External tissue expansion to salvage failed scalp and forehead reconstruction: a case report.

The reconstruction of forehead and scalp defects is a difficult task. Common reconstructive methods are associated with multiple complications and may fail, requiring a difficult second surgery. We present the use of external tissue expansion as a method to achieve effective closure of a failed scalp and forehead reconstruction.

Phrenic nerve paralysis and phrenic nerve reconstruction surgery.

Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.

Phrenic Nerve Reconstruction for Effective Surgical Treatment of Diaphragmatic Paralysis.

ABSTRACT: Diaphragmatic paralysis due to phrenic nerve injury may cause orthopnea, exertional dyspnea, and sleep-disordered breathing. Phrenic nerve reconstruction may relieve symptoms and improve respiratory function. A retrospective review of 400 consecutive patients undergoing phrenic nerve reconstruction for diaphragmatic paralysis at 2 tertiary treatment centers was performed between 2007 and 2019. Symptomatic patients were identified, and the diagnosis was confirmed on radiographic evaluations. Assessment parameters included pulmonary spirometry (forced expiratory volume in 1 second and FVC), maximal inspiratory pressure, compound muscle action potentials, diaphragm thickness, chest fluoroscopy, and Short Form 36 Health Survey Questionnaire (SF-36) survey. There were 81 females and 319 males with an average age of 54 years (range, 19-79 years). The mean duration from diagnosis to surgery was 29 months (range, 1-320 months). The most common etiologies were acute or chronic injury (29%), interscalene nerve block (17%), and cardiothoracic surgery (15%). The mean improvements in forced expiratory volume in 1 second and FVC at 1 year were 10% (P < 0.01) and 8% (P < 0.05), respectively. At 2-year follow-up, the corresponding values were 22% (P < 0.05) and 18% (P < 0.05), respectively. Improvement on chest fluoroscopy was demonstrated in 63% and 71% of patients at 1 and 2-year follow-up, respectively. There was a 20% (P < 0.01) improvement in maximal inspiratory pressure, and compound muscle action potentials increased by 82% (P < 0.001). Diaphragm thickness demonstrated a 27% (P < 0.01) increase, and SF-36 revealed a 59% (P < 0.001) improvement in physical functioning. Symptomatic diaphragmatic paralysis should be considered for surgical treatment. Phrenic nerve reconstruction can achieve symptomatic relief and improve respiratory function. Increasing spirometry and improvements on Sniff from 1 to 2 years support incremental recovery with longer follow-up.

Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers.

OBJECTIVES: Bilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction. METHODS: Patients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database. RESULTS: Fourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side. CONCLUSIONS: PR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.

Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned?

BACKGROUND: Bariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes. METHODS: All laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions. RESULTS: A total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period. CONCLUSIONS: The surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others.

H. Pylori in a gastric schwannoma: a case report.

Schwannomas are benign, often asymptomatic, slow-growing tumors that originate from Schwann cells of the neural sheath. Although H. Pylori has been associated with gastric adenocarcinoma, there has never been a recorded association with schwannoma formation. We present a 64-year-old woman who underwent a laparoscopic partial wedge gastrectomy for an incidentally discovered gastric mass. Histologic examination was consistent with schwannoma; however, chronic inflammation with microorganisms morphologically consistent with H. Pylori was also present. This case suggests the first recorded case of H. Pylori in an immunohistochemically confirmed gastric schwannoma.

Nitric oxide levels regulate the immune response of Drosophila melanogaster reference laboratory strains to bacterial infections.

Studies on the innate immune response against microbial infections in Drosophila melanogaster involve mutant strains and their reference strains that act as experimental controls. We used five standard D. melanogaster laboratory reference strains (Oregon R, w1118, Canton-S, Cinnabar Brown, and Yellow White [YW]) and investigated their response against two pathogenic bacteria (Photorhabdus luminescens and Enterococcus faecalis) and two nonpathogenic bacteria (Escherichia coli and Micrococcus luteus). We detected high sensitivity among YW flies to bacterial infections and increased bacterial growth compared to the other strains. We also found variation in the transcription of certain antimicrobial peptide genes among strains, with Oregon and YW infected flies showing the highest and lowest gene transcription levels in most cases. We show that Oregon and w1118 flies possess more circulating hemocytes and higher levels of phenoloxidase activity than the other strains upon infection with the nonpathogenic bacteria. We further observed reduced fat accumulation in YW flies infected with the pathogenic bacteria, which suggests a possible decline in physiological condition. Finally, we found that nitrite levels are significantly lower in infected and uninfected YW flies compared to w1118 flies and that nitric oxide synthase mutant flies in YW background are more susceptible to bacterial infection compared to mutants in w1118 background. Therefore, increased sensitivity of YW flies to bacterial infections can be partly attributed to lower levels of nitric oxide. Such studies will significantly contribute toward a better understanding of the genetic variation between D. melanogaster reference strains.