Volume 134, Number 1 • Letters Reply: Salvage of Infected Left Ventricular Assist Device with Antibiotic Beads Sir:
Professor Viroj Wiwanitkit presents an excellent discussion of studies that will improve our understanding of efficacy and safety of antibiotic beads. These include both local and systemic effects of antibiotics on tissues of the body, and the method for optimum use of antibiotic beads. With respect to antibiotic safety, all precautions that are taken with systemic antibiotics should be taken with antibiotic beads. As the professor points out, antibiotic hypersensitivity1 and antibiotic toxicity have been reported with use of antibiotic beads,2,3 whereas others have reported use without toxicity.4 As studies emerge with the use of antibiotic beads in vascular and cardiothoracic patients, often with multiple comorbidities and organ dysfunction, our understanding of the systemic consequences of their use can be better delineated. In addition, animal studies may also enable elucidation of local effects of high-dose local antibiotic therapy. Lastly, as the author mentions, there is no universally acceptable number of bead exchanges required for infection treatment.5 Empirically, cultures taken at the time of débridement drive both the type of antibiotics used and the number of débridements/exchanges needed to achieve a sterile wound before coverage.5,6 DOI: 10.1097/PRS.0000000000000270
Shayan A. Izaddoost, M.D., Ph.D. Larry H. Hollier, Jr., M.D. Division of Plastic Surgery Baylor College of Medicine Houston, Texas Correspondence to Dr. Hollier 6701 Fannin Street, Suite 610.00 Houston, Texas 77030
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Song EK, Seon JK, Jeong MS. Delayed-type hypersensitivity reaction to piperacillin/tazobactam in a patient with an infected total knee replacement. J Bone Joint Surg Br. 2010;92:1596–1599. 2. Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother. 2006;40:2037–2042. 3. Dovas S, Liakopoulos V, Papatheodorou L, et al. Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol. 2008;69:207–212. 4. Mounasamy V, Fulco P, Desai P, Adelaar R, Bearman G. The successful use of vancomycin-impregnated cement beads in a patient with vancomycin systemic toxicity: A case report with review of literature. Eur J Orthop Surg Traumatol. 2013;23(Suppl 2):S299–S302. 5. Stone PA, Armstrong PA, Bandyk DF, et al. Use of antibioticloaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections. J Vasc Surg. 2006;44:757–761.
6. Stone PA, Mousa AY, Hass SM, et al. Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections. J Vasc Surg. 2012;55:1706–1711.
A Comparison of Vascularized Cervical Lymph Node Transfer with and without Modified Charles’ Procedure for the Treatment of Lower Limb Lymphedema Sir:
W
e read with interest the article by Althubaiti et al.1 in a recent issue of the Journal. We agree that the use of physiologic methods of surgical management of lymphedema, such as vascularized lymph node transfer2 and lymphaticovenular anastomosis,3 are gaining popularity and are the way forward. Unfortunately, the intermediate- and long-term results of such procedures are still lacking at this time. Based on the senior author’s yet unpublished data, the reduction of lymphedema in advanced cases where only vascularized lymph node transfer is performed is usually incomplete, and requires additional excisional procedures for significant symptomatic relief. We present a case of bilateral lower limb lymphedema of 20 years’ duration occurring in a 51-yearold woman who was injured in a road traffic accident 30 years previously and was treated conservatively for contusion. Her preoperative circumferential measurements were 55.0, 44.0, 37.0, and 26.0 cm at the right midthigh, midleg, ankle, and midfoot, respectively; and 50.0, 42.0, 32.0, and 24.0 on the left side, respectively (Fig. 1, left). Lymphoscintigraphy showed bilateral lower limb tracer uptake delay (Fig. 2). She initially underwent free vascularized lymph node transfer to the right ankle from the transverse cervical lymph node chain. One year after the first operation, her circumference measurements were 52.0, 42.0, 36.0, and 26.0 cm for the right side and 49.0, 41.0, 31.0, and 24.0 cm for the left side (Fig. 1, second from left). Because the patient desired further improvement than what was attained on the right side, she agreed to proceed with vascularized lymph node transfer from the left supraclavicular region to the left ankle and a modified Charles procedure concurrently to the left lower limb. She was followed up at 2 years after vascularized lymph node transfer on the right lower limb (also 1 year after vascularized lymph node transfer with the modified Charles procedure on the left lower limb). Her limb circumference measurements were 46.8, 42.8, 26.2, and 24.2 cm for the right and 35.2, 32.1, 21.0, and 25.6 cm for the left (Fig. 1, second from right and right). Because of superior symptomatic relief of the left lower limb compared with the right, she prefers the result on the left over that on the right despite the more extensive scar, and is awaiting a modified Charles procedure to the right lower limb (in addition to the previous lymph node transfer). This is a unique case in which a patient gave consent for different procedures on each lower limb, and allows us to make a direct comparison of the
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Plastic and Reconstructive Surgery • July 2014
Fig. 1. (Left) Preoperative photograph of the patient. (Second from left) Photograph of the patient 1 year after vascularized lymph node transfer to the right ankle. (Second from right and right) Photographs of the patient 2 years after vascularized lymph node transfer to the right ankle and 1 year after vascularized lymph node transfer and a modified Charles procedure to the left lower limb.
Matthew Sze-Wei Yeo, F.A.M.S.(Plast.), M.R.C.S.Ed. Seong Yoon Lim, M.D. Kidakorn Kiranantawat, M.D. Pedro Ciudad, M.D. Hung-Chi Chen, M.D., Ph.D. Department of Plastic Surgery China Medical University Hospital Taichung, Taiwan Correspondence to Dr. Chen Department of Plastic Surgery China Medical University Hospital 2 Yuh-Der Road Taichung 40447, Taiwan [email protected] Fig. 2. The first two images (left and second from left) were taken 30 minutes after injection of contrast, and the next two (second from right and right) were taken at 2 hours after injection, and demonstrate delayed uptake of contrast.
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES
postoperative result of the respective procedures, because the patient serves as her own control. Based on the result obtained from vascularized lymph node transfer alone,4 the authors recommend that excision surgery, such as a modified Charles procedure, should be performed concurrently for optimal results in advanced cases of lymphedema. This is based on our experience of 30 cases of combined vascularized lymph node transfer and modified Charles procedure, which shows promising result for advanced lymphedema, and will be presented in a separate article in the near future. DOI: 10.1097/PRS.0000000000000295
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1. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013; 131:133e–135e. 2. Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. (in press). 3. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg. 2003;19:209–215. 4. Feng GM, Yang WG, Huang CH, Wang SY, Chen HC. Lymph node transfer for treating mild to moderate limb lymphedema: A preliminary result. J Plast Surg Assoc ROC 2003;12:95–104.
Professor Viroj Wiwanitkit presents an excellent discussion of studies that will improve our understanding of efficacy and safety of antibiotic beads. These include both local and systemic effects of antibiotics on tissues of the body, and the method for optimum use of antibiotic beads. With respect to antibiotic safety, all precautions that are taken with systemic antibiotics should be taken with antibiotic beads. As the professor points out, antibiotic hypersensitivity1 and antibiotic toxicity have been reported with use of antibiotic beads,2,3 whereas others have reported use without toxicity.4 As studies emerge with the use of antibiotic beads in vascular and cardiothoracic patients, often with multiple comorbidities and organ dysfunction, our understanding of the systemic consequences of their use can be better delineated. In addition, animal studies may also enable elucidation of local effects of high-dose local antibiotic therapy. Lastly, as the author mentions, there is no universally acceptable number of bead exchanges required for infection treatment.5 Empirically, cultures taken at the time of débridement drive both the type of antibiotics used and the number of débridements/exchanges needed to achieve a sterile wound before coverage.5,6 DOI: 10.1097/PRS.0000000000000270
Shayan A. Izaddoost, M.D., Ph.D. Larry H. Hollier, Jr., M.D. Division of Plastic Surgery Baylor College of Medicine Houston, Texas Correspondence to Dr. Hollier 6701 Fannin Street, Suite 610.00 Houston, Texas 77030
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Song EK, Seon JK, Jeong MS. Delayed-type hypersensitivity reaction to piperacillin/tazobactam in a patient with an infected total knee replacement. J Bone Joint Surg Br. 2010;92:1596–1599. 2. Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother. 2006;40:2037–2042. 3. Dovas S, Liakopoulos V, Papatheodorou L, et al. Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol. 2008;69:207–212. 4. Mounasamy V, Fulco P, Desai P, Adelaar R, Bearman G. The successful use of vancomycin-impregnated cement beads in a patient with vancomycin systemic toxicity: A case report with review of literature. Eur J Orthop Surg Traumatol. 2013;23(Suppl 2):S299–S302. 5. Stone PA, Armstrong PA, Bandyk DF, et al. Use of antibioticloaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections. J Vasc Surg. 2006;44:757–761.
6. Stone PA, Mousa AY, Hass SM, et al. Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections. J Vasc Surg. 2012;55:1706–1711.
A Comparison of Vascularized Cervical Lymph Node Transfer with and without Modified Charles’ Procedure for the Treatment of Lower Limb Lymphedema Sir:
W
e read with interest the article by Althubaiti et al.1 in a recent issue of the Journal. We agree that the use of physiologic methods of surgical management of lymphedema, such as vascularized lymph node transfer2 and lymphaticovenular anastomosis,3 are gaining popularity and are the way forward. Unfortunately, the intermediate- and long-term results of such procedures are still lacking at this time. Based on the senior author’s yet unpublished data, the reduction of lymphedema in advanced cases where only vascularized lymph node transfer is performed is usually incomplete, and requires additional excisional procedures for significant symptomatic relief. We present a case of bilateral lower limb lymphedema of 20 years’ duration occurring in a 51-yearold woman who was injured in a road traffic accident 30 years previously and was treated conservatively for contusion. Her preoperative circumferential measurements were 55.0, 44.0, 37.0, and 26.0 cm at the right midthigh, midleg, ankle, and midfoot, respectively; and 50.0, 42.0, 32.0, and 24.0 on the left side, respectively (Fig. 1, left). Lymphoscintigraphy showed bilateral lower limb tracer uptake delay (Fig. 2). She initially underwent free vascularized lymph node transfer to the right ankle from the transverse cervical lymph node chain. One year after the first operation, her circumference measurements were 52.0, 42.0, 36.0, and 26.0 cm for the right side and 49.0, 41.0, 31.0, and 24.0 cm for the left side (Fig. 1, second from left). Because the patient desired further improvement than what was attained on the right side, she agreed to proceed with vascularized lymph node transfer from the left supraclavicular region to the left ankle and a modified Charles procedure concurrently to the left lower limb. She was followed up at 2 years after vascularized lymph node transfer on the right lower limb (also 1 year after vascularized lymph node transfer with the modified Charles procedure on the left lower limb). Her limb circumference measurements were 46.8, 42.8, 26.2, and 24.2 cm for the right and 35.2, 32.1, 21.0, and 25.6 cm for the left (Fig. 1, second from right and right). Because of superior symptomatic relief of the left lower limb compared with the right, she prefers the result on the left over that on the right despite the more extensive scar, and is awaiting a modified Charles procedure to the right lower limb (in addition to the previous lymph node transfer). This is a unique case in which a patient gave consent for different procedures on each lower limb, and allows us to make a direct comparison of the
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Plastic and Reconstructive Surgery • July 2014
Fig. 1. (Left) Preoperative photograph of the patient. (Second from left) Photograph of the patient 1 year after vascularized lymph node transfer to the right ankle. (Second from right and right) Photographs of the patient 2 years after vascularized lymph node transfer to the right ankle and 1 year after vascularized lymph node transfer and a modified Charles procedure to the left lower limb.
Matthew Sze-Wei Yeo, F.A.M.S.(Plast.), M.R.C.S.Ed. Seong Yoon Lim, M.D. Kidakorn Kiranantawat, M.D. Pedro Ciudad, M.D. Hung-Chi Chen, M.D., Ph.D. Department of Plastic Surgery China Medical University Hospital Taichung, Taiwan Correspondence to Dr. Chen Department of Plastic Surgery China Medical University Hospital 2 Yuh-Der Road Taichung 40447, Taiwan [email protected] Fig. 2. The first two images (left and second from left) were taken 30 minutes after injection of contrast, and the next two (second from right and right) were taken at 2 hours after injection, and demonstrate delayed uptake of contrast.
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES
postoperative result of the respective procedures, because the patient serves as her own control. Based on the result obtained from vascularized lymph node transfer alone,4 the authors recommend that excision surgery, such as a modified Charles procedure, should be performed concurrently for optimal results in advanced cases of lymphedema. This is based on our experience of 30 cases of combined vascularized lymph node transfer and modified Charles procedure, which shows promising result for advanced lymphedema, and will be presented in a separate article in the near future. DOI: 10.1097/PRS.0000000000000295
172e
1. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013; 131:133e–135e. 2. Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. (in press). 3. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg. 2003;19:209–215. 4. Feng GM, Yang WG, Huang CH, Wang SY, Chen HC. Lymph node transfer for treating mild to moderate limb lymphedema: A preliminary result. J Plast Surg Assoc ROC 2003;12:95–104.
