 patients. In 16 cases it was used for elective breast reconstruction. In the remaining eight cases it was used in the corrective procedures symmetry and shape of the previously reconstructed breast. Based on our own experience it can be concluded that the LD flap with an alternative to microvascular techniques. Complication rate when using the LD flap is relatively low and includes: seroma and slight motor disability of the shoulder girdle.

Salvage surgery of recurrence after laryngectomy--when should the alt free flap be modified?

BACKGROUND: Reconstruction of the pharynx and cervical esophagus has significantly progressed in the last 2 decades. A revolution in microvascular surgery has provided numerous choices for primary restoration, or in secondary reconstructions necessary for recurrences or complications of primary surgery. The goals of reconstruction after laryngopharyngoesophagectomy are to provide continuity of the alimentary tract, to protect major blood vessels, to heal the primary wound, and to restore the swallowing and breathing functions with minimal donor site and neck morbidity and deformation. CASE REPORT: We present 3 cases with complex defects of the laryngopharynx, cervical esophagus and trachea and anterior neck skin following central neck exenteration safely reconstructed with a single anterolateral thigh flap. No postoperative complications occurred in any of the 3 cases of reconstructions, each using a single anterolateral thigh flap. CONCLUSIONS: This approach significantly simplified the reconstruction, with quick recovery, short hospital stay and excellent functional and aesthetic results.

The use of prefabrication technique in microvascular reconstructive surgery.

AIM OF THE STUDY: The aim of the study was to develop standards for the prefabrication of free microvascular flaps in an animal model, followed by their application in clinical practice, and quantitative/qualitative microscopic assessment of the extent of development of a new microvascular network. MATERIAL AND METHODS: The study was carried out in 10 experimental pigs. As the first stage, a total of 20 prefabricated flaps were created using polytetrafluoroethylene (PTFE) as a support material, placed horizontally over an isolated and distally closed vascular pedicle based on superficial abdominal vessels. After completing the animal model study, one patient was selected for the grafting of the prefabricated free flap. RESULTS: All 20 free flaps prefabricated in the animal model were analyzed microscopically, exhibiting connective tissue rich in fibroblasts and small blood vessels in the porous areas across the entire thickness of the PTFE element. CONCLUSIONS: Flap prefabrication is a new and fast developing reconstruction technique. The usefulness of prefabrication techniques and their status in reconstructive surgery still needs to be investigated experimentally and clinically. The method based on prefabricated free flaps is the first step towards anatomical bioengineering that will make it possible to replace missing organs with their anatomically perfect equivalents.

Effect of gender on efficacy of preoperative intra-aortic balloon pump in high risk patients undergoing surgical coronary revascularisation.

BACKGROUND: There is no strong evidence supporting the use of preoperative intra-aortic balloon pump (IABP) in high-risk patients undergoing coronary artery bypass grafting (CABG). This issue has only been investigated in small studies which analysed the general population of patients, without focusing on specific subgroups, including gender. AIM: We sought to determine if there is any benefit from preoperative IABP in high-risk patients undergoing CABG with the analysis of its determinants including gender. METHODS: We randomly assigned 502 high-risk patients (351 men, 151 women) to the group receiving preoperative IABP support or to the control group with no preoperative IABP. Primary end-point was a major adverse cardiac or cerebrovascular event (MACCE), defined as death from any cause, myocardial infarction, cerebrovascular accident or repeat revascularisation within 30 days post-surgery. RESULTS: A significant reduction of MACCE rate in patients with the preoperative IABP counterpulsation in comparison to controls was noticed in the total population of high risk patients (p=0.001) and in the female subgroup (p=0.005). After adjustment for baseline characteristics, the hazard ratio for MACCE was 0.7 (p=0.005) in the total population; 0.6 (p=0.01) for females and 0.8 (p=0.1) for males. CONCLUSIONS: There is a beneficial effect of preoperative IABP use in high-risk patients undergoing CABG, particularly in women and patients with co-morbidities (diabetes, obesity, and peripheral vascular disease).

[Surgical correction of the Bland-White-Garland syndrome with anomalous origin of right coronary artery - a case report]. / Korekcja chirurgiczna zespolu Blanda-White'a-Garlanda z nieprawidlowym odejsciem prawej tetnicy wiencowej - opis przypadku.

The main cause of the Bland-White-Garland (BWG) syndrome is usually an anomalous origin of the left coronary artery, however, the right coronary artery can be affected as well. We report on the surgical treatment of an adult type BWG syndrome in a 59-year-old male patient. The reason for angiography was anginal pain which occurred 7 years prior to the operation. At that time patient did not agree to undergo surgery, however, symptom aggravation brought him to the hospital again. Because of the vessel anatomy the operator decided to implant a vein graft.

Totally epicardial cardiac resynchronization therapy system implantation in patients with heart failure undergoing CABG.

BACKGROUND: Systolic dyssynchrony is present in a considerable number of patients with heart failure (HF) undergoing coronary artery bypass grafting (CABG). Surgical revascularization offers an optimal setting for totally epicardial cardiac resynchronization therapy (CRT) system implantation. AIM: To assess the efficacy of totally epicardial CRT implantation during CABG, in patients with HF. METHODS: Twenty three patients with HF and dyssynchrony underwent totally epicardial CRT system implantation during CABG. This randomised, single-blind, cross-over study compared clinical and echocardiographic parameters during two periods: 3 months of active CRT (CRT+) and 3 months of inactive CRT (CRT-) pacing. RESULTS: Twenty two patients underwent randomisation and completed both study periods. In the CRT+ group more patients improved by two NYHA classes (p=0.028), had a longer 6-minute walk test distance (p=0.047) and better quality of life (p=0.003) compared with the CRT- group. Echocardiography revealed an improved LV ejection fraction (p<0.001), smaller LV end-systolic volume (p=0.04), reduced mitral regurgitation (p=0.026) and improved LV synchrony in the CRT+ group compared with the CRT- group. CONCLUSION: CRT delivered by a totally epicardial system implanted during CABG is associated with additional improvement of clinical and echocardiographic parameters in patients with HF and systolic dyssynchrony.

Oligonucleotide microarray analysis of genes regulating apoptosis in chronically ischemic and postinfarction myocardium.

The pathology of cardiomyocyte death during and after myocardial infarction involves both necrosis and apoptosis. Although both mechanisms lead to cell death, participation of apoptosis in this process carries the potential of developing therapies influencing at least part of the population of dying cells. Therefore the aim of this study was to determine (using oligonucleotide microarrays) expression profiles of apoptosis-regulating genes in postinfarction myocardium, comparing chronically ischemic and healthy heart muscle. Tissue samples were obtained during elective surgery from the right cardiac auricles of three patients. The expression of 141 genes involved in fibrosis was assessed using the Affymetrix HG_U133A microarray. The patients' transcriptomes were compared using hierarchical clusterization. Differentiating genes were determined using regression analysis and Bland-Altman graph analysis. Hierarchical clusterization demonstrated that the profile of gene expression in postinfarction myocardium was different from that in the remaining specimens. Further statistical analysis showed two important differentiating genes: FOXO3A (underexpressed in post-MI sample) and CFLAR (overexpressed in post-MI sample). The expression of apoptosis-regulating genes is significantly different in post-MI myocardium from chronically ischemic and a nonischemic myocardium. Our results suggest that CFLAR is important in the induction of apoptosis in postinfarction cardiac tissue.

Totally epicardial cardiac re-synchronization therapy system implantation in patients with heart failure undergoing CABG--description of 3 cases.

INTRODUCTION: Systolic dyssynchrony as an indication for cardiac re-synchronization therapy is present in a considerable subset of patients with congestive heart failure undergoing surgical coronary revascularisation. Coronary artery bypass grafting offers an optimal setting for totally epicardial cardiac re-synchronization system implantation. AIM: To assess the feasibility and safety of totally epicardial cardiac re-synchronization system implantation in patients with ischaemic heart disease and heart failure undergoing coronary artery bypass grafting. METHODS: Three male patients with coronary artery disease and postinfarction functional class III congestive heart failure underwent a combined procedure of on-pump surgical coronary revascularisation and totally epicardial cardiac re-synchronization system implantation (all three leads implanted epicardially). In all patients intraventricular dyssynchrony was revealed in preoperative echocardiography. RESULTS: There was no perioperative morbidity or mortality. The mean total time required for cardiac re-synchronization system implantation was 17.3+/-2.3 minutes. We obtained excellent pacing and sensing parameters at implant (left ventricular pacing thresholds: 0.8, 0.5, 0.5 V at 0.5 ms; left ventricular sensing thresholds: 17, 15, 20 mV, respectively in consecutive patients). After 12 months pacing and sensing parameters remained stable. Significant improvement in 6-minute walk test distance, functional class and echocardiographic parameters (left ventricular ejection fraction, intraventricular dyssynchrony) was observed in all patients. CONCLUSIONS: Totally epicardial cardiac re-synchronization system implantation is safe and can be regarded as an important supplement to surgical coronary revascularisation in the still growing population of patients with severe heart failure and systolic dyssynchrony, which can be used for the optimisation of treatment results.

[Antegrade warm blood cardioplegia versus cold blood cardioplegia in normothermia in the coronary artery bypass grafting procedures. Troponine I release as a marker of periopertive myocardial ischemia]. / Porównanie stopnia niedokrwienia miesnia sercowego w operacjach pomostowania tetnic wiencowych w normotermii przy uzyciu roztworu cieplej krwistej i zimnej krwistej kardiopleginy. Troponina I jako okolooperacyjny marker niedokrwienia miesnia sercowego.

UNLABELLED: Warm myocardial protection has had a strong impact on modern cardiac surgery. The O2 consumption of a heart, arrested by potassium-enriched normothermic blood is 90% less than baseline values. Hypothermia gives only a slight reduction in oxygene consumption. THE AIM OF THIS STUDY: was to test the quality of myocardial protection provided by intermittent antegrade warm blood cardioplegia (IAWBC) by comparing it with cold blood cardioplegia. MATERIAL AND METHODS: We designed a prospective randomized study by using 2 different temperatures of blood cardioplegia: warm, from 35 degrees C to 37 degrees C (group I--36 men and 14 women, mean age 56 +/- 7); and cold, from 6 degrees C to 8 degrees C (group II--40 men and 10 women, mean age 58 +/- 9). Cardiac troponin I release was the criterion used to evaluate the adequacy of myocardial protection, RESULTS: The heartbeat in 92% of patients treated with warm cardioplegia converted to normal sinus rhythm spontaneously after removal of the aortic crossclamp compared with only 18% of the cold cardioplegia group. Cardiac troponin I concentration was significantly higher in the cold group. Our study demonstrates a significant reduction of myocardial cell damage with the use of IAWBC. CONCLUSION: Our clinical results have shown that IAWBC is a superior method compared to intermittent cold cardioplegia.

[Heart surgery in patients with chronic renal insufficiency: risk factors, outcome, management]. / Operacje serca u chorych z przewlekla przedzabiegowa niewydolnoscia nerek: czynniki ryzyka, rokowanie, postepowanie terapeutyczne.

Cardiovascular diseases are one of the most common causes of hospitalization. Renal failure is a very important risk factor in patients undergoing heart surgery. So far few authors have written about non-dialysis dependent patients with mild renal insufficiency undergoing heart surgery. The purpose of this study is to present most important risk factors and outcomes in patients with different stages of renal insufficiency. The authors have studied attentively non-dialysis dependent patients with mild renal insufficiency because of high risk of pooperative renal failure in this population. To diminish high risk of perioperative death in these patients, there is a need for very close co-operation between cardiologists, cardiac surgeons and nephrologists.

Primary direct stenting versus endoscopic atraumatic coronary artery bypass surgery in patients with proximal stenosis of the left anterior descending coronary artery--a prospective, randomised study.

BACKGROUND: The dynamic development of interventional cardiology resulted in an increasing proportion of patients treated with various forms of coronary angioplasty instead of surgery. On the other hand, it has been well established that the results of coronary artery by-pass surgery of the left anterior descending (LAD) coronary artery with the use of the internal mammary artery are excellent. AIM: To compare the results of primary direct stenting (PDS) and endoscopic atraumatic coronary artery bypass (EACAB) surgery in patients with an isolated proximal LAD type A or B1 lesion. METHODS: This prospective and randomised study included 100 patients with an isolated critical (> or =70%) LAD stenosis who underwent PDS (n=50) or EACAB (n=50). RESULTS: After a six-month follow-up period, 32 (64%) PDS patients and 47 (94%) EACAB patients were angina-free. The rate of major cardiac adverse events (MACE) was significantly higher in the PDS group than in surgically treated patients (p<0.05). After one year of follow-up, 40 (80%) PDS-treated patients and all 50 EACAB patients had no recurrences of angina. After two-year follow-period, the survival rate without MACE was significantly higher in the EACAB group than in the PDS-treated patients (94% vs 76%, p<0.05). CONCLUSIONS: Minimally invasive cardiac surgery is an alternative method to direct stenting in the treatment of patients with proximal LAD stenosis.

[Assessment of surgical treatment in patients with severe depressed left ventricular function]. / Ocena chirurgicznego leczenia choroby wiencowej u chorych ze znacznie uposledzona czynnoscia lewej komory.

The aim of the study was to analyze perioperative risk factors, with special attention to cardioprotective techniques. Additionally we compared effectiveness of standard risk scales (Cleveland and Canadian) and own risk scale (modified by inclusion Graham, Chambers, Davies classification of distal coronary arteries) in investigated group. The obtained data indicate that cardioprotective techniques have no impact on clinical results but there are some important factors which influence surgical treatment: age (over 75 years), ejection fraction less than 20% and poor distal parts of coronary vessels. The regression model results were used to calculate predictive value of Cleveland or Canadian risk scale (measured area under ROC curve). Effectiveness of anticipation: mortality (Cleveland and Canadian), complications, ICU and hospital stay in patients with severely depressed left ventricular function achieved 71%, 70%, 70%, 71%, 69%, respectively. After including Graham, Chambers, Davies classification of distal coronary arteries predictive value improved 3-4% and thereby raised to 74%, 73%, 74%, 74% and 72%.

Force distribution in wire sternum sutures: the consequences for sternal closure rigidity.

BACKGROUND: This article provides a biomechanical analysis of the distribution of force in wire sutures used for sternal closure in cardiothoracic surgery. MATERIAL/METHODS: The parameters we measured included displacement in the elastic region, plastic limit, and rupture load on the closure. Force distribution analysis was carried out for every kind of wire suture. A linear regression line of displacement as a function of increasing load was determined for each closure method. RESULTS: Straight wire had less displacement at each load, figure-8 had medium, and interlocking multitwisted (IM) had the most displacement within the elastic range of the specimen. The differences between straight and interlocking multitwisted sutures were statistically significant. When the plastic limit was compared between straight and interlocking multitwisted closure, the differences were statistically significant. In the straight suture the forces used to approximate the sternal halves are perpendicular to the incision. With the figure-8 and interlocking multitwisted suture, the forces are dispersed and the effective approximation force is lower than that applied to the wires. CONCLUSIONS: Straight wires provide good fixation stability for the durability of the sternum, and the somewhat lower strength could be compensated by increasing the number of sutures. The figure-8 and IM have better strength and are less likely to cut the sternum because of advantageous redistribution of shearing forces of the wire as compared to straight closures.