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Intraoperative indocyanine green fluorescent angiography-assisted modified superior gluteal artery perforator flap for reconstruction of sacral pressure sores: ICG-assisted modified SGAP flap for sacral pressure sore
International Wound Journal
Abstract
Pressure sores are often observed in patients who are bedridden. They can be a severe problem not only for patients and their caregivers but also for plastic surgeons. Here, we describe a new method of superior gluteal artery perforator flap harvesting and anchoring with the assistance of intraoperative indocyanine green fluorescent angiography. In this report, we describe the procedure and outcomes for 19 patients with grades III and IV sacral pressure sores who underwent the operation between September 2015 and November 2016. All flaps survived, and two experienced wound-edge partial dehiscence. With the assistance of this imaging device, we were able to acquire a reliable superior gluteal artery perforator flap and perform modified operations with it that are safe, easy to learn and associated with fewer complications than are traditional.
... Several different kinds of flaps have been introduced over the years to reconstruct sacral defects, such as local flaps, V-Y advancement fasciocutaneous flaps, gluteus maximum muscle-based flaps, inferior gluteal artery perforator flaps, and superior gluteal artery perforator (SGAP) flaps [1]. Reliable perforators are the most important factors for a successful perforator-based flaps reconstruction [2]. Thus, an accurate preoperative mapping of the perforators is essential for the safe planning of propeller flaps. ...
... Thus, an accurate preoperative mapping of the perforators is essential for the safe planning of propeller flaps. To date, various methods have been reported: (1) handheld acoustic Doppler sonography (ADS), (2) color duplex sonography, (3) perforator computed tomographic angiography (P-CTA), (4) magnetic resonance angiography, and (5) indocyanine green fluorescence nearinfrared angiography (ICGFA) [3,4]. Out of these ways of mapping perforators, the golden standards are perforator computed tomographic angiography (P-CTA) and the magnetic resonance angiograph. ...
Aims: Pressure injury is a gradually increasing disease in the aging society. The reconstruction of a pressure ulcer requires a patient and surgical technique. The patients were exposed to the radiation risk under other ways of detection of perforators such as computed tomographic angiography and magnetic resonance angiography. Here, we compared two radiation-free methods of a superior gluteal artery perforator (SGAP), flap harvesting and anchoring. One is the traditional method of detecting only handheld acoustic Doppler sonography (ADS) (Group 1). The other involves the assistance of intraoperative indocyanine green fluorescent near-infrared angiography (ICGFA) and handheld ADS (Group 2). Materials and Methods: This is a single-center, retrospective, observational study that included patients with sacral pressure injury grades III and IV, who had undergone reconstructive surgery with an SGAP flap between January 2019 and January 2021. Two detection methods were used intraoperatively. The main outcome measures included the operative time, estimated blood loss, major perforator detection numbers, wound condition, and incidence of complications. Results: Sixteen patients underwent an SGAP flap reconstruction. All patients were diagnosed with grade III to IV sacral pressure injury after a series of examinations. Group 1 included 8 patients with a mean operative time of 91 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 4. Postoperative complications included one wound infection in one case and wound edge dehiscence in one case. No mortality was associated with this procedure. The mean total hospital stay was 16 days. Group 2 included 8 patients with a mean operative time of 107.5 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 5. Postoperative complications included one wound infection. No mortality was associated with this procedure. The mean total hospital stay was 13 days. Conclusions: The combination of detection of the SGAP by ICGFA and handheld ADS for the reconstruction of a sacral pressure injury provides a more accurate method and provides the advantage of being radiation-free.
... A study of smokers and patients with comorbidities including obesity showed that ICG angiography decreased the risk of skin flap necrosis following mastectomy [14]. A retrospective study demonstrated the efficiency of harvesting superior gluteal artery perforator (SGAP) flaps with ICG angiography, which detected superior gluteal artery perforators for the flap design and thus ensured adequate vascularity [15]. These flaps survived beyond six months with no major complications [15]. ...
... A retrospective study demonstrated the efficiency of harvesting superior gluteal artery perforator (SGAP) flaps with ICG angiography, which detected superior gluteal artery perforators for the flap design and thus ensured adequate vascularity [15]. These flaps survived beyond six months with no major complications [15]. A cadaveric study showed that ICG angiography allowed for the harvesting of a more favorable gracilis myofasciocutaneous flap, in which taking adjacent deep fascia increased the probability of a viable skin paddle [16]. ...
Indocyanine green (ICG) angiography is a procedure that uses a fluorescent dye for a variety of medical diagnostics, including the real-time examination of blood flow in tissue. Herein, we report a case in which ICG angiography was used to assess the viability of a sternocleidomastoid (SCM) muscle flap during post-parotidectomy facial reconstruction. To our knowledge, this is the first report documenting the intraoperative use of ICG for the evaluation of SCM flap perfusion. ICG angiography may prove beneficial for cases involving complex reconstructions and suspected organ hypoperfusion.
... All patients were admitted by or had consulted with a single plastic surgeon who specializes in pressure sores. [6][7][8][9][10] Patients and their families were well informed of the operative risks, and they all agreed with the proposed treatment. All reconstructive strategies were guided by our treatment protocol (Fig. 1). ...
... Kalamazoo, MI, USA) on pALT and SGAP flaps. [7] Using ICG angiography we could identify the compromised area and resect it simultaneously during surgery (Fig. 6). This helped avoid secondary revision of the flap. ...
With aging, pressure ulcers become a common health problem causing significant morbidity and mortality for physically limited or bedridden elderly persons. Here, we present our strategy for such patients. Between August 2010 and March 2019, 117 patients were enrolled. Patient age, etiology, defect size and location, flap reconstruction, outcome, and follow-up period were reviewed. Of these patients, 64 were female and 53 were male, with an age range of 21 to 96 years (mean 75.6). The mean area of defect was 61.5 cm. The most common etiology was dementia (33.3%), and ulcers were most frequently caused by sacral pressure (70.3%). The commonest surgical treatment was a V-Y advancement flap (50%). The complication rate was 27.5%, including dehiscence and late recurrence. Negative pressure wound therapy could be used if the initial defect was large. V-Y advancement flap is the most frequent surgical treatment for sacral pressure ulcers because it is simple and available for most types of defect. Primary closure may be considered as the simplest method if the defective area is <16 cm. Intraoperative indocyanine green angiography can help avoid secondary flap revisions. Our protocol ensures a short surgery time, little bleeding, and a low complication rate.
... In another study, Kaneko et al. examined the effect of ICG in human hepatocarcinoma cells (HuH-7 and HepG2 cell line), demonstrating that the NIR could penetrate the deeper parts of the tumor [136]. The penetration depth was reported from 10 mm to several centimeters [128,146,147]. Moreover, the major portion of the absorbed light (~88%) is converted to heat under PTT and singlet oxygen generation via PDT elicits cancer cell destruction [137]. ...
... Unilateral revascularization procedures using ICG (Figure 8a(iii)) significantly reflected the increase/decrease of perfusion in the treated/contralateral limb and reduction in the contralateral foot circulation [84]. With the help of intraoperative ICG fluorescence angiography, Chang et al. described a method of a superior gluteal artery perforator flap that was safer, easier, and had fewer complications [43,85,147]. ...
In recent times, photo-induced therapeutics have attracted enormous interest from researchers due to such attractive properties as preferential localization, excellent tissue penetration, high therapeutic efficacy, and minimal invasiveness, among others. Numerous photosensitizers have been considered in combination with light to realize significant progress in therapeutics. Along this line, indocyanine green (ICG), a Food and Drug Administration (FDA)-approved near-infrared (NIR, >750 nm) fluorescent dye, has been utilized in various biomedical applications such as drug delivery, imaging, and diagnosis, due to its attractive physicochemical properties, high sensitivity, and better imaging view field. However, ICG still suffers from certain limitations for its utilization as a molecular imaging probe in vivo, such as concentration-dependent aggregation, poor in vitro aqueous stability and photodegradation due to various physicochemical attributes. To overcome these limitations, much research has been dedicated to engineering numerous multifunctional polymeric composites for potential biomedical applications. In this review, we aim to discuss ICG-encapsulated polymeric nanoconstructs, which are of particular interest in various biomedical applications. First, we emphasize some attractive properties of ICG (including physicochemical characteristics, optical properties, metabolic features, and other aspects) and some of its current limitations. Next, we aim to provide a comprehensive overview highlighting recent reports on various polymeric nanoparticles that carry ICG for light-induced therapeutics with a set of examples. Finally, we summarize with perspectives highlighting the significant outcome, and current challenges of these nanocomposites.
... Various flaps, such as the gluteus maximus myocutaneous flap designed in a V-Y pattern or rotation fashion, exist for sacral-pressure ulcer reconstruction [1,3,30,31]. Recently, the perforator flap has played an important role in reconstructions because of lower donor-site morbidity and free rotational arc [2,[32][33][34][35]. For a single flap, the reported maximum reconstruction area for SGAP flaps can reach 12 × 14 cm [2], whereas it can reach 12 × 12 cm for bilateral gluteus maximus myocutaneous V-Y advancement flaps [1]. ...
Background: In this study, we aimed to analyze the clinical efficacy of closed-incision negative pressure wound therapy (CiNPWT) when combined with primary closure (PC) in a patient with pressure ulcers, based on one single surgeon’s experience at our medical center. Methods: We retrospectively reviewed the data of patients with stage III or IV pressure ulcers who underwent reconstruction surgery. Patient characteristics, including age, sex, cause and location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, application of CiNPWT to reconstructed wounds, duration of hospital stay, and wound complications were analyzed. Results: Operation time (38.16 ± 14.02 vs. 84.73 ± 48.55 min) and duration of hospitalization (36.78 ± 26.92 vs. 56.70 ± 58.43 days) were shorter in the PC + CiNPWT group than in the traditional group. The frequency of debridement (2.13 ± 0.98 vs. 2.76 ± 2.20 times) was also lower in the PC + CiNPWT group than in the traditional group. The average reconstructed wound size did not significantly differ between the groups (63.47 ± 42.70 vs. 62.85 ± 49.94 cm²), and there were no significant differences in wound healing (81.25% vs. 75.38%), minor complications (18.75% vs. 21.54%), major complications (0% vs. 3.85%), or mortality (6.25% vs. 10.00%) between the groups. Conclusions: Our findings indicate that PC combined with CiNPWT represents an alternative reconstruction option for patients with pressure ulcers, especially in those for whom prolonged anesthesia is unsuitable.
... 5,6 A perforator vascular flap raised on the buttocks was first reported by Koshima et al 7 in 1993, and it addressed the deficiencies of gluteus maximus myocutaneous flaps. Currently, the perforator vascular flap is increasingly being used to repair sacral wounds 8,9 ; however, the operation is complicated, and it is still difficult to repair large bedsores. We have modified the perforator vascular flap and designed the clover-style fasciocutaneous perforator flap for the repair of massive sacral pressure sores. ...
Background:
As a common complication of the long-term bedridden patients, pressure sore is a great challenge for surgeons. The purpose of this study was to explore the surgical method of using a clover-style fasciocutaneous perforator flap raised on the buttocks for the treatment of massive sacral pressure sores and report the clinical outcomes.
Methods:
The study included 15 patients from January 2015 to June 2017 with an average age of 52.87 years (range, 32-73 years). The size of the sacral pressure sores ranged from 10 cm × 13 cm to 18 cm × 20 cm. The defects were reconstructed using a fasciocutaneous perforator flap raised on the buttocks after debridement and vacuum sealing drainage treatment for 1 to 2 weeks. All the donor areas were sutured directly.
Results:
All flaps survived completely; 13 patients achieved healing by primary intention, and the other 2 patients achieved healing by secondary intention. At the mean follow-up period of 20.8 months (range, 12-46 months), the appearance of the flap, including its texture and color, in all patients was satisfactory. No patients had deep infection, necrosis, or shrinkage of the flap during the follow-up period. One patient had a recurrent bedsore during the 2-year follow-up.
Conclusions:
The clover-style fasciocutaneous perforator flap is ideal for the reconstruction of massive sacral pressure sores because it is a relatively simple procedure and results in good appearance and function, few complications, and a low recurrence rate.
... Our previous studies showed that a modified SGAP flap with less dissection of the perforator and assistance of intraoperative indocyanine green fluorescent angiography provides a shorter operative time and lesser bleeding, which make the SGAP flaps an excellent choice for sacral sore coverage. 11,12 As a result, in sacrum pressure sore management, we preferred to utilise V-Y advancement flap for a smaller defect and SGAP for a larger defect. In ischium pressure sores, the defect is usually deep, and delayed primary closure often leads to high recurrence and complication rates. ...
Pressure sores remain a common health problem, particularly among the physically limited or bedridden elderly, and can cause significant morbidity and mortality. This study aimed to present our surgical treatment and strategy for patients with multiple pressure sores. Between January 2010 and December 2016, 18 patients were enrolled. After adequate debridement, pressure sores were managed based on our treatment protocol. Patients' age, aetiology, defect size and location, flap reconstruction, outcome, and follow‐up period were reviewed. A total of 10 men and 8 women (average age, 82.3 years) with a mean follow‐up period of 28.3 months (6‐72 months) were included. The mean defect area was 63.7 cm². The most common aetiology of the bedridden state was cerebrovascular accident (38.89%), and the most frequent sores were trochanteric pressure sores (53.57%). The average operative time and blood loss were 105.5 minutes and 100.8 mL, respectively. No haemodynamic variation or blood transfusion was noted during the surgery. The complication rate for each sore was 10.7%, including late recurrence. In conclusion, treating pressure ulcers requires careful patient education, intensive multidisciplinary optimisation, and meticulous wound care, and our treatment protocol ensures a shorter surgery time, less bleeding, and low complication rate.
... Additional resources are needed to identify, prevent, and treat pressure injuries. Emerging technologies such as infrared spectroscopy tissue oxygen saturation assessments [19], indocyanine green fluorescence imaging (ICG-FI) [20], infrared thermal imagery analysis [21], three-dimensional ultrasound pressure injury [22] in conjunction with accountability and quality care interventions such as frequent weight shifts, proper skin cleaning and turning routines will decrease the amount of unnecessary patient pain and suffering. ...
Introduction:
Pressure sores are agonizing complications of chronically bedridden patients. The management of these lesions particularly with respect to grades III and IV lesions are chiefly surgical and involves a multidisciplinary approach. Although there are a variety of local flap options, like fasciocutaneous flaps, musculocutaneous flaps, perforator flaps, and combinations of these to choose from, there is a paucity of literature regarding which flap is better among these in terms of complication and recurrence rates.
Methods:
The databases searched were as follows: Cochrane Central Register of Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to August of 2020). Key words used were "pressure ulcer," "flaps," "surgery," "pressure sore" with limits, "human," and "English." Primary outcomes were "overall complication rates" and "recurrence rates." Overall complication was further categorized as flap necrosis, flap dehiscence, infection, and others.
Results:
Thirty-nine articles were included in the final analysis. There was a statistically significant difference among the various types of flaps for overall complication, flap dehiscence, infection, flap necrosis, and recurrence rates.
Conclusions:
Our study indicates that musculocutaneous flaps have lower recurrence rates, and combined flaps have lower complication rates. However, various other factors, like donor site morbidity, initial defect size, operating time, intraoperative blood loss, salvage options in case of recurrence, should also be considered while choosing a flap to reconstruct a defect.
The sacral area is the most common site of pressure sore in bed-ridden patients. Though many treatment methods have been proposed, a musculocutaneous flap using the gluteus muscles or a fasciocutaneous flap is the most popular surgical option. Here, we propose a new method that combines the benefits of these 2 methods: combined V-Y fasciocutaneous advancement and gluteus maximus muscle rotational flaps. A retrospective review was performed for 13 patients who underwent this new procedure from March 2011 to December 2013. Patients’ age, sex, accompanying diseases, follow-up duration, surgical details, complications, and recurrence were documented. Computed tomography was performed postoperatively at 2 to 4 weeks and again at 4 to 6 months to identify the thickness and volume of the rotational muscle portion. After surgery, all patients healed within 1 month; 3 patients experienced minor complications. The average follow-up period was 13.6 months, during which time 1 patient had a recurrence (recurrence rate, 7.7%). Average thickness of the rotated muscle was 9.43 mm at 2 to 4 weeks postoperatively and 9.22 mm at 4 to 6 months postoperatively (
p
=
0.087
). Muscle thickness had not decreased, and muscle volume was relatively maintained. This modified method is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little muscle donor-site morbidity.
Indocyanine green can selectively accumulate in primary hepatocellular carcinoma (HCC) and extrahepatic metastases. We report a patient who underwent resection of pulmonary metastasis of HCC using a thoracoscopic near-infrared imaging system and fluorescent navigation surgery. A 66-year-old man with suspicion of pulmonary metastasis of HCC was referred to our hospital. Indocyanine green was injected intravenously at a dose of 0.5 mg/kg body weight, 20 h before thoracoscopic surgery. An endoscopic indocyanine green near-infrared fluorescence imaging system showed clear blue fluorescence, indicating pulmonary metastasis of HCC in a lingular segment. We performed wide wedge resection using the fluorescence image for navigation to confirm the surgical margins. The specimen was histologically confirmed as a pulmonary metastasis of HCC. In conclusion, thoracoscopic indocyanine green near-infrared fluorescence imaging for pulmonary metastases of HCC is useful in identifying tumor locations and ensuring resection margins.
Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.
The purpose of this paper is to report the use of the superior gluteal artery perforator (SGAP) flap in the closure of sacral pressure sores here in Singapore. This fasciocutaneous flap is a refinement of the musculocutaneous flap which is popularly used for the closure of sacral sores. There were minimal complications. This is a reliable flap and gives the option of further reconstructive possibilities should a recurrence occur.
Treating patients with multiple pressure ulcers is a very challenging task for physicians. However, there are very few reports on treatment protocols for multiple pressure ulcers and treatment outcomes. The authors have consistently treated multiple pressure ulcers in a one-stage operation rather than a staged operation. We evaluated multiple pressure ulcers patients who underwent a one-stage operation from 2007 to 2014. A comparison was made between 20 patients who underwent a one-stage operation on 44 foci and 68 patients with a single focus. Though the results, we could conclude that one-stage operation of multiple pressure ulcers was found to have a shorter recovery period and shorter hospitalization without a significant increase in complications.
Background:
The superior gluteal artery perforator (SGAP) flap is a useful technique for breast reconstruction. This perforator flap allows for the transfer of the patient's own skin and subcutaneous tissue with minimal donor-site morbidity. Despite its usefulness, the SGAP flap is not widely used among reconstructive surgeons. The challenging perforator dissection and need for microsurgery may contribute to the reluctant use of the flap by many reconstructive surgeons. The ability to perform a single-stage breast reconstruction with buttock tissue when abdominal or thigh tissue are unavailable provides a significant service to the patient desiring an autologous breast reconstruction.
Methods:
The authors performed a retrospective review and outcomes analysis of a single surgeon's surgical technique and experience. Consecutive patients, who underwent SGAP flaps for breast reconstruction during a 7-year period from 2007 to 2014, were compared to a matched cohort of consecutive patients undergoing deep inferior epigastric perforator (DIEP) flaps and clinical outcomes were analyzed.
Results:
Thirteen patients underwent SGAP flap breast reconstruction for a total of 16 flaps during the study period compared to 34 consecutive DIEP flaps for breast reconstruction. There was no significant difference in flap or donor-site complications between the 2 groups. There was no statistically significant difference between the average operative time for unilateral breast reconstruction in the SGAP and DIEP flap groups. In 4 patients, a bipedicled SGAP flap was used due to perforator anatomy. All SGAP patients returned to full activity. Average follow-up time was 1 year.
Conclusions:
Although utilization of buttock tissue for breast reconstruction can be challenging and requires microsurgical expertise, in the hands of experienced microsurgeons the SGAP flap is a safe and reliable option for autologous breast reconstruction with minimal donor-site morbidity and excellent aesthetic results.
Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon. The flap from the gluteal crease derives blood supply from the inferior gluteal artery perforator (IGAP) and reliably preserves the entire contralateral side as a donor site. To incorporate the IGAP in the reconstruction of sacral pressure ulcers, a skin paddle over the gluteal crease was created and implemented by the authors. Data from 11 patients (8 men, 3 women; mean age 67 [range 44-85] years old) whose sacral ulcers were closed with an IGAP flap between June 2006 and May 2012 were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of carbon monoxide intoxication was referred from a local clinic, 2 patients had Parkinson's disease, and 8 patients had a history of stroke. The average defect size was 120 cm2 (range 88-144 cm2). The average flap size was 85.8 cm2 (range 56-121 cm2). Only 1 flap failure occurred during surgery and was converted into V-Y advancement flap; 10 of the 11 flaps survived. After surgery, the patients' position was changed every 2 hours; patients remained prone or on their side for approximately 2 weeks until the flap was healed. After healing was confirmed, patients were discharged. Complications were relatively minor and included 1 donor site wound dehiscence that required wound reapproximation. No surgeryrelated mortality was noted; the longest follow-up period was 24 months. In this case series, flaps from the gluteal crease were successfully used for surgical closure of sacral pressure ulcers. This flap design should be used with caution in patients with hip contractures. Studies with larger sample sizes are needed to ascertain which type of flap is best suited to surgically manage extensive pressure ulcers in a variety of patient populations.
A gluteal perforator-based flap employing the gluteus maximus muscle perforators located around the sacrum is described. A cadaveric study disclosed the existence of several significant perforators all around the gluteal region. Among these, the parasacral perforators originating from the internal pudendal artery and lateral sacral artery have proven useful for the repair of sacral pressure sores. A total of eight decubitus in seven patients were treated with gluteal perforator-based flaps. There were no postoperative complications, such as flap necrosis and wound infection, with the exception of fistula formation in one case. This flap requires no transection or sacrifice of the gluteus maximus muscle, and elevation time for the flap is short. However, the perforators are located at various sites and thus require some careful dissection. (C)1993American Society of Plastic Surgeons
Object:
To avoid disorientation during endoscopic endonasal transsphenoidal surgery (ETSS), the confirmation of anatomical landmarks is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MR images. On Doppler ultrasonography the shape of concealed arteries and veins cannot be visualized. To address these problems, the authors evaluated the clinical usefulness of the indocyanine green (ICG) endoscope.
Methods:
The authors included 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), chordomas (n = 2), Rathke's cleft cyst (n = 1), dermoid cyst (n = 1), or fibrous dysplasia (n = 1). After opening the sphenoid sinus and placing the ICG endoscope, the authors injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary.
Results:
The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The intercavernous and cavernous sinuses were visualized a few seconds later. In patients with tuberculum sellae meningiomas, the abnormal tumor arteries in the dura were seen and the vague outline of the attachment was identified. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time.
Conclusions:
The ICA and the patent cavernous sinus were detected with the ICG endoscope in real time and at high resolution. The ICG endoscope is very useful during ETSS. The authors suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function.
We investigated the feasibility and validity of intraoperative fluorescence imaging using indocyanine green for the detection of sentinel lymph nodes and lymphatic vessels during open prostatectomy.
Indocyanine green was injected into the prostate under guidance of transrectal ultrasound just prior to surgery. Intraoperative fluorescence imaging was performed using a near-infrared camera system in 66 consecutive patients with clinically localized prostate cancer after a ten-patient pilot test to optimize indocyanine green dosing, observation timing, and injection method. Lymphatic vessels were visualized and followed to identify the sentinel lymph nodes. Confirmatory pelvic lymph node dissection including all fluorescent nodes and open radical prostatectomy were performed in all patients.
Lymphatic vessels were successfully visualized in 65 patients (98%), and sentinel lymph nodes in 64 patients (97%). Sentinel lymph nodes were located in the obturator fossa, internal and external iliac regions, and rarely in the common iliac and presacral regions. Median of 4 sentinel lymph nodes per patient were detected. Three lymphatic pathways, the paravesical, internal and lateral routes were identified. Pathological examination revealed metastases to 9 sentinel lymph nodes in 6 patients (9%). All pathologically positive lymph nodes were detected as sentinel lymph nodes using this imaging. No adverse reactions due to use of indocyanine green were observed.
Intraoperative fluorescence imaging using indocyanine green during open prostatectomy enables the detection of lymphatic vessels and sentinel lymph nodes with high sensitivity. This novel method is technically feasible, safe, and easy to apply with minimal additional operative time.
Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
In this study, the histological and vital effects of rotation on multiple and single based perforator flaps were evaluated. A 6 cm × 6 cm abdominal perforator flap model was used on 80 male rats; half of these received a single-pedicled flap, and the other half double-pedicled. The flaps of control subgroups were raised and sutured without rotation. In rotation subgroups 90-, 180-, 270-degree rotations were performed, and rotation effects on flap viability and histological changes were analyzed. Among single- and double-pedicled perforator flaps, respectively, mean survival area was 12.59 cm2 and 27.84 cm2 in non-rotated subgroups, 12.49 cm2 and 17.06 cm2 in 90-degree rotation subgroups, 5.96 cm2 and 9.96 cm2 in 180-degree rotation subgroups, and 1.45 cm2 and 1.70 cm2 in 270-degree rotation subgroups. While survival areas of double- and single-pedicled perforator flaps with the same rotation degree showed no statistically significant difference, non-rotated double-pedicled perforator flaps had a statistically larger survival area compared to single-pedicled perforator flap (P = 0.001). In the single-pedicled flap group, there were no statistical differences between survival flap areas of the non-rotated subgroup and the 90- and 180-degree rotation subgroups (P > 0.05), but the non-rotated subgroup had a statistically larger survival area compared to the 270-degree rotation subgroup (P = 0.003). In double-pedicled perforator flap group, the control subgroup had a statistically larger flap survival area compared to 90-degree, 180-degree, and 270-degree rotation subgroups (P = 0.004, P = 0.002, P = 0.001). Degenerative histological changes gradually increased in correlation with the rotation angle in both single- and double-pedicled groups. When double- and single-pedicled groups were compared; degenerative histology score displayed no statistical difference between control subgroups and rotated subgroups (P > 0.05). In this rat abdominal propeller perforator flap model, we found that double perforators without pedicle rotation could support larger flap survival when compared to the single pedicle. However, double perforators did not cause an increase of survival area when pedicles were rotated. In the single-pedicled perforator flap, the flap survival area did not significantly decrease until 180-degree pedicle rotation. In the double-pedicled perforator flap, the flap survival area decreased when the degree of rotation increased. The degenerative changes increased in correlation with the rotation degree in both single- and double-pedicled perforator flaps. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.
After studying this article, the participant should be able to: 1. Cite risk factors for pressure sore development. 2. Detail the pathophysiology of pressure sores. 3. List the types and classification of pressure sores. 4. Consider the various nonsurgical conservative wound management strategies. 5. Describe the appropriate surgical interventions for each pressure sore type. 6. Understand the causes of recurrent pressure sores and methods of avoiding recurrence.
Pressure sores are the result of unrelieved pressure, usually over a bony prominence. With an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of $11 billion, pressure sores represent a costly and labor-intensive challenge to the health care system. A comprehensive team approach can address both prevention and treatment of these recalcitrant wounds. Consideration must be given to the patient's medical and socioeconomic condition, as these factors are significantly related to outcomes. Mechanical prophylaxis, nutritional optimization, treatment of underlying infection, and spasm control are essential in management. A variety of pressure sore patterns exist, with surgical approaches directed to maximize future coverage options. A comprehensive approach is detailed in this article to provide the reader with the range of treatment options available.
We describe the use of a large skin-subcutaneous tissue flap based on one perforator of the superior gluteal artery (SGA) to reconstruct large midline posterior defects in one stage. The integrity of the gluteus muscles is preserved and we feel this is particularly important in non-paralysed patients. Donor sites were always closed primarily. Use of the superior gluteal artery perforator (SGAP) flap preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We recommend this flap in an area where reconstructive possibilities are limited, as it preserves other reconstructive flap options, both on the ipsilateral and contralateral sides.
Four grades of pressure can be recognized on the basis of pathophysiology of soft tissue breakdown overlying bony prominences. Management is correlated with the extent of the lesion and ranges from local wound care, turning and systemic support for Grade I and II, to local and radical excision with soft tissue flap closure for the more extensive Grades III and IV.
The practice of multiple-stage management in the treatment of patients with multiple pressure ulcers has long represented the standard of care in many specialty centers. The authors have observed that an aggressive surgical approach has proved necessary for control of this devastating problem in these patients. Their experience with one-stage reconstruction of multiple pressure sores over a 10-year period (between 1986 and 1996) in 120 spinal cord-injured patients has revealed certain advantages of this comprehensive method of surgical management. Although cumulative operating time and intraoperative blood loss were somewhat increased, the number of anesthetic episodes and the hospital stay were less than that seen in patients managed in multiple stages. Accordingly, rehabilitation and societal reintegration can be initiated earlier, and overall hospital cost may be better contained.
The gluteal artery perforator free flap represents the state of the art in autogenous breast reconstruction for the patient with insufficient abdominal donor tissue. Preservation of the gluteal musculature limits morbidity and allows for rapid patient recovery. The need for intraoperative repositioning has historically limited gluteal artery perforator flap breast reconstruction to one breast per operation. This results from a desire to avoid marathon surgical times when the flaps are dissected out sequentially and/or having the patient lie on the first reconstructed breast as the second flap is harvested. Prior protocols have relied on staging the reconstructions weeks apart to address these concerns. This is a significant issue for patients requiring bilateral mastectomy and results in the patient being subjected to two major sequential operations and their associated recoveries.
The authors describe their experience and associated technical considerations with an initial 20 patients (40 flaps).
The average operative time was 7 hours 47 minutes (excluding mastectomy). There were no vascular complications and no flap failures.
Bilateral simultaneous gluteal artery perforator flap breast reconstruction may be performed safely with reproducible success and a complication rate that is comparable to that of other commonly performed autogenous tissue techniques. This report represents the largest described experience to date and the first dedicated treatise on a protocol that provides significant advantages and an option that has heretofore been unavailable to this group of patients.
Perforator flaps have allowed reconstruction of soft-tissue defects throughout the body. The superior and inferior gluteal artery perforator flaps have been used clinically, yet the published anatomical studies describing the blood supply to the gluteal skin are inadequate. This study comprehensively evaluated the anatomical basis of these flaps to present anatomical landmarks to facilitate flap dissection.
In six fresh cadavers, the integument of the gluteal region was dissected. Cutaneous perforators of the superior and inferior gluteal arteries were identified. Their course, size, location, and type (septocutaneous versus musculocutaneous) were recorded based on dissection, angiography, and photography. The surface areas of cutaneous territories and perforator zones were measured and calculated.
The average number of superior and inferior cutaneous perforators greater than or equal to 0.5 mm in the gluteal region was 5 +/- 2 and 8 +/- 4, respectively, with all of the superior and 99 percent of the inferior gluteal artery perforators being musculocutaneous. Their average perforator internal diameter was 0.6 +/- 0.1 mm. The average superior and inferior gluteal artery cutaneous vascular territory was 69 +/- 56 cm and 177 +/- 38 cm, respectively. The superior gluteal perforators were found adjacent to the medial two-thirds of a line drawn from the posterior superior iliac spine to the greater trochanter. The inferior gluteal artery perforators were concentrated along a line in the middle third of the gluteal region above the gluteal crease.
The reliable size and consistency of the superior and inferior gluteal artery perforators allow the use of pedicled and free superior and inferior gluteal artery perforator flaps in a variety of clinical situations.
Evidence-based medicine: pressure sores
- C A Cushing
- L G Phillips
Cushing CA, Phillips LG. Evidence-based medicine: pressure sores.
Plastic Reconstr Surg 2013;132:1720-32.