Simona Donina

Background and Objectives: Microvascular flap surgery is a widely used reconstructive technique for the repair of various defects. Biomarkers have become an essential tool for monitoring flap viability, early detection of complications, and prediction of surgical outcomes. Studies focusing on immunomodulatory cytokines in the early prediction of microvascular flap complications are lacking. We aimed to investigate the predictive value of postoperative changes in transforming growth factor beta-1 (TGF-β1) for microvascular flap complications. Materials and Methods: This prospective observational study comprised 44 adults scheduled for elective microvascular flap surgery. Preoperative blood samples for analysis were obtained before surgery, prior to the administration of intravenous fluids. Postoperative blood draws were collected after surgery, before leaving the operating room. Preoperative and postoperative serum concentrations of TGF-β1, as well as preoperative plasma albumin, total protein, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, full blood count, albumin, interleukin-6, C-reactive protein, and fibrinogen, were determined. Results: Postoperative changes in TGF-β1 were higher in cases with flap loss compared to patients with healthy recovery or patients with minor flap complications (0.403 log10 of ng/mL [0.024–0.782] vs. 0.157 [0.029–0.285] vs. −0.089 [−0.233–0.056], p = 0.002). Increased postoperative TGF-β1 was positively linked to preoperative C-reactive protein (p = 0.021), fibrinogen (p = 0.020), hematocrit (p = 0.039), and hemoglobin (p = 0.009). Conclusions: The postoperative increase in circulating TGF-β1 was associated with microvascular flap complications. Assessment of the postoperative changes in circulating TGF-β1 may be valuable for the early postoperative prediction of true flap loss.

Vitiligo is a relatively benign autoimmune condition characterized by the destruction of melanocytes, leading to depigmentation of the skin. While primarily considered a cosmetic disorder, emerging evidence suggests that vitiligo may have important prognostic implications in oncology, particularly in melanoma. Several studies have reported an association between vitiligo development and treatment response in advanced melanoma patients undergoing immunotherapy. Although vitiligo expansion does not directly correlate with tumour regression, it has been linked to prolonged progression-free survival (PFS) and shows a trend toward improved overall survival (OS). This suggests that vitiligo may serve as an immune-related biomarker indicative of a favourable clinical course during immunotherapy. Here, we present two cases of advanced melanoma (BRAF wild-type) treated with pembrolizumab, emphasizing the complex interplay between vitiligo and immune-mediated responses to treatment. Case 1: a 77-year-old male diagnosed with stage IIIC metastatic melanoma developed vitiligo during pembrolizumab treatment. Despite the persistence of metastatic disease, he has maintained stable disease over an extended period, suggesting a potential link between vitiligo onset and durable disease control. Case 2: a 68-year-old male with metastatic melanoma developed long-term eyelash poliosis, a localized depigmentation phenomenon, during pembrolizumab therapy. Similar to the first case, he has exhibited stable disease, reinforcing the hypothesis that vitiligo and related depigmentation phenomena may be associated with favourable immunotherapy outcomes. These cases, alongside accumulating literature, support the potential role of vitiligo as a biomarker for prolonged survival in melanoma patients undergoing anti-PD-1 therapy. A deeper understanding of vitiligo expansion, its mechanistic connection to anti-tumour immunity, and its clinical implications could enhance prognostic assessment and aid in optimising the management of immune-related adverse events during immunotherapy.

Complex microvascular techniques and in-depth knowledge of blood rheology and microanastomosis function are required for success in microvascular flap surgery. Substantial progress has been achieved in preventing complications, but the rate of flap loss is still significant and can have significant adverse effects on the patient. Flap thrombosis, flap hematoma, and flap loss are the most frequent and severe major surgical complications. Advances in understanding the pathophysiology of different flap complications, the use of preoperative risk assessment and new treatment concepts could improve the perioperative care of microvascular flap surgery patients. Our aim was to outline novel avenues for best practice and provide an outlook for further research of anesthesia and perioperative care concepts in microvascular flap surgery.

Background: Microvascular flap surgery has become a routine option for defect correction. The role of von Willebrand factor antigen (VWF:Ag) in the pathophysiology of flap complications is not fully understood. We aim to investigate the predictive value of VWF:Ag for microvascular flap complications and explore the relationship between chronic inflammation and VWF:Ag. Methods: This prospective cohort study included 88 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws were collected on the day of surgery before initiation of crystalloids. The plasma concentration of VWF:Ag as well as albumin, neutrophil-to-lymphocyte ratio (NLR), interleukin-6, and fibrinogen were determined. Results: The overall complication rate was 27.3%, and true flap loss occurred in 11.4%. VWF:Ag levels were higher in true flap loss when compared to patients without complications (217.94 IU/dL [137.27–298.45] vs. 114.14 [95.67–132.71], p = 0.001). Regression analysis revealed the association between VWF:Ag and true flap loss at the cutoff of 163.73 IU/dL (OR 70.22 [10.74–485.28], p = 0.043). Increased VWF:Ag concentrations were linked to increases in plasma fibrinogen (p < 0.001), C-reactive protein (p < 0.001), interleukin-6 (p = 0.032), and NLR (p = 0.019). Conclusions: Preoperative plasma VWF:Ag concentration is linked to biomarkers of inflammation and may be valuable in predicting complications in microvascular flap surgery.

Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659–0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99–16.11 vs. 25.38, 14.82–35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery.

Background and Aims Microvascular flap surgery is an effective method for difficult reconstructions and major defects.[1] There is an ongoing debate about the preferred method of anaesthesia for flap success.[2] We aim to evaluate the differences in the rate of microvascular flap surgery complications and duration of hospitalization between patients receiving regional anaesthesia (RA) and general anaesthesia (GA). Methods This retrospective cohort study includes 54 adult patients undergoing elective microvascular flap surgery. The study was approved by the Ethics Committee of Riga Stradins University. The method of anaesthesia was chosen according to individual surgical necessity. Patients were divided into two groups – RA group (N=25) and GA group (N=29). Postoperative outcome data on surgical flap complications, duration of intensive care stay, and total duration of hospitalization was obtained. Results RA and GA groups had no statistically significant differences in the rate of flap failure, infection, hematoma, or any other type of flap complication. GA group had a mean intensive care stay duration of 2.33 days (CI95% 0.62–5.25). RA group had a significantly lower mean intensive care stay duration of 0.26 days (0.06–0.57; p=0.002). GA group had a mean hospitalization duration of 24.4 days (14.42–34.31). RA group had a comparatively lower mean hospitalization duration of 14.25 days (9.55–19.01; p=0.032). Conclusions The rate of surgical complications in microvascular flap surgery is equal for both RA and GA. Patients who receive GA have a longer mean intensive care stay and duration of hospitalization. In contrast to previous assertions, a meticulously administered regional anaesthesia might be preferred when surgically feasible.

Primary malignant melanoma of the uterine cervix is a rare disease with poor prognosis and high recurrence rate. We used Rigvir^® as adjuvant therapy for a stage IVA patient. Tolerability, overall and progression‐free survival are good.

The relationship between beta‐herpesviruses reactivation and the development of complications after autologous peripheral blood stem cell transplantation was investigated. Viral genomic sequences were detected by the polymerase chain reaction, virus‐specific antibodies by ELISA, and human herpesvirus (HHV)‐6 variants by restriction endonuclease analysis. Virus reactivation, serum levels of tumor necrosis factor (TNF)‐α, interleukin (IL)‐1β, IL‐6, soluble IL‐2 receptor (sIL‐2R), IL‐2, and IL‐4 were compared with clinical features in 44 patients before and after transplantation. Anti‐CMV and anti‐HHV‐6 antibodies were found in 70.5% and 81.8% of patients, respectively. The frequency of plasma viremia was significantly higher in patients after transplantation (41% vs. 11.4%). Reactivation of more than one virus was identified in 55.6% of patients and reactivation of HHV‐7 alone in 44.4%. In cases of concurrent infection, HHV‐7 was reactivated before HHV‐6, and both HHV‐6 and HHV‐7 were reactivated before CMV. There was a significant increase in HHV‐6 load in peripheral blood leukocytes DNA during viremia. In all cases HHV‐6B variant was detected. Complications after transplantation occurred in 27.3% of patients and virus reactivation was detected in all patients with complications. The significant increases in the rate of HHV‐6 and HHV‐7 reactivation and in serum levels of TNF‐α, IL‐1β, and sIL‐2R, as well as aggravated immunosuppression, suggest that both viruses were involved in the complications after autologous peripheral blood stem cell transplantation, via their immunomodulatory activity. The kinetics of reactivation suggests a potential role of HHV‐7 as a co‐factor of HHV‐6 reactivation, and of both HHV‐6 and HHV‐7 as co‐factors of CMV reactivation. J. Med. Virol. 84:1953–1960, 2012.