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Sharma McCleary posted an update 6 months, 3 weeks ago
Using ASGE guidelines, 230 (22.1 %), 678 (65.1 %), and 134 (12.9 %) met high, intermediate, and low likelihood criteria, respectively. Specificity and positive predictive value (PPV) of ASGE high likelihood criteria were 96.87 % (95 % confidence interval 95.37 - 97.98) and 89.57 % (95 %CI 85.20 - 92.75) for choledocholithiasis compared with 98.96 % (95 %CI 97.95 - 99.55) and 96.24 % (95 %CI 92.76 - 98.09), respectively, for ESGE criteria. ASGE classified 17 (7.4 %) additional patients as high likelihood compared with ESGE, only one of whom had choledocholithiasis. ASGE classified 58 (8.6 %) additional patients as intermediate, none of whom had choledocholithiasis. A-438079 CONCLUSION This study validates the clinical utility of new ESGE and ASGE criteria for predicting choledocholithiasis. ESGE risk stratification appears more specific than ASGE. © Georg Thieme Verlag KG Stuttgart · New York.BACKGROUND Anastomotic couplers expedite venous microvascular anastomoses and have been established as an equivalent alternative to hand-sewn anastomoses. However, complications unique to the coupler such as palpability and extrusion can occur. The purpose of this study was to perform a systematic review of the literature to assess complications distinct to the venous anastomotic coupler. METHODS A Medline, PubMed, EBSCO host search of articles involving anastomotic venous couplers was performed. Studies involving arterial anastomotic couplers, end-to-side anastomoses, and reviews were excluded. Data points of interest were flap failure, venous thrombosis, hematoma, partial flap necrosis, infection, coupler extrusion, and coupler palpability. RESULTS The search identified 165 articles; 41 of these met inclusion criteria. A total of 8,246 patients underwent 8,955 venous-coupled anastomoses. Combined reoperation rate was 3.3% and all-cause unsalvageable flap failure was 1.0%. Complications requiring reoperation included venous thrombosis (2.0%), hematoma (0.4%), partial flap necrosis (0.4%), and infection (0.3%). Eight patients had palpable couplers and 11 patients had extrusion of couplers (head/neck, hand, and feet) and required operative management. CONCLUSION Venous couplers remain an equivalent alternative to conventional hand-sewn anastomosis. However, venous coupler extrusion and palpability in the late postoperative period is a complication unique to anastomotic couplers, particularly in radiated head and neck, feet and hand free flaps. Removing extruded venous couplers is safe after tissue integration 3 weeks postoperatively. Coupler palpability and extrusion should be integrated into preoperative patient counseling and assessed in follow-up examinations. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.BACKGROUND The deep inferior epigastric perforator (DIEP) flap is the most common perforator flap for microsurgical breast reconstruction. Contrary to the conventional open approach, robotic-assisted DIEP flap harvest intends to preserve ARS integrity, thereby reducing the morbidity. We assessed the feasibility and compared performance outcomes of a robotic, cadaveric training model for DIEP flap harvest using two approaches transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). METHODS A robotics system (da Vinci Xi) was applied in conjunction with a cadaveric training model. Ports were placed in the abdominal wall to triangulate each DIEP flap. Surgical time and technical characteristics were recorded. Values were analyzed and compared. RESULTS Eight female cadavers (16 hemi-DIEP flaps) were dissected 50% TAPP and 50% TEP approaches. Mean harvest time was 56 minutes (range 48-74 minutes) and 65 minutes (range 60-83 minutes) for TAPP versus TEP groups, respectively (p 0.05). Intra-abdominal contents were manipulated twice on average in the TAPP group versus 0 times in the TEP group (p less then 0.05). One TAPP case had an injury to the bowel, and one TEP case was converted to conventional open due to pneumoperitoneum. CONCLUSION Robotic-assisted DIEP flap harvest represents a technological enhancement for advanced regenerative plastic surgery. Our model demonstrated both TAPP and TEP are feasible, with TEP less invasive, preserving the posterior rectus sheath, and decreasing complication risks. However, there is a steeper and longer learning curve for TEP. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Systemic mastocytosis (SM) has greatly benefited from the broad application of precision medicine techniques to hematolymphoid neoplasms. Sensitive detection of the recurrent KIT D816V mutation and use of next generation sequencing (NGS) panels to profile the genetic landscape of SM variants have been critical adjuncts to the diagnosis of SM, subclassification of SM, and development of clinical-molecular prognostic scoring systems. Multilineage KIT involvement and multi-mutated clones are characteristic of advanced SM, especially SM with an associated hematologic neoplasm (SM-AHN). A major challenge is how to integrate conventional markers of mast cell disease burden (percent bone marrow mast cell infiltration, serum tryptase levels) with molecular data (e.g. serial monitoring of both KIT D816V variant allele frequency and NGS panels) to lend more diagnostic and prognostic clarity to the heterogeneous clinical presentations and natural histories of advanced SM. The approval of the multikinase / KIT inhibitor midostaurin has validated the paradigm of KIT inhibition in advanced SM, while the efficacy and safety of 2nd generation agents, such as the switch-control inhibitor ripretinib (DCC-2618) and the D816V-selective inhibitor avapritinib (BLU-285) are being further defined in ongoing clinical trials. Looking forward, perhaps the most fruitful marriage of the advances in molecular genetics and treatment will be the design of adaptive basket trials that combine histopathology and genetic profiling to individualize treatment approaches for patients with diverse AHNs and relapsed/refractory SM. Copyright © 2020 American Society of Hematology.