Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 5 appraisals
Hernia : the journal of hernias and abdominal wall surgery
Clinical outcomes in abdominal wall autologous flap reconstruction: a systematic review
PURPOSE: Complex abdominal wall defects present major reconstructive challenges when restoration of fascial continuity must be combined with durable soft-tissuecoverage, visceral protection, and, in selected cases, functional repair. Although autologous flap reconstruction is well established for selected indications, its overall role across defect types has yet to be established. METHODS: A systematic review was performed in accordance with PRISMA guidelines (PROSPERO: CRD42023491916). PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched from inception to April 2026 for studies reporting adult autologous flap-based abdominal wall reconstruction. Given substantial clinical and methodological heterogeneity, data were analysed descriptively. RESULTS: 172 studies comprising 4,421 patients were included. Pedicled flaps predominated (n=4,095, 92.6%), with free flaps used in 146 patients (3.3%) and mixed approaches in 180 (4.1%). Hernia-related pathology was the commonest indication (n=3751, 84.8%), followed by malignancy (n=470, 10.6%). Frequently used flap categories included anterolateral thigh, tensor fascia lata, rectus-based, and latissimus dorsi-based flaps. Flap selection was primarily defect-driven: fascia-bearing regional and turnover techniques were used mainly for structurally focused hernia repair, whereas composite flaps were used more often for oncologic, fistulating, traumatic, contaminated, or full-thickness defects. Common short-term complications include seroma, surgical site infection, and wound dehiscence. Flap failure and reported long term hernia recurrence were low. Free flaps were used more often for larger defects weighted mean 401 cm² vs 250 cm² for pedicled flaps), although size ranges overlapped. CONCLUSIONS: Autologous flap reconstruction is a durable and versatile option for selected complex abdominal wall defects. Reconstructive strategy should be guided primarily by defect composition.
10 July 2026
Read appraisal →Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology
Vascularized versus nonvascularized free fibular grafts in reconstruction of post-traumatic critical long bone defects, a comparative study
BACKGROUND: Reconstruction of critical-sized long bone defects is a complex orthopedic challenge. Free fibular grafts, vascularized (FVFG) and nonvascularized (NVFG), are established reconstructive options, but comparative clinical outcomes remain uncertain. PURPOSE: To compare clinical and radiological outcomes of FVFG and NVFG in patients with post-traumatic critical bone defects more than 10 cm. METHODS: A randomized controlled trial was conducted with 50 patients assigned equally to FVFG or NVFG groups. The primary outcome was time to union, while secondary outcomes included graft hypertrophy, functional scores (DASH and LEFS), complication rates, and donor site morbidity. RESULTS: The mean time to union was 5.78 months in the FVFG group and 6.17 months in the NVFG group, showing no statistically significant difference (p = 0.447). Rates of graft hypertrophy, functional recovery, and complications were comparable between the groups. CONCLUSIONS: Both FVFG and NVFG provide effective reconstruction for critical bone defects, with nearly similar healing times and functional outcomes. NVFG may represent a less complex alternative in selected cases.
26 May 2026
Read appraisal →Journal of plastic surgery and hand surgery
Atlas of recipient vessels for the superficial venous system of DIEP-flaps - a systematic literature review and clinical practice review
BACKGROUND: Venous congestion contributes to up to 40% of failures in abdominally based free flaps, underscoring the importance of optimising superficial venous drainage in deep inferior epigastric perforator (DIEP) flap breast reconstruction. The superficial inferior epigastric vein (SIEV) is sometimes essential to flap outflow. This systematic review investigates the choice of recipient vessels for superficial venous supercharging. METHODS: A systematic review was performed according to a PROSPERO-registered protocol (CRD42022353591) and PRISMA guidelines. PubMed, CINAHL, Embase, and the Cochrane Library were searched for studies describing SIEV recipient vessels or vessel-selection algorithms. Extracted data included study design, recipient vessel, graft use, and decision strategies. A clinical practice review was also conducted at Sahlgrenska University Hospital, where prophylactic SIEV-cephalic vein (CV) anastomosis has been used for over two decades. RESULTS: Twenty-nine studies were included. Reported recipient vessels outside the flap comprised, for example, the following veins: internal mammary, cephalic, thoracoacromial, and thoracodorsal. Intra-flap options included anastomoses to branches or the caudal end of the deep inferior epigastric vein. Three studies described interposition grafts, and eight proposed selection algorithms, with no consensus. The internal mammary vein was most frequently used. At Sahlgrenska, a short axillary-fold incision provides consistent and cosmetically favourable access to the CV, adding minimal operative time. CONCLUSION: Recipient vessel selection for SIEV anastomosis remains highly variable in the literature. Long-term institutional experience supports the CV as a reliable and versatile option. Prospective studies are needed to evaluate outcomes.
14 May 2026
Read appraisal →PloS one
A remote monitoring system based on deep learning for real-time assessment of free flaps
PURPOSE: Venous congestion is a major cause of postoperative free flap compromise, and early detection is crucial for improving flap salvage rates and patient outcomes. This study aimed to develop and validate a deep learning (DL)-integrated remote monitoring system with a smartphone application for real-time, quantitative assessment of free flaps, with a specific focus on the early detection of venous congestion. METHODS: This diagnostic study was conducted at our institution. Patients aged 18-60 years who underwent free flap reconstruction between January 2019 and June 2025 were included. The study was divided into three phases: a 5-month model training phase for DL model development and internal validation, a 5-month external validation and clinical application phase, and a 4-month clinical comparison phase. The DL model was developed using TensorFlow Lite and a Flap Segmentation Network (FS-Net). Performance was evaluated through accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and clinical outcomes including time to detection and flap survival. RESULTS: A total of 1649 photographs from 615 patients were analyzed in the development and validation of the DL classification model between January 2019 and February 2025. During model development, the model achieved an accuracy of 86.8%, sensitivity of 92.4%, specificity of 79.7%, and AUC of 0.88. Internal validation improved these metrics to 87.6%, 95.0%, 81.1%, and 0.92, respectively. External validation demonstrated the model's generalizability, with an accuracy of 89.3%, sensitivity of 96.2%, specificity of 84.9%, and AUC of 0.93. The clinical application phase showed that the system had an overall accuracy of 92.16%, sensitivity of 95.18%, false-positive rate of 2.62%, and false-negative rate of 4.82%. A total of 113 patients were included in clinical comparison between March 2025 and June 2025. The remote monitoring group exhibited a trend towards a shorter mean time to congestion detection, higher flap survival rate, and shorter mean time to re-exploration, although these differences were not statistically significant. CONCLUSIONS: The DL-integrated remote monitoring system demonstrated high accuracy and reliability in detecting venous congestion. It provided an objective and real-time tool that may help reduce clinical burden and support timely intervention in free flap management. However, its impact on definitive clinical outcomes required further validation in larger studies.
13 May 2026
Read appraisal →Annals of plastic surgery
Immediate Lymphatic Reconstruction to Prevent Postmastectomy Lymphedema: A National Analysis of Outcomes and Regional Trends
BACKGROUND: Lymphedema is a chronic disease characterized by swelling, inflammation, adipose deposition, and fibrosis. In the United States, lymphedema occurs most frequently as a sequela of oncologic lymphadenectomy. Axillary lymph node dissection (ALND) for breast cancer has been associated with a 5%-40% incidence of upper limb lymphedema. In immediate lymphatic reconstruction (ILR), surgeons perform lymphovenous anastomosis (LVA) with ALND to prevent the development of future lymphedema. Although early evidence supports a protective effect of ILR, there have been few large-scale studies on the topic. We leveraged a large claims database to better characterize the outcomes of ILR and national trends related to its adoption. METHODS: Adult female patients with breast cancer who underwent axillary lymph node dissection (ALND) between 2007 and 2022 were identified within the Merative MarketScan Research Databases and stratified according to whether they underwent ILR. Adjusted odds of undergoing ILR, both overall and regionally, and of experiencing postmastectomy lymphedema syndrome (PMLS) were calculated. RESULTS: Of all patients undergoing mastectomy and ALND, 1.3% received ILR. ILR was associated with decreased odds of developing PMLS (OR, 0.81; P = 0.02). The frequency of ILR procedures increased in all regions between 2017 and 2022, most dramatically in the Midwest and East US. More recent surgery year, younger age, complete mastectomy, and delayed ALND elevated the odds of undergoing ILR ( P ≤ 0.01). CONCLUSIONS: The popularity of ILR has grown rapidly since 2017, with significant regional variability. Patients with breast cancer who undergo ILR at the time of ALND are significantly less likely to develop lymphedema.
13 Apr 2026
Read appraisal →