Indocyanine green angiography guidance for vascular preservation in skin and nipple sparing mastectomy.

PURPOSE: The skin and/or nipple-sparing approach has become an oncologically sound and desirable choice for women choosing mastectomy. Indocyanine green (ICG) perfusion imaging has been shown to reduce ischemic complications in mastectomy skin flaps. Immediate reconstruction requires a well-vascularized skin flap capable of tolerating full expansion. Identification of the perforating subcutaneous vessels to the skin envelope may allow for better and more consistent blood vessel preservation and flap perfusion. METHODS: The authors conducted an institutional review board-approved prospective study with 41 patients to assess the feasibility of using ICG perfusion imaging to visualize, cutaneously map, and preserve the vessels that supply the skin flap and nipple-areolar complex. For each patient, the number of vessels initially mapped, the number of vessels preserved, the extent to which each vessel was preserved, and the proportion of the flap with adequate perfusion (as defined by the SPY-Q > 20% threshold) was recorded and analyzed. RESULTS: Vessels were able to be identified and marked in a high majority of patients (90%). There was a moderate linear relationship between the number of vessels marked and the number preserved. Successful mapping of vessels was associated with lower rates of wound breakdown (p = 0.036). Mapping and preserving at least one vessel led to excellent flap perfusion (> 90%). No increase in complications was observed from utilizing ICG angiography preoperatively. CONCLUSION: This prospective study using preoperative ICG perfusion mapping demonstrated safety, feasibility, and good prognostic outcomes. LEVEL OF EVIDENCE: III.

Sarcopenia and sarcopenic obesity in patients with complex abdominal wall hernias.

BACKGROUND: Chronic muscle wasting, or sarcopenia, has been associated with poor-health outcomes after major surgical procedures. Here, we explore the utility of CT-generated determinations of sarcopenia as markers of risk in patients undergoing evaluation for complex ventral hernia repair. METHODS: In 148 successive patients being evaluated for complex ventral hernia repair, CT scans were analyzed retrospectively for attributes of the hernia and indices of core-muscle mass, correlating them with preoperative clinical/laboratory profiles and outcomes in 82 patients who had undergone surgery. RESULTS: Prevalence of sarcopenia, and sarcopenia corrected for obesity, was 26% and 20% respectively. Sarcopenia was associated with age, some laboratory indicators, and increased hospital length of stay but not with a higher likelihood of surgical site occurrence. CONCLUSIONS: Obesity may obscure the value of sarcopenia as a marker of metabolic disturbance and postoperative outcome. Image-based measurements of core-muscle mass should be used with caution as predictors of risk in similar surgical populations.

Impaired recovery from peritoneal inflammation in a mouse model of mild dietary zinc restriction.

SCOPE: Mild dietary zinc (Zn) deficiency is wide-spread in human populations, but the effect on Zn-dependent processes of immune function and healing are not well understood. The consequences of mild dietary Zn restriction were examined in two mouse models of inflammation and recovery. METHODS AND RESULTS: Male C57BL/6 mice were fed a Zn adequate diet (ZA, 30 mg Zn/kg diet), or diets containing sub-optimal Zn levels (ZM, 15 mg Zn/kg diet; ZD, 10 mg Zn/kg diet) for 30 days before a thioglycollate peritonitis challenge. Plasma lipid profiles were distinct, with greater Zn restriction resulting in a greater impact on metabolites. The milder ZM diet was selected for immune studies. Peritoneal macrophages from ZM mice displayed increased phagocytosis and amplified pro-inflammatory cytokine (IL-1ß, IL-6, and TNFα) release compared to ZA, at baseline and after a secondary LPS challenge. Splenocytes isolated from ZM mice displayed an increase in IL-6 and a reduction in anti-inflammatory IL-4 compared to ZA. Cytokine levels in plasma were unaltered. Following mechanical manipulation of the intestines to induce ileus, ZM mice had delayed intestinal transit compared to ZA. CONCLUSION: Mild Zn deficiency enhances local inflammatory responses, amplifying macrophage functions and delaying recovery from acute insults within the peritoneum.

Association of postoperative hyperglycemia with outcomes among patients with complex ventral hernia repair.

IMPORTANCE: Patients with medically complex conditions undergoing repair of large or recurrent hernia of the abdominal wall are at risk for early postoperative hyperglycemia, which may serve as an early warning for delays in recovery and for adverse outcomes. OBJECTIVE: To evaluate postoperative serum glucose level as a predictor of outcome after open ventral hernia repair in patients with major medical comorbidities. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical record review of 172 consecutive patients who underwent open ventral hernia repair at Penn State Milton S. Hershey Medical Center, an academic tertiary referral center, from May 1, 2011, through November 30, 2013. We initially identified patients by medical complexity and repair requiring a length of stay of longer than 1 day. MAIN OUTCOMES AND MEASURES: Postoperative recovery variables, including time to the first solid meal, length of stay, total costs of hospitalization, and surgical site occurrence. RESULTS: Postoperative serum glucose values were available for 136 patients (79.1%), with 130 (95.6%) obtained within 48 hours of surgery. Among these patients, Ventral Hernia Working Group grade distributions included 8 patients with grade 1, 79 with grade 2, 41 with grade 3, and 8 with grade 4. Fifty-four patients (39.7%) had a postoperative glucose level of at least 140 mg/dL, and 69 patients (50.7%) required insulin administration. Both outcomes were associated with delays in the interval to the first solid meal (glucose level, ≥140 vs <140 mg/dL: mean [SD] delay, 6.4 [5.3] vs 5.6 [8.2] days; P = .01; ≥2 insulin events vs <2: 6.5 [5.5] vs 5.4 [8.4] days; P = .02); increased length of stay (glucose level, ≥140 vs <140 mg/dL: mean [SD], 8.0 [6.0] vs 6.9 [8.2] days; P = .008; ≥2 insulin events vs <2: 8.3 [6.1] vs 6.5 [8.4] days; P < .001); increased costs of hospitalization (glucose level, ≥140 vs <140 mg/dL: mean [SD], $31 307 [$20 875] vs $22 508 [$22 531]; P < .001; ≥2 insulin events vs <2: $31 943 [$22 224] vs $20 651 [$20 917]; P < .001); and possibly increased likelihood of surgical site occurrence (glucose level, ≥140 vs <140 mg/dL: 37.5% [21 of 56 patients] vs 22.5% [18 of 80 patients]; P = .06; ≥2 insulin events vs <2: 36.4% [24 of 66 patients] vs 21.4% [15 of 70 patients]; P = .06). Not all patients with diabetes mellitus developed postoperative hyperglycemia or needed more intense insulin therapy; however, 46.4% of the patients who developed postoperative hyperglycemia were not previously known to have diabetes mellitus, although most had at least 1 clinical risk factor for a prediabetic condition. CONCLUSIONS AND RELEVANCE: Postoperative hyperglycemia was associated with outcomes in patients in this study who underwent complex ventral hernia repair and may serve as a suitable target for screening, benchmarking, and intervention in patient groups with major comorbidities.

Prevalence of systemic inflammation and micronutrient imbalance in patients with complex abdominal hernias.

OBJECTIVE: To determine the prevalence of low-grade inflammation, micronutrient imbalances and associated clinical profiles in patients being evaluated for complex abdominal hernia repair. METHODS: Review of 127 consecutive adult patients for evaluation of complex ventral hernias from January 2012 to March 2013. Records were analyzed to determine the prevalence and correlations of clinical risk factors, attributes of hernias identified by computerized tomography, and laboratory indices of metabolism, inflammation and micronutrient imbalances. RESULTS: Strong correlations (p < 0.001) were established for body mass index (BMI) with volume of hernia content and C-reactive protein (CRP) level. CRP levels correlated strongly with red cell distribution width and inversely with zinc (p < 0.01). Evidence of micronutrient imbalance (abnormal zinc or red cell distribution width [RDW]) was observed in 48%. CONCLUSIONS: In this comorbidity-rich population with known variability in surgical outcomes, the prevalence of chronic inflammation and micronutrient deficiency are high enough to warrant systemic preoperative evaluation given their possible effect on wound healing and convalescence. Simple repletion is unlikely to improve outcomes without attention to the biological stresses that are associated with micronutrient imbalance.