Effect of Chemical Component Separation using Botulinum Toxin A injection for abdominal wall reconstruction in a Rat Hernia model

연구 목적 탈장은 개복 수술 이후 흔히 발생하는 부작용으로 발생율이 전체 복부 수술을 받은 환자의 10-28%에 도달하는 것으로 보고되고 있다. 만성 탈장 환자들은 복벽의 외측 근육의 섬유화와 단축화가 발생한다. 이를 해결하기 위해 Mechanical component separation을 시행하여 외복사근과 복직근의 물리적인 연결을 제거해주었으나, 광범위 박리가 필요하여 감염, 혈종, 장액종 등의 발생 가능성이 증가한다. Chemical component separation은 보툴리늄 독소 A를 외복사근과 내복사근에 주입하여 근육의 이완성 마비를 유도하는 방법이다. 본 연구의 목적은 chemical component separation의 과학적 근거를 랫드를 이용한 만성 탈장 모델을 통해 입증하는 것이다. 더 나아가 그 효과를 mechanical component separation 과 비교하고, 두가지 방법을 병행했을 때는 차이에 대한 과학적 근거를 구축하고자 한다. 연구 방법 총 30마리의 Lewis 랫드 (8주령)을 5군으로 나누었다. 1군 : 만성 탈장 모델에서 복직근의 봉합을 시행한 군 2군 : 만성 탈장 모델에서 chemical component separation 시행 후 복직근 봉합을 시행한 군 3군 : 만성 탈장 모델에서 chemical component separation 은 시행하지 않고 복직근 봉합시 mechanical component separation 을 병행한 군 4군 : 만성 탈장 모델에서 chemical component separation 시행 후 복직근 봉합시 mechanical component separation 을 병행한 군 5군 : 만성 탈장 생성 없이 각 수술에서 연부조직의 절개만 동일하게 시행한 군 1. 랫드의 만성 탈장 모델 생성 랫드의 복부에서 6x5cm 크기의 심부근막 바로 위를 따라 근막피부 피판을 거상 후 Linea alba에 5cm 길이의 절개를 시행하였다. Linea alba의 재건 없이 근막피부 피판을 Vicryl (polyglactin 910; Ethicon, Somerville, NJ, USA) 3-0 봉합사를 이용해 연속 봉합하였다. 2. 보톨리늄 독소 A 주입 4주간의 안정화 기간 후 2군과 4군 랫드에 보툴리늄 독소 A(Botulax®, Hugel Inc., Chuncheon, Korea)를 마리당 10 units씩 0.5 cc 멸균 생리 식염수(0.9% Sodium Chloride solution)에 희석하여 주입하였다. 1군과 3군의 랫드는 동일한 과정을 시행하되 보툴리늄 독소 A 주입없이 동일한 양의 생리 식염수만을 주입하였다. 3. 복벽 재건 수술 시행 재건에 앞서 복벽 결손 부위의 크기를 재측정 하였다. 또한 복직근을 봉합하기 위하여 필요한 장력을 스프링저울(Pesola, swiss, medio line 40300)을 이용하여 측정하였다. 1군과 2군에서는 복벽 재건을 위해 Vicryl Rapide (polyglactin 910; Ethicon, Somerville, NJ, USA) 4-0 봉합사를 이용하여 결손부위를 3등분하는 두 지점에서 단속 봉합을 시행하였다. 3군과 4군에서는 단속 봉합에 앞서 mechanical component separation을 시행하였다. 4. 복압 측정 재건 후 1주일이 되는 시점에서 복압을 측정하였다. 복압의 측정은 Whiteside et al. 에 의해 소개된 방법을 이용하여 측정하였다. 각 랫드별로 3회의 압력을 측정하였으며, 3회 측정값 중 중간값을 대표값으로 기록하였다. 5. 복벽 재건의 결과 비교 복벽 재건 이후 2주가 지나는 시점에서 이전의 절개를 통해 근막피부피판을 거상하였다. 탈장의 재발 지표로 탈장의 재발 여부, 탈장이 재발하였다면 재발한 탈장의 면적을 측정하였다. 6. 통계분석 그룹간 비교를 위해 비모수 검정법인 독립 K 표본(Kruskal-wallis test) 통계법을 사용하여 비교하였다. 독립 K 표본 검사에서 유의한 차이가 있을 경우에는 사후분석으로 독립 2 표본(Mann-Whitney U test)를 시행하였다. 결과 재건 직전 만성탈장의 결손부위 크기는 1군이 5.87±0.23 cm2, 2군이 3.99±0.32 cm2, 3군이 5.86±0.17 cm2, 4군이 4.00±0.43 cm2 이었다. 보툴리늄 독소 A를 주입한 군에서 통계적으로 유의하게 결손부위 크기가 감소하였다.(p=0.001) 복직근을 내측으로 1cm 당기는데 필요한 장력의 평균은 1군이 52.33±5.57 g, 2군이 22.33±3.26 g, 3군이 21.33±3.50 g, 4군이 9.00±2.10 g 이었으며 통계적으로 유의한 차이를 보였다. (p<0.001) 재건 수술 후 1주일 뒤 평가한 복압의 평균은 1군이 16.83±1.72 mmHg, 2군이 10.67±1.63 mmHg, 3군이 10.17±1.63 mmHg, 4군이 9.67±1.21 mmHg, 5군이 13.17±1.47 mmHg 이었고 이는 통계적으로 유의한 차이를 보였다.(p<0.001) 탈장이 재발한 비율은 1군에서 100% (6/6), 2군이 17% (1/6), 3군이 100% (6/6), 4군이 17% (1/6) 로 통계적으로 유의한 차이를 보였다.(p=0.001) 복벽 결손부위 면적의 평균은 1군이 4.52±1.39 cm2, 2군이 0.12±0.30 cm2, 3군이 2.40±0.87 cm2, 4군이 0.14±0.35 cm2 으로 통계적으로 유의한 차이를 보였다.(p<0.001) 결론 본 연구는 만성 탈장에서의 chemical component separation의 효과를 입증하기 위한 최초의 동물실험 연구로, 본 실험을 통해 chemical component separation은 구축된 가쪽 근육의 이완성 마비를 유도하여 결손부위의 크기를 줄이고, 복직근 간의 직접 봉합을 통한 재건을 가능하게 할 것으로 기대된다. 또한 탈장의 재발률을 감소시키고, 탈장이 발생하더라도 결손부위의 면적을 줄이는 것으로 확인되었다. 이러한 효과가 임상에서도 동일한 효과를 나타낼 수 있을지에 대한 추가적인 연구가 필요하다.Maste

Lymph Node to Vein Anastomosis (LNVA) for lower extremity lymphedema

Abstract The microsurgical options for lower limb lymphedema is a challenge. In search to improve the overall result, we hypothesized it would be beneficial to add the functioning lymph nodes to vein anastomosis (LNVA) in addition to lymphovenous anastomosis (LVA). This is a retrospective study of 160 unilateral stage II & III lower extremity lymphedema comparing the outcome between the LNVA + LVA group and the LVA only group from May 2013 to June 2018. MRI was used to identify the functioning lymph nodes. Patient outcome, including lower extremity circumference, body weight, bio impedance test, and other data were analyzed to evaluate whether lymph nodes to vein anastomosis (LNVA) improved outcome. The LNVA + LVA group showed significantly better results for circumference reduction rate, body weight reduction rate, and extracellular fluid reduction rate of the affected limb as compared to the LVA only group for both stage II and III lymphedema. The MRI imaging revealed that 9 cases had no identifiable lymph nodes of the affected limb and 54 cases with a nonfunctioning lymph node upon exploration despite positive imaging. Correlation showed the lymph node size needed to be at least 8 mm in the MRI to be functional. The LNVA + LVA approach for lymphedema has the benefit of better reduction as compared to LVA alone in the lower limb as well as the suprapubic region. Preoperative MRI will help to identify the functioning lymph node by increasing the overall probability of positive outcome

Patient-specific surgical options for breast cancer-related lymphedema: technical tips

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned

Long Pedicled Superficial Circumflex Iliac Artery Flap Based on a Medial Superficial Branch

Background: A superficial circumflex iliac artery perforator flap has several advantages, such as reduced thickness, minimal donor-site morbidity, and inconspicuous scar. However, the application of a superficial circumflex iliac artery perforator flap is restricted because of its limited pedicle length. The aim of this article was to outline the technical modifications of superficial circumflex iliac artery perforator flap elevation to obtain long pedicles. Methods: This is a prospective study of 31 consecutive patients who required a long pedicled superficial circumflex iliac artery perforator flap between September of 2016 and December of 2019 at the authors' center. According to a preoperatively marked pathway of the superficial branch of the superficial circumflex iliac artery, the superficial circumflex iliac artery perforator flap was designed. During the elevation, the design was modified according to the perforator location in the free-style technique. The characteristics of the patients and the flaps, including pedicle length, were recorded. The revision rate, complication rate, and need for a secondary procedure were analyzed. Results: The mean follow-up period was 563 days (range, 92 to 1383 days). The mean length of the pedicle obtained was 6.9 cm (range, 6 to 8 cm) from the point where the pedicle merges into the flap. Long pedicles were anastomosed to the main source vessel or branch without tension. No major complications were reported. Conclusions: Overcoming the short pedicle length of a superficial circumflex iliac artery perforator flap by designing the flap laterally and performing an intraflap dissection is a reliable option when a longer pedicle is required, irrespective of the specific anatomy of the superficial circumflex iliac artery

Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients

Background Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. Methods Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. Results Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. Conclusion TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results