Plastic and Reconstructive Surgery

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding.

Therapeutic, V.

Lymphaticovenular anastomosis and lymphaticovenous implantation are the most popular lymphovenous shunt operations for the treatment of obstructive lymphedema. However, no study has been reported regarding direct comparison between lymphaticovenular anastomosis and lymphaticovenous implantation. This study aimed to compare postoperative patency of lymphaticovenular anastomosis and lymphaticovenous implantation using a rat model.

Twelve Wistar rats were used for the study. The rats were randomized into the lymphaticovenular anastomosis group (n= 6) or the lymphaticovenous implantation group (n= 6). In the lymphaticovenular anastomosis group, the largest femoral lymphatic vessel was anastomosed to a similar-size vein in an end-to-end intima-to-intima coaptation manner, and the other lymphatics were ligated. In the lymphaticovenous implantation group, the femoral lymphatic vessel and surrounding tissue were inserted into the short saphenous vein with a telescopic anastomosis technique. Patency was evaluated intraoperatively and 1 week postoperatively with patent blue dye and indocyanine green lymphography.

The mean diameters of the lymphatic vessels and the veins were 0.242 mm (range, 0.20 to 0.35 mm) and 0.471 mm (range, 0.30 to 0.75 mm), respectively. Intraoperative patency was 100 percent (six of six) in both groups (p= 1.000). Postoperative patency was significantly higher in the lymphaticovenular anastomosis group compared with the lymphaticovenous implantation group [100 percent (six of six) versus 33.3 percent (two of six);p= 0.014]

Postoperative patency of the lymphaticovenular anastomosis group was higher than that of the lymphaticovenous implantation group, although intraoperative patency rates of the lymphaticovenular anastomosis and lymphaticovenous implantation groups were comparable.

Các flap nguồn giáp chì đã cho thấy ứng dụng lâm sàng ngày càng tăng trong phẫu thuật tái tạo trong thập kỷ qua. Bài viết này làm nổi bật các sửa đổi flap và tính linh hoạt của chúng trong ứng dụng lâm sàng và quản lý các khuyết tật phức tạp.

Một nghiên cứu hồi cứu đã được thực hiện trên các bệnh nhân liên tiếp trải qua tái tạo flap giáp chì tại cơ sở của các tác giả từ tháng 1 năm 2012 đến tháng 12 năm 2014. Dữ liệu về nhân khẩu học của bệnh nhân, chỉ định, và chi tiết phẫu thuật cùng sau phẫu thuật được trích xuất.

Chiều dài của 42 flap giáp chì đã được thực hiện trên 36 bệnh nhân. Các chỉ định bao gồm u hắc tố ác tính (n = 14), sarcoma mô mềm (n = 12), các tình trạng bệnh lý lành tính (ví dụ, phần cứng bị lộ, dò giữa ruột cắt và da, hoại tử mô) (n = 6), và ung thư da không phải hắc tố (n = 4). Hai mươi tám phần trăm bệnh nhân nhận xạ trị tiền phẫu, và 70 phần trăm trong số đó là cho sarcoma. Có hai flap hỗ trợ khu vực tại chỗ được thực hiện trên tám bệnh nhân. Vùng màng sâu gần như hoàn toàn được thực hiện theo hướng vòng quanh trong 18 trong số 36 bệnh nhân (50 phần trăm), trong 92 phần trăm các tái tạo sarcoma, và chủ yếu nằm ở chi dưới. Kích thước khuyết tật trung bình là 215 cm² (từ 4 đến 1000 cm²). Kích thước khuyết tật trung bình là 474 cm² và 35.8 cm² sau khi loại bỏ sarcoma và u hắc tố ác tính, tương ứng. Kích thước flap trung bình là 344 cm² (từ 5 đến 1350 cm²). Chín mươi phần trăm các trường hợp có kích thước flap vượt quá tỷ lệ truyền thống 1:1. Không có mất flap hoặc hoại tử một phần nào. Thời gian trung bình để di chuyển được là 1.8 ngày, và thời gian nằm viện trung bình là 6.8 ngày.

Fatigue is inevitable at all stages of a surgical career. The sustained high degree of concentration required for surgery is complicated by long surgeon working hours and sleep deprivation, which force surgeons to learn to manage and mitigate the effects of physical and mental fatigue on their performance. Extensive evidence exists detailing the potentially dangerous effects of surgeon fatigue on patient safety, but few reports exist offering a comprehensive strategy to mitigate the effects of fatigue on clinical performance. To promote improved detection and mitigation of fatigue among surgeons, the authors have highlighted several deliberate fatigue-management techniques that they have found to be particularly effective in their own experiences. These techniques include proper planning to maximize team efficiency, and the use of scheduled and unscheduled intraoperative breaks for mental and physical rest and regeneration. The decision to take a much-needed break is often neglected because of concerns about prolonging the duration of an operation; with proper self-awareness of fatigue and brief mental checks during natural intraoperative slowdowns, however, the surgeon can quickly assess the need for a much-needed moment of recovery. The authors hope surgeons will find the fatigue-mitigation strategies presented here to be helpful in promoting both their own wellness and the safety and wellness of their patients.