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Background: The latissimus dorsi (LD) flap is a commonly used method for breast reconstruction after mastectomy. In this study, we present a long-term follow-up and effects of refining surgery on patient satisfaction and quality of life after breast reconstruction with the extended LD flap, using the BREAST-Q questionnaire., Objectives: The aim of this study was to investigate the patient-reported long-term results after breast reconstruction with the extended LD myocutaneous flap., Methods: A retrospective cohort study of adult patients ( n = 101) who were operated on using the extended LD flap for breast reconstruction at the Linköping University Hospital during 1997 to 2012 was made using data retrieved from medical records. The patients were asked to complete the BREAST-Q questionnaire at 2 different postoperative time points., Results: Eighty-three patients replied to the first questionnaire, and 56 patients also replied to the second. Mean follow-up was 11.7 years. Higher age and living together with someone correlated to higher BREAST-Q results, while postoperative infection, bilateral LD flaps, smoking, and prior breast surgery had a negative impact on the results. Overall BREAST-Q results increased over time. No independent effect of refining surgery could be shown., Conclusions: Patient satisfaction after breast reconstruction with the LD flap as measured with the BREAST-Q questionnaire is high and in line with other studies. The overall satisfaction with the reconstruction method seems to increase with time, but no further increase in satisfaction after refining surgery could be established., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Preclinical experiments show that an inflammatory reaction causes degradation of the endothelial glycocalyx layer and accelerated capillary leakage of albumin and fluid. The hypothesis in the present study was that elevated plasma concentrations of glycocalyx degradation products are associated with greater capillary leakage in humans., Methods: This open clinical trial involved administration of an intravenous infusion of 20% albumin at 3 mL/kg over 30 minutes to 15 postburn patients who showed an activated inflammatory response. Blood samples and urine were collected for 300 minutes. The plasma concentrations of 2 biomarkers of glycocalyx degradation-syndecan-1 and heparan sulfate-were measured at 0, 60, and 300 minutes and compared to the capillary leakage of albumin and fluid obtained by mass balance calculations and population kinetic analysis., Results: Patients were studied at 7 days (median) after a burn injury that covered 15% (maximum 48%) of the body surface area. The median plasma syndecan-1 concentration was 71 (25th-75th percentiles, 41-185) ng/mL. The 2 patients with highest values showed 2279 and 2395 ng/mL (normal 15 ng/mL). Heparan sulfate concentrations averaged 915 (673-1539) ng/mL. The infused amount of albumin was 57 (48-62) g, and 6.3 (5.1-7.7)% of that leaked from the plasma per hour.Linear correlation analysis of the relationship between the 10logarithm of the mean syndecan-1 and the albumin leakage showed a slope coefficient of -1.3 (95% confidence interval [CI], -3.6 to 1.0) and a correlation coefficient of -0.33 (P = .24). The kinetic analysis revealed that syndecan-1 served as a statistically significant covariate to the albumin leakage, but the relationship was inverse (power exponent -0.78, 95% CI, -1.50 to -0.05; P < .02). Heparan sulfate levels did not correlate with the capillary leakage of albumin or fluid in any of the analyses., Conclusions: A raised plasma concentration of syndecan-1 alone cannot be extrapolated to indicate increased capillary leakage of albumin and fluid., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 International Anesthesia Research Society.)

Background: Early treatment of severe hyperglycemia involves large shifts of body fluids that entail a risk of hemodynamic instability. We studied the feasibility of applying a new electrolyte equation that estimates the degree of volume depletion and the distribution of infused 0.9% saline in this setting., Methods: The new equation was applied to plasma and urinary concentrations of sodium and chloride measured before and 30 min after a 30-min infusion of 1 L of 0.9% saline on two consecutive days in 14 patients with severe hyperglycemia (mean age 50 years). The extracellular fluid (ECF) volume was also estimated based on the volume dilution kinetics of chloride., Results: On day 1, the baseline ECF volume amounted to 11.5 L. The saline infusion expanded the ECF space by 160 mL and the intracellular fluid space by 375 mL. On day 2, the ECF volume was 15.5 L, and twice as much of the infused fluid remained in the ECF space. The chloride dilution kinetics yielded baseline ECF volumes of 11.6 and 15.2 L on day 1 and day 2, respectively. No net uptake of glucose to the cells occurred during the two 1-h measurement periods despite insulin administration in the intervening time period., Conclusions: The electrolyte equation was feasible to apply in a group of hyperglycemic patients. The ECF space was 3 L smaller than expected on admission but normal on the second day. Almost half of the infused fluid was distributed intracellularly.

Background: The pectoralis major flap, which is usually harvested bilaterally, is considered a workhorse flap in the reconstruction of sternal defects. After a median sternotomy for open heart surgery, 1%-3% of patients develop deep infection and dehiscence of the sternal wound, some of which will eventually require reconstructive surgery. Our aim was to describe the clinical feasibility and associated complications of the unilateral pectoralis major advancement flap in the reconstruction of sternal defects., Methods: A retrospective analysis of all adult patients who were operated on using a unilateral pectoralis major flap for reconstruction of the chest wall at the Linköping University Hospital during 2008-18 was made using data retrieved from medical records., Results: Forty-three patients had reconstructions with unilateral pectoralis major flaps. Three flaps failed completely, and another 10 patients developed complications that required further operation. The factors that were independently associated with loss of the flaps and complications were: older age, male sex, the number of different antibiotics used, and a long duration of treatment with negative wound pressure. Fewer wound revisions before the reconstruction resulted in more complications. The factors that were independently associated with prolonged time to complete healing were emergency reoperation after the initial operation and complications after reconstruction., Conclusion: The unilateral pectoralis major advancement flap has proved to be a useful technique in the reconstruction of most sternal defects after sternal wound infection in older patients. There is, however, need for a follow-up study on a larger number of procedures to evaluate the long-term outcome compared with other methods of sternal reconstruction.

Background: Ringer's solution might be used to treat volume depletion (extracellular dehydration) and hemorrhage, but there is no integrated view of how these fluid balance disorders influence the kinetics of the infused volume., Methods: Acute dehydration (mean 1.7 L) was induced by repeated doses of furosemide (5 mg) in 10 healthy male volunteers, and 0.5 L and 0.9 L of blood was withdrawn in random order on different occasions in another 10 male volunteers, just before administration of Ringer's acetate solution. Infusions performed in the normovolemic state served as controls. Measurements of blood hemoglobin and urinary excretion were used to create volume kinetic profiles that were analyzed using mixed-effects modeling software., Results: Infusions over 15 to 30 min showed a marked distribution phase during which the plasma volume transiently increased by 50% to 75% of the administered volume. Dehydration and hemorrhage accelerated redistribution but retarded the elimination; the half-life of the infused fluid increased from 36 to 51 min (mean) from 1 L of dehydration and to 95 min from 1 L of hemorrhage. Extravascular accumulation decreased with the dehydration volume and increased with the hemorrhage volume.Simulations show that 60% as much Ringer is needed to replace volume depletion amounting to 1 L as compared with hemorrhage over a 2-h period. A continued but slower drip after the initial fluid resuscitation prevents rebound hypovolemia., Conclusions: Furosemide-induced dehydration and blood withdrawal in normotensive volunteers had modest effects on the Ringer's acetate kinetics. Urinary excretion was inhibited more by hemorrhage than by dehydration.

Aims: A population kinetic model was developed for the body fluid shifts occurring when 20% albumin is given by intravenous infusion. The aim was to study whether its efficacy to expand the plasma volume is impaired after major surgery., Methods: An intravenous infusion of 3 mL/kg 20% albumin over 30 minutes was given to 15 volunteers and to 15 patients on the 1 st day after major open abdominal surgery. Blood samples and urine were collected during 5 hours. Mixed-effect modelling software was used to develop a fluid volume kinetic model, using blood haemoglobin and urine excretion the estimate body fluid shifts, to which individual-specific covariates were added in sequence., Results: The rise in plasma albumin expanded the plasma volume in excess of the infused volume by relocating noncirculating fluid (rate constant k 21 ), but it also increased losses of fluid from the kinetic system (k b ). The balance between k 21 and k b maintained the rise in plasma albumin and plasma volume at a virtual steady-state for almost 2 hours. The rate constant for urinary excretion (k 10 ) was slightly reduced by the preceding surgery, by a marked rise in plasma albumin, and by a high preinfusion urinary concentration of creatinine. The arterial pressure, body weight, and plasma concentrations of C-reactive protein and shedding products of the endothelial glycocalyx layer (syndecan-1, heparan sulfate, and hyaluronic acid) did not serve as statistically significant covariates., Conclusions: There were no clinically relevant differences in the kinetics of 20% albumin between postoperative patients and volunteers., (© 2019 The British Pharmacological Society.)

Background: Reconstruction of complex defects in the lower leg is a challenge. Although microvascular free tissue transfer is a popular technique, experience and available resources limit its use. Furthermore, free tissue transfer is not always required in the reconstruction of small lower leg defects, as many of them can be reconstructed with local alternatives such as an extensor digitorum brevis flap (EDB). Our aim was to describe our experience of the last 20 years with the EDB as a local muscle flap to cover small complex lower leg defects to establish its clinical feasibility and to document its associated complications., Methods: All adult patients who were operated with EDB flap reconstruction of the lower limb during 1997-2017 at the Department of Hand and Plastic Surgery, Linköping University Hospital, were included in this retrospective study., Results: Of 64 patients operated, only 7 had total flap failure, and the rate of complete success was 73% (47/64). Most of the skin defects were associated with fractures or complications thereof and were located in the ankle region, the dorsum of the foot, and the distal third of tibia or even the proximal tibia. Defects in the malleolar region and coexisting cardiovascular condition were factors associated with flap loss (either partial or total)., Conclusion: The pedicled EDB-flap has, in our hands, proved to be a versatile and safe reconstructive option in the reconstruction of small defects in the lower leg and foot. Long-time follow-up is, however, recommended.

Background: Volume kinetic fluid turnover of three beverages was investigated for the purpose of estimating their rates of absorption and elimination as well as their maximum effect on the blood volume. The results were then used to simulate the effects of ingesting different combinations of these fluids., Method: Ten healthy volunteers ingested 0.5 L of tap water, lemonade (90 g/L carbohydrates) and isotonic saline (9 g/L) on different occasions. Venous blood samples for measurement of the blood haemoglobin (Hb), haematocrit and glucose concentrations were collected on 10 occasions over 2 h. A kinetic model based on haemoglobin dilution and urinary excretion was used to estimate the rate of absorption, the blood volume expansion over time, and the rate of elimination. Obtained kinetic data was used to simulate combinations of the three beverages in order to reach a predetermined goal of a 1:1 hydration of the blood volume and peripheral tissues over 6 h., Results: Tap water had the fastest absorption but primarily hydrated peripheral tissues. Maximum hydration was reached after 17 min. Lemonade effectively expanded the blood volume and was absorbed and excreted at a high rate. The maximum hydration from isotonic saline occurred 60 min after ingestion. Slow excretion could make it possible to use saline to prolong the effects of the other two beverages., Conclusions: It is possible to use the kinetic model to evaluate fluid turnover and compartmental distribution. Composition and timing of fluid intake can be calculated mathematically to meet predetermined goals of hydration and distribution., Trial Registration: NCT01360333 Date of registration: 05/23/2011.

Introduction: The turnover of Ringer´s solutions is greatly dependent on the physiological situation, such as the presence of dehydration or anaesthesia. The present study evaluates whether the kinetics is affected by previous infusion of colloid fluid., Methods: Ten male volunteers with a mean age of 22 years underwent three infusion experiments, on separate days and in random order. The experiments included 10 mL/kg of 6% hydroxyethyl starch 130/0.4 (Voluven™), 20 mL/kg of Ringer's acetate, and a combination of both, where Ringer´s was administered 75 minutes after the starch infusion ended. The kinetics of the volume expansion was analysed by non-linear least- squares regression, based on urinary excretion and serial measurement of blood haemoglobin concentration for up to 420 minutes., Results: The mean volume of distribution of the starch was 3.12 L which agreed well with the plasma volume (3.14 L) estimated by anthropometry. The volume expansion following the infusion of starch showed monoexponential elimination kinetics with a half-life of two hours. Two interaction effects were found when Ringer´s acetate was infused after the starch. First, there was a higher tendency for Ringer´s acetate to distribute to a peripheral compartment at the expense of the plasma volume expansion. The translocated amount of Ringer´s was 70% higher when HES had been infused earlier. Second, the elimination half-life of Ringer´s acetate was five times longer when administered after the starch (88 versus 497 minutes, P<0.02)., Conclusions: Starch promoted peripheral accumulation of the later infused Ringer´s acetate solution and markedly prolonged the elimination half-life., Trial Registration: ClinicalTrials.gov: NCT01195025.

Background: Patients admitted to surgery may be dehydrated, which is difficult to diagnose except when it is severe (>5% Gl116 of the body weight). We hypothesized that modest dehydration can be detected by kinetic analysis of the blood hemoglobin concentration after a bolus infusion of crystalloid fluid., Methods: Four series of experiments were performed on 10 conscious, healthy male volunteers. Separated by at least 2 days, they received 5 or 10 mL/kg acetated Ringer's solution over 15 minutes. Before starting half of the IV infusions, volume depletion amounting to 1.5 to 2.0 L (approximately 2% of body weight) was induced with furosemide. The elimination clearance and the half-life of the infused fluid were calculated based on blood hemoglobin over 120 minutes. The perfusion index and the pleth variability index were monitored by pulse oximetry after a change of body position., Results: Dehydration decreased the elimination clearance of acetated Ringer's solution [median (25th-75th percentile)] from 1.84 (1.23-2.57) to 0.53 (0.41-0.79) mL/kg/min (Wilcoxon matched-pair test P < 0.001) and increased the half-life from 23 (12-37) to 76 (57-101) minutes (P < 0.001). The smaller infusion, 5 mL/kg, fully discriminated between experiments performed in the euhydrated and dehydrated states, whereas the urinary excretion provided a less-reliable indication of hydration status. Dehydration decreased the perfusion index but did not affect the pleth variability index., Conclusion: Dehydration amounting to 2% of the body weight could be detected from the elimination clearance and the half-life of an infusion of 5 mL/kg Ringer's solution.

Aim: To contrast the effects of various modifications of body fluid volumes on thirst as reported by healthy volunteers., Methods: Ten male volunteers aged between 19 and 37 years (mean 22 years) underwent four experiments each, which comprised infusion of 400-800 mL of acetated Ringer's solution and intake of 600 mL of tap water. Half of the experiments were preceded by volume depletion (median 1.7 L) with furosemide. A visual analogue scale (0-100 mm) was used to assess perceived thirst during each experiment., Results: Volume depletion (P < 0.001) and tap water (P < 0.03) both affected thirst by 13 mm per L of fluid, whereas spontaneous diuresis and infusion of Ringer's acetate did not significantly change the thirst rating (multiple regressions). More detailed analyses showed that the volume depletion increased the median (25th-75th percentiles) thirst rating from 28 mm (21-43) to 59 mm (46-72, P < 0.001) while no change occurred in those who were only slightly thirsty (< 30 mm) before the volume depletion began. Ringer's solution alleviated thirst in those who were very thirsty, but tended to increase thirst in the volunteers who were not thirsty before the infusion. Similarly, hydration with tap water decreased thirst (by 24 mm, P < 0.04) in those who were thirsty (> 60 mm) while the others reported no change., Conclusion: The change in thirst rating during volume depletion, administration of Ringer's acetate, and ingestion of tap water were all dependent on the thirst rating obtained when the manipulation of the body fluid volume was initiated.

Background: Medical implants often fail as a result of so-called foreign body reactions during which inflammatory cells are recruited to implant surfaces. Despite the clinical importance of this phenomenon, the mechanisms involved in these reactions to biomedical implants in humans are not well understood. The results from animal studies suggest that both fibrinogen adsorption to the implant surface and histamine release by local mast cells are involved in biomaterial-mediated acute inflammatory responses. The purpose of this study was to test this hypothesis in humans., Methods: Thirteen male medical student volunteers (Caucasian, 21-30 years of age) were employed for this study. To assess the importance of fibrinogen adsorption, six volunteers were implanted with polyethylene teraphthalate disks pre-coated with their own (fibrinogen-containing) plasma or (fibrinogen-free) serum. To evaluate the importance of histamine, seven volunteers were implanted with uncoated disks with or without prior oral administration of histamine receptor antagonists. The acute inflammatory response was estimated 24 hours later by measuring the activities of implant-associated phagocyte-specific enzymes., Results: Plasma coated implants accumulated significantly more phagocytes than did serum coated implants and the recruited cells were predominantly macrophage/monocytes. Administration of both H1 and H2 histamine receptor antagonists greatly reduced the recruitment of macrophages/monocytes and neutrophils on implant surfaces., Conclusion: In humans--as in rodents--biomaterial-mediated inflammatory responses involve at least two crucial events: histamine-mediated phagocyte recruitment and phagocyte accumulation on implant surfaces engendered by spontaneously adsorbed host fibrinogen. Based on these results, we conclude that reducing fibrinogen:surface interactions should enhance biocompatibility and that administration of histamine receptor antagonists prior to, and shortly after, medical device implantation should improve the functionality and longevity of medical implants.