Microsurgery最新文献

Background: There is limited data regarding the surgical outcomes of urosymphyseal fistula (USF) repair with primary repair or autologous tissue transfer. We performed a study to compare outcomes of USF repair with primary repair, VRAM flap, and omental flap.

Methods: We retrospectively identified patients with a diagnosis of USF who underwent fistula decompression and urinary tract reconstruction. The minimal follow-up was 3 months. Patients with distal urethral obstruction, radiation cystitis, or a non-viable sphincter underwent anterior exenteration and flap transfer.

Results: Fifty-six patients were included. Eleven patients underwent surgical management for USF using primary repair (19.6%), 34 had omental flap-based reconstruction (60.8%), and a VRAM flap was used in 11 patients (19.6%). The 90-day rate of sepsis was lower with omentum flap transposition (3%) compared with VRAM flap (27%) or primary repair (18%, p = 0.041). The rate of fistula recurrence was lower in the omentum flap group compared with USF primary repair (30%) or VRAM flap repair group (27.3%, p = 0.04). On multivariable analysis, USF repair with the omentum flap decreased the odds of fistula recurrence 90 days after surgery compared with primary repair (OR 0.012, p = 0.011) but not when compared with VRAM.

Conclusion: The omentum flap may offer a better safety profile in terms of decreasing the rate of early sepsis and rate of fistula recurrence for USF repair in comparison to primary repair. There is limited evidence regarding the superiority of the omentum flap to decrease the rate of late fistula recurrence when compared with the VRAM flap.

Lymphovenous anastomosis (LVA) is a cornerstone of physiologic lymphedema surgery. Its success, however, depends on the presence of a functional lymphatic vessel and a suitable reflux-free recipient vein in close proximity. In some cases, anatomical limitations make direct LVA impossible. In these situations, interposition of a vein graft may bridge the anatomical gap and allow completion of a functional bypass. In this case report, we present a case of a 58-year-old woman with secondary left upper-limb lymphedema following mastectomy, axillary lymphadenectomy, and autologous breast reconstruction. Preoperative indocyanine green (ICG) lymphography showed functional lymphatic channels, and LVA was planned. After an initial unsuccessful attempt on the dorsal wrist, a second incision on the volar forearm revealed a suitable lymphatic vessel and superficial vein, allowing an end-to-end anastomosis. Persistent retrograde lymphatic flow led to the creation of a second bypass using a short autologous vein graft, with an end-to-end anastomosis to the lymphatic vessel and an end-to-side anastomosis to the recipient vein. Intraoperative ICG confirmed that both LVAs were patent. The postoperative course was uneventful. At 1-year follow-up, the patient showed a clear reduction in limb swelling, subjective improvement, and less need for compression garments. This case report adds insight demonstrating that an interposition vein graft can enable successful LVA in anatomically challenging situations where a direct lymphaticovenous connection is not feasible. Vein graft-assisted LVA may expand the applicability of supermicrosurgery for lymphedema, though long-term data and larger series are needed to validate its durability and clinical efficacy.

Introduction: Pedicled latissimus dorsi flap (PLDF) and gracilis free flap (GFF) are techniques for restoration of elbow flexion after brachial plexus injuries with late presentation or poor outcomes following nerve surgery, as well as after traumatic or oncological loss of arm flexor muscles. The aim of this study is to compare the results of both techniques.

Material and methods: A systematic review was conducted following PRISMA guidelines, including articles providing information on the maximum degrees of elbow flexion or flexion strength according to the MRC scale. Outcomes were synthesized through single-arm meta-analyses using random-effects models, with indirect comparisons between PLDF and GFF performed using Z-tests. Study quality was appraised with MINORS and JBI tools, and publication bias was assessed using funnel plots and Egger's test.

Results: Forty-seven studies comprising 814 patients were included: 19 on PLDF (n = 122) and 28 on GFF (n = 692). PLDF achieved a higher mean elbow flexion angle (119.2°; 95% CI 112.5°-125.9°) compared to GFF (91.4°; 95% CI 82.9°-99.9°), a difference that was statistically significant. Likewise, mean muscle strength was greater with PLDF (MRC 3.85; 95% CI 3.61-4.09) than with GFF (MRC 2.95; 95% CI 2.72-3.18). In terms of functional thresholds, 95% of patients in the PLDF group achieved at least MRC ≥ 3 and 87% reached ≥ 4, whereas in the GFF group the corresponding rates were 72% and 65%. Heterogeneity across studies was moderate but consistent with the direction of effect.

Conclusion: PLDF was associated with higher pooled flexion angles and strength values than GFF; however, due to the absence of direct comparative studies, these findings should be interpreted as comparative trends rather than evidence of superiority.

Background: Xylazine is a veterinary sedative that is added to illicit fentanyl to enhance its effects. Xylazine-associated wounds differ from those found in patients who inject other drugs. They are larger and frequently involve deeper structures, such as bone. The outcomes of reconstruction using free tissue transfer are not well understood.

Methods: All consecutive free flap reconstructions of xylazine-associated wounds at a tertiary care center in the northeast US between January 2021 and December 2024 were retrospectively reviewed. Data were stored in a HIPAA-compliant REDCap database.

Results: Eleven free flap reconstructions were performed among 10 patients. Median age was 34 years (IQR: 31-38), all were White, 20% were Hispanic, and 90% were female. Median BMI was 20.9 (IQR: 19.9-39.3). Comorbidities included HCV (70%) and active tobacco smoking (60%). Wounds were located on the neck (9.1%), chest (18.2%), upper extremity (45.5%), and hand (27.3%). 81.8% presented with exposed bone. Median debridements were two (IQR 1-3). Free flaps included: four anterolateral thigh (36.4%), three gracilis (27.3%), one rectus abdominis (9.1%), one scapular (9.1%), one latissimus dorsi (9.1%), and one lateral arm (9.1%) flap. Two patients were discharged against medical advice (18.2%). Median follow-up was 364 days (IQR: 287-710). All flaps were viable at 3 weeks. Roughly half of patients (45.5%) continued to use injection drugs after reconstruction. Early complications included: one venous congestion requiring exploration and one partial flap dehiscence. Late complications included two surgical site infections and two wound recurrences due to continued xylazine use resulting in trans-humeral amputation (40% of those who continued to inject drugs).

Conclusion: Free tissue transfer can effectively reconstruct xylazine-associated wounds and is necessary for limb salvage in patients with exposed bone. All flaps were viable at 3 weeks. Late wound recurrence due to continued xylazine use is associated with poor outcomes, including amputation. Abstinence from injection drug use is critical to optimizing the chances of recovery, and a multidisciplinary approach is essential.

Purpose: Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects.

Methods: We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review.

Results: Six patients with eight MVFFs were included. Five were adults and one was a child; four were females and two were males. All defects were located on the posterior trunk/buttocks. Flap types included four standard latissimus dorsi (LD), three anterolateral thigh (ALT), and one extended conjoined LD flap. Average skin paddle size was 232 cm² (±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases.

Conclusions: Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.