Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. AIM: The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. MATERIALS AND METHOD: By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24 h after abdominal skin closure, for 13 patients. RESULTS: The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p = 0.007)] and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p = 0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n = 3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12 mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24 h. One patient developed a non-fatal lung embolism. CONCLUSION: The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 h after the closure of the skin.

Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: an observational study.

Use of anticoagulants is common and practice regarding continuation or discontinuation of the medication peri-operatively for cutaneous surgery lacks evidence-based consensus. Therefore, we aimed to do a prospective observational study with patients who were referred to cutaneous surgery and needed full thickness or split skin grafting and using antitrombotic or non-antitrombotic therapies. Data on patients characteristics, diagnosis, location of surgery and surgery performed, antithrombotic medication and complications in skin grafts were collected. Skin grafts were traced on a transparent film and areas of unhealed skin graft were marked. All patients were routinely followed-up on days 5-7 postoperative. Chi-square test, Fisher's exact test or Mann-Whitney U-test were used to compare patients taking antitrombotic medication with patients receiving no antitrombotic therapy. In addition, associations were calculated for treatment with the different antithrombotic therapies. No severe bleeding requiring blood transfusion or re-operation was observed in this study. The results showed no statistically significant difference between patients who continued treatment with antithrombotic therapy compared with patients having no antithrombotic treatment regarding sub graft hematomas or graft take. Continuing antithrombotic monotheraphy with acetylsalicylic, clopidogrel, warfarin or fish oil in relations to cutaneous surgery do not seem to increase risk of haematoma or graft lost.

[Local anaesthetics].

Local anaesthetics are widely used in clinical practice. They comprise a group of weak organic bases, which selectively block sodium channels in the nerve cell membrane, thus blocking transmission of nociception by impeding depolarisation of the nerve. Local anaesthetics are generally safe and readily used and provide reduction of pain during biopsies, invasive procedures and surgery. This is an updated review of pharmacology and utilisation of local anaesthetics, as well as an overview of adjuvants, allergies, and adverse effects.

[Reconstruction of ritual female genital mutilation].

This review discusses female genital mutilation (FGM), which is a culturally founded ritual of unknown origin. The definition is intentional altering or injuring the female genitals for non-medical reasons. The WHO estimates, that more than 200 million women have sequelae from FGM. Acute compli-ca-tions range from haemorrhage and infection to death, while the most common chronic complications are vulvar pain, problems with micturition and childbirth, recurrent infec-tions, dysmenorrhoea, and dyspareunia. Favourable surgical techniques are available. Hitherto, these techniques are limited to certain types of FGM.

[Post-operative infections after cosmetic tourism].

Cosmetic tourism is defined as patient mobility across borders, typically constituted by patients seeking cosmetic surgery at lower costs abroad. The most common procedures are abdominoplasty, fat grafting and breast augmentation. Very little is known about the complication rates after cosmetic tourism, and there is a paucity of evidence in all aspects of cosmetic tourism. In this review, we focus on post-operative complications i.e. post-operative infections, in particular with rare microorganisms such as mycobacteria.

[Mycobacterium abscessus infection after cosmetic breast surgery in India].

A 36-year-old Danish woman underwent cosmetic breast surgery in India. Post-operatively, she presented with infection and ulcers under the breasts, and dicloxacillin was administered. The patient did not return for follow-up. Two years later the ulcer under the right breast had not healed, and the patient returned to hospital, where a wound culture was done. The result showed Mycobacterium abscessus. Hence, cephalexin administration was instituted, but the ulcer did not heal, and it was excised. The subsequent healing was rapid. Mycobacterial infections in Denmark are rare, serious, and often resistant to antibiotics.

Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: A systematic review.

The risk of postoperative bleeding and wound healing complications in skin grafts among anticoagulated patients undergoing cutaneous surgery has not been firmly established. The objective was to examine the literature and assess the risk of postoperative bleeding or wound healing complications in skin grafts among anticoagulated patients, compared with patients who discontinue or patients who are not receiving antithrombotic therapy prior to cutaneous surgery requiring skin grafting. A systematic review examining the effect of antithrombotic therapy on cutaneous surgery was performed according to the PRISMA-guidelines. PubMed and Embase databases were primarily searched for relevant literature in the period from the start date of each database to 2014. A total of eight studies representing 443 patients met criteria for inclusion. No randomised controlled trials were found; the included studies were of prospective and retrospective design. Most of the reviewed studies suggest that the use of antithrombotic therapy can increase the risk of bleeding complications in skin grafts. These complications are only wound threatening and not life threatening. Therefore, this is of concern mostly in terms of hemostasis by the surgeon and good pressure dressings. Care should be taken when operating on anticoagulated patients undergoing cutaneous surgery requiring skin grafting. However, graft failure is rare and, given the risk of thrombotic events, the reviewed studies recommend continuing all medically necessary antithrombotic therapy. The limitations of this study are the small sample sizes and the level of evidence; hence, more research is needed to substantiate these preliminary findings.

Effect of active site-inactivated factor VIIa on ischaemia/reperfusion injury in a porcine flap model.

In free flap surgery, restored blood flow following a lengthy ischaemic period may lead to necrosis as a result of ischaemia/reperfusion (IR) injury. This injury comprises both proinflammatory and prothrombotic events, where the tissue factor/factor VIIa complex probably has a key role. Active site-inactivated factor VIIa (FFR-rFVIIa) exerts an antithrombotic effect by binding to tissue factor without initiating coagulation. In this study we have evaluated the potential protective effects of FFR-rFVIIa in IR injury. Bilateral musculocutaneous latissimus dorsi flaps in 16 pigs were made ischaemic for eight hours, then given 1 mg/kg/flap of FFR-rFVIIa or vehicle intra-arterially, and reperfused for 10 hours. The viable:necrotic tissue ratio, and accumulation of radiolabelled leucocytes, fibrinogen, and platelets were measured. There was no effect on tissue survival, but radiolabelled components in viable tissue were increased, though not significantly so. We conclude that FFR-rFVIIa did not prevent IR injury, indicating that tissue factor-mediated coagulation is not an important determinant of IR injury in this setting.