Lower-limb reconstruction with chimeric flaps: The quad flap.

Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity.

A Survey of the Prevalence and Practice Patterns of Human Acellular Nerve Allograft Use.

BACKGROUND: There have been many technical and scientific advances over the last decade in peripheral nerve surgery. Human acellular nerve graft (HANA) has become increasingly popular but current practice patterns among hand surgeons have yet to be defined. Coding practices may not have kept up with this innovation. A 26 question survey of hand surgeons was performed to evaluate the adoption of HANA, and current coding and billing practices. The survey was sent to hand surgeons trained in orthopedic, plastic, general, and neuro surgery. The survey was designed and implemented by the Mayo Clinic Survey Center. RESULTS: Four hundred sixty-one responses to the survey were received. Most respondents currently use HANA (70%). Of those surgeons who do use HANA, nearly all use it less than 10 times per month (98%). There was no significant difference in the use of HANA across different specialties. There was a significant difference in HANA use depending on practice type with higher use by those in group private practice (57%) compared with academic practice (28%), solo practice (12%), and other practice environment (3%). There was a significant difference in HANA use depending on the number of years in practice. Those in practice less than 5 years used HANA the most (32%), followed by > 20 years in practice (27%), 6-10 years in practice (16%), 16-20 years in practice (14%), and 11-15 years in practice (11%). When asked the Current Procedural Terminology code they would use to bill for the procedure of choice, the most common response was 64910 (nerve repair with synthetic conduit or vein allograft). CONCLUSIONS: HANA has surpassed nerve conduit as the traditional gold standard in our study with nearly 70% of hand surgeons using HANA in their practice and a greater percentage of respondents choosing HANA as their first choice to repair as compared with nerve conduit, nerve autograft, or vein graft. There remains confusion regarding appropriate billing practices for the use of HANA. Due to its common use, a Current Procedural Terminology code should specifically designated for the use of HANA in the hand.

Feedback in Plastic and Reconstructive Surgery Education: Past, Present, and Future.

Education is to be provided efficiently and effectively according to guidelines in the United States by the Accreditation Council for Graduate Medical Education as core competencies and in Canada by the Royal College according to the CanMEDS framework. This article defines formative feedback, reviews the currently available validated feedback tools, and describes the future use of technology to enhance feedback in plastic surgery education.

Postoperative electrolyte management: Current practice patterns of surgeons and residents.

BACKGROUND: Managing postoperative electrolyte imbalances often is driven by dogma. To identify areas of improvement, we assessed the practice pattern of postoperative electrolyte management among surgeons and residents. STUDY DESIGN: An online survey was distributed among attending surgeons and surgical residents at the University of Toronto. The survey was designed according to a systematic approach for formulating self-administered questionnaires. Questions addressed workload, decision making in hypothetical clinical scenarios, and improvement strategies. RESULTS: Of 232 surveys distributed, 156 were completed (response rate: 67%). The majority stated that junior residents were responsible for managing electrolytes at 13 University of Toronto-affiliated hospitals. Supervision was carried out predominately by senior residents (75%). Thirteen percent reported management went unsupervised. Approximately 59% of residents were unaware how often attending surgeons assessed patients' electrolytes. Despite the majority of residents (53.7%) reporting they were never given tools or trained in electrolyte replacement, they considered themselves moderately or extremely confident. The management of hypothetical clinical scenarios differed between residents and attending surgeons. The majority (50.5%) of respondents considered that an electrolyte replacement protocol is the most appropriate improvement strategy. CONCLUSION: Electrolyte replacement represents an important component of surgeons' workload. Despite reporting that formal training in electrolyte management is limited, residents consider themselves competent; however, their practice is highly variable and often differs from pharmacologic-directed recommendations. Optimizing how postoperative electrolytes are managed in surgical wards requires building a framework that improves knowledge, training, and limits unnecessary interventions.

Graft type in pediatric liver transplantation.

PURPOSE OF REVIEW: To review the literature on graft type in pediatric liver transplantation, with a specific focus on publications since 2010. RECENT FINDINGS: Due to the limited availability of whole livers for transplantation, the majority of pediatric patients will receive a technical variant graft (live donor, reduced, split). Although the outcomes of these grafts may be inferior to whole organs, the detrimental impact needs to be balanced with the impact of technical variants on improved access and survival to transplantation. Vigilance in detecting and managing posttransplant complications is critical in ensuring the optimal outcome. Infants under 5 kg pose a particular challenge in terms of graft selection with hyperreduced and monosegment grafts proposed for this population. Grafts from donors after cardiac death show promise in expanding the donor pool. However, experience in pediatric patients with these grafts is quite limited, particularly in young children who form the majority of pediatric transplant recipients. Auxiliary transplantation is proposed as a strategy for children presenting with fulminant hepatic failure and for children with metabolic diseases. SUMMARY: The majority of children will receive a technical variant graft, with graft choice being largely determined by organ availability.

Living donor hepatectomy: the importance of the residual liver volume.

Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n = 4) or left lateral segmentectomy (LLS; n = 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P = 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation.

Prevention of local tumor growth with paclitaxel-loaded microspheres.

OBJECTIVES: Lung cancer is associated with a significant rate of locoregional recurrence after surgical resection, particularly when nonanatomic wedge resections are performed. The primary aim of this study was to assess the feasibility of a microsphere drug delivery system to locally deliver chemotherapy and prevent the establishment and growth of lung cancer cells and establish proof of concept for a potential future approach to target occult microscopic disease remaining at the surgical resection margin. METHODS: Poly-(D,L-lactic-co-glycolic acid) (PLGA) microspheres loaded with the antineoplastic agent paclitaxel were prepared and tested for antitumor efficacy in an in vitro cell proliferation assay for tumor inhibition and induction of apoptosis. The in vivo prevention of Lewis lung carcinoma cell establishment and growth in subcutaneous tissues of mice was also assessed by comparing 4 treatment groups: Lewis lung carcinoma cells alone, Lewis lung carcinoma cells combined with 100 x 10(6) unloaded (carrier alone) PLGA microspheres, and Lewis lung carcinoma cells combined with 50 x 10(6) or 100 x 10(6) paclitaxel-loaded PLGA microspheres. After the coinjection of Lewis lung carcinoma cells with or without microspheres, in vivo tumor growth was monitored, and tumor weight was recorded on death. RESULTS: Paclitaxel-loaded PLGA microspheres were found to effectively prevent growth of tumor cells in culture through the induction of apoptosis. Similarly, paclitaxel-loaded PLGA microspheres significantly inhibited tumor growth in vivo at both the 50 x 10(6) and 100 x 10(6) microsphere dose (0.497 +/- 0.183 and 0.187 +/- 0.083 g total tumor weight, respectively) compared with 2.91 +/- 0.411 g for Lewis lung carcinoma cells with unloaded microspheres and 3.37 +/- 0.433 g for untreated tumor (P < .001). Toxicity was not clinically apparent in any animal treated with paclitaxel-loaded PLGA microspheres. CONCLUSIONS: Paclitaxel-loaded PLGA microspheres induce tumor apoptosis and inhibit the establishment and growth of lung cancer cells both in vitro and in vivo without obvious systemic toxicity. By using models consistent with localized microscopic tumor burdens, these results suggest that local delivery of paclitaxel through a microsphere system might lead to an effective future method of decreasing local tumor recurrence in non-small cell lung cancer when applied to the surgical margins at risk for microscopic tumor foci. Such an approach might be particularly efficacious after wedge resection in the setting of poor pulmonary reserve or significant comorbidity, where local recurrence rates are increased and acceptable alternative treatment options are limited.