Therapeutic, IV.

No abstract

reast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare lymphoma associated with long-term placement of textured breast implants. [1][2][3][4] The first case of BIA-ALCL was reported in 1997 5 and, until recently, this disease process was poorly described. There have been approximately 600 to 700 documented cases worldwide, and because of the rarity of the disease, the National Comprehensive Cancer Network did not release staging guidelines until 2017 6 (most recently updated in 2019). BIA-ALCL has been the subject of avid research in plastic surgery, oncology, immunology, and cellular biology, in addition to governmental regulation; internationally, 38 countries have banned or restricted sale of Allergan Biocell (Allergan, Inc., Dublin, Ireland) textured expanders because of concern of BIA-ALCL.

We study the problem of zero-order optimization of a strongly convex function. The goal is to find the minimizer of the function by a sequential exploration of its values, under measurement noise. We study the impact of higher order smoothness properties of the function on the optimization error and on the cumulative regret. To solve this problem we consider a randomized approximation of the projected gradient descent algorithm. The gradient is estimated by a randomized procedure involving two function evaluations and a smoothing kernel. We derive upper bounds for this algorithm both in the constrained and unconstrained settings and prove minimax lower bounds for any sequential search method. Our results imply that the zero-order algorithm is nearly optimal in terms of sample complexity and the problem parameters. Based on this algorithm, we also propose an estimator of the minimum value of the function achieving almost sharp oracle behavior. We compare our results with the state-of-the-art, highlighting a number of key improvements.

Background: Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas. Methods: A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed. Results: A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment. Conclusions: Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background and Objectives Standard treatment for extremity sarcoma is limb‐sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time. Methods We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi‐modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss. Results There were 159 thigh reconstructions followed for 30 months on average. Eighty‐seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant. Conclusions Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

The course of patient described in this case report is typically: patient reports an intermittent remission of the symptoms, intraoral examination may reveal dental restorations and periodontal diseases, but the clinician should keep in mind that even the tooth involved can appear healthy. Some authors claim that extra-oral fistulas are more common in the children and adolescents because the teeth are not yet fully erupted and the alveolar processes is not fully developed and so roots are more deeply seated. 6-10 However, most case reports available in the literature are predominantly of adults and thus do not support this theory.Odontogenic cutaneous fistula typically arises from periapical infections around the root apices as a result of pulpal necrosis due to penetrant caries or traumatic injury. Routine tests used to locate the involved teeth include pulp sensitivity tests and radiographic analysis. In the clinical case described here, the radiographies clearly revealed pericoronaritis and boneless which the cause of suppuration and fistula. [11][12][13] As far as definitive treatment is concerned, root canal or surgical extraction is the treatment of choice. After surgical treatment of the pathogenic tooth the fistula often heals without furthers intervention by 14 days. Healing occurs by secondary intention and occasionally a residual scar may be persist after a few months. In these cases, surgery may be indicated to improve aesthetics. In this case report we have preferred to have surgical excision in order to speed up the healing process.In conclusion, a dental etiology must always be considered for any cutaneous fistula in the head or in the neck region. 2,3,13 -16 Elimination of the dental source of infection results in resolution of the fistula and the healing of the fistula is expected within 5 to 14 days. In case with of restorable teeth, even just the elimination of the infection through endodontic treatment leads to resolution of the fistula. 2,8,17 The case here described is particular because the fistula was caused by a pericoronaritis and not by a dental necrosis. The pericoronaritis started from the third molar, whose existence was ignored, in an old edentulous woman. This case teaches that clinicians should always look for odontogenic causes of cutaneous fistula, even though they seem unlikely.

Background Gastrointestinal-to-genitourinary fistulas may occur secondary to obstetric complications, radiation therapy, cancer without radiation, inflammatory bowel disease, or previous surgery. Flap reconstruction is useful for complex cases refractory to standard techniques, separating the fistula tracts to aid healing. The purpose of this study was to investigate outcomes and risk factors for complications in flap reconstruction of fistulas from several different etiologies performed over a 20-year period. Methods All patients who underwent flap reconstruction between January 1995 and December 2014 were reviewed. Patient demographics, prior treatment failures, surgical indications, and comorbidities were obtained. Operative and postoperative data were collected, including flap type, length of stay, early and late complications, recurrences, and follow-up time. Operative success was defined as definitive treatment of the fistula without recurrence within 6 months. Results There were 59 patients who underwent 66 reconstructions. The overall complication rate was 59.1%. Complications included infection (21%), dehiscence (17%), and partial flap loss (1.5%). Operative success rate was 51.5%. Smoking history (p = 0.021) and body mass index (BMI) > 35 (p = 0.003) were significantly associated with increased likelihood of postoperative complications following flap reconstruction in these patients. Additionally, fistulas due to cancer resections had a higher likelihood of postoperative complications compared with fistulas due to bowel disease or obstetric complications (p = 0.04). Conclusion Flap reconstruction can be successfully used for complex or refractory gastrointestinal-to-genitourinary fistulas. However, considerable complication and recurrence rates were found in this population. Patients with a BMI > 35 and a history of smoking were at greatest risk in this cohort of experiencing postoperative complications.