4D-HyCoSy performed in a reproductive center: retrospective analysis of pain perception, complications and spontaneous pregnancy rate after the technique.

OBJECTIVE: Nowadays 4D hysterosalpingocontrast sonography (4D-HyCoSy) represents a primary technique in the evaluation of tubal impairment, with a low rate of pain referred and complications related, but its role in increasing the chance of spontaneous clinical pregnancy in women in childbearing age is still debated. PATIENTS AND METHODS: Retrospective study of 359 women performed 4D-HyCoSy at Reproductive Physiopathology and Andrology Unit, Sandro Pertini Hospital, Rome, during the period 2018-2020. INCLUSION CRITERIA: women attending our IVF (in vitro fertilization) center with at least 1 year of infertility. EXCLUSION CRITERIA: female age over 43 years, previously known severe tubal infertility, suspected anovulation, and semen abnormalities. PRIMARY OUTCOME: evaluation of tubal patency, complications related to technique, and pain perception evaluated thanks to a 10-cm visual analogue scale (VAS) Scale. SECONDARY OUTCOMES: clinical pregnancy rate (PR) after the technique confronted between the group of women with bilateral tubal patency (group A) with the group of monolateral tubal patency (group B) within 30 days and between 30-180 days, and 180 days-1 year from the exam. Time to pregnancy (TTP) and other obstetrical outcomes were evaluated too. RESULTS: The average age of the study's population was 33.3 years. Mean duration of infertility was 2.1 years. Complication rate was 6.4%, and in any case the use of ephedrine was required. 182 (50.6%) women reported absence of pain during the exam (VAS scale value 0) and 131 (36.5%), reported mild pain experience (VAS scale value between 1-4). Spontaneous pregnancy rate was of 29.3% in group A and 30.3% in group B; time to pregnancy was 32 ± 14.7 days in group A and 35 ± 13.1 days in group B. The insurgence of a spontaneous pregnancy was significantly lower for both 4D-HyCosy sub-groups after 30 days following technique respect to 30-180 days and 180 days-1 year following the technique (both p-value < 0.001). CONCLUSIONS: We confirm that 4D-HyCoSy is a safe and user-friendly technique, used as first line assessment of tubal patency of women afferent to a reproductive center. We also reported a positive impact on spontaneous pregnancy rate in women performing 4D-HyCoSy, emphasized within the first following month. This mandatory technique for tubal investigation, has not only a function in the diagnostic assessment of female infertility, but also has a therapeutic role, in young women who desire a pregnancy, avoiding, in some cases, the need of IVF treatments and clinical risks linked, while saving medical and monetary resources.

Isolation of Pseudobutyrivibrio ruminis and Pseudobutyrivibrio xylanivorans from rumen of Creole goats fed native forage diet.

We isolated and identified functional groups of bacteria in the rumen of Creole goats involved in ruminal fermentation of native forage shrubs. The functional bacterial groups were evaluated by comparing the total viable, total anaerobic, cellulolytic, hemicellulolytic, and amylolytic bacterial counts in the samples taken from fistulated goats fed native forage diet (Atriplex lampa and Prosopis flexuosa). Alfalfa hay and corn were used as control diet. The roll tubes method increased the possibility of isolating and 16S rDNA gene sequencing allowed definitive identification of bacterial species involved in the ruminal fermentation. The starch and fiber contents of the diets influenced the number of total anaerobic bacteria and fibrolytic and amylolytic functional groups. Pseudobutyrivibrio ruminis and Pseudobutyrivibrio xylanivorans were the main species isolated and identified. The identification of bacterial strains involved in the rumen fermentation helps to explain the ability of these animals to digest fiber plant cell wall contained in native forage species.

Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis.

BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) is a cause of bleeding in patients with liver cirrhosis. Argon plasma coagulation (APC) is the most used endoscopic treatment for GAVE-related bleeding. Treatment failures have been described in patients with haemorrhagic diathesis; post-procedure complications include haemorrhages and septicaemia. The aim of the study was to evaluate efficacy and safety of APC treatment of GAVE-related bleeding in patients with liver cirrhosis. METHODS: Patients included were suffering from GAVE-related bleeding and liver cirrhosis. APC treatment was performed until eradication. Resolution of transfusion-dependent anaemia and evaluation of complications were the primary outcomes. RESULTS: 20 patients (16 Child C and 4 Child B) were enrolled and prospectively followed for a mean period of 28 months. GAVE eradication was achieved in all patients after a median of 3 sessions (range 1-10). Resolution of anaemia was achieved in 18 patients. Six patients had relapse of GAVE after a mean of 7.7 months, successfully retreated by APC. Hyperplastic polyps developed in 3 patients causing active bleeding in 2 cases. Five patients had liver transplants and 1 had a relapse of GAVE after transplantation. CONCLUSION: APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.

The adductor flap: a new method for transferring posterior and medial thigh skin.

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11. When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.

Total face reconstruction with one free flap.

A bilateral extended scapular (scapular-parascapular) free flap was used in five patients with severe facial burn sequelae for complete resurfacing of the face with the exception of the nose, which was reconstructed in a separate operative procedure. All the flaps survived. Four were utilized for complete face resurfacing and one for neck and partial face resurfacing. The results were classified subjectively according to both patient and surgeon opinion. Good to fair results were obtained. The authors believe that this method might be further explored to obtain better results in these difficult cases.

Latissimus dorsi musculocutaneous flap without muscle.

The possibility of raising the cutaneous island of the latissimus dorsi musculocutaneous flap without muscle based on only one cutaneous perforator is presented in this paper. An anatomic study performed in 40 fresh cadaver specimens injected with colored latex demonstrated that the vertical intramuscular branch of the thoracodorsal artery gives off two to three cutaneous branches (perforators) that are consistently present. The largest one, measuring approximately 0.4 to 0.6 mm in diameter, provides the blood supply to a 25 x 15 cm cutaneous island. The incorporation of the proximal trunk of the thoracodorsal artery lengthens the pedicle, facilitating the anastomosis or the arc of rotation (in the case of island flaps) but does not increase the amount of tissue transferable. Five clinical cases were done with this technique without tissue necrosis or flap loss.

Reconstrucción mamaria con colgajo TRAM libre / Breast reconstruction with free TRAM flap

Se presenta la experiencia clínica de 28 reconstrucciones mamarias con colgajo transverso abdominal libre con microanastomosis vascular realizada desde 1991 en el Servicio de Patología Mamaria del Hospital Fiorito de Avellaneda. Se manifiesta la preferencia por la reconstrucción inmediata. Se presenta la posibilidad de realizar el colgajo TRAM (transverso abdominal) con una sola perforante sin músculo y sin aponeurosis abdominal con lo que se disminuye notoriamente la morbilidad de la zona dadora. De los 28 casos realizados hubo una pérdida total del colgajo atribuible a razones técnicas. No hubo sufrimientos parciales una vez transferido. El resultado estético fue bueno excepto en los casos con radiodermitis o radiofibrosis en la zona mamaria que impidió una colocación adecuada del colgajo. La comparación con una serie de colgajos TRAM en la isla realizados por uno de los autores reveló que la transposición en forma libre facilita la colocación del colgajo y asegura más su irrigación; por último esta técnica permite la anulación de las secuelas de la zona dadora.

A new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores.

In the paraplegic patient who has had previous surgeries for pressure sores, local tissue is frequently unavailable for further use. The posterolateral aspect of the thigh, however, is almost always available and provides an excellent reconstructive alternative for this difficult problem. In 1983, Baek described the skin territory supplied by the third perforator of the profunda femoris artery. A musculocutaneous flap can be raised consisting of the same skin territory and a portion of the biceps femoris muscle (short head) through which the third perforator courses. In addition, the distal part of the vastus lateralis muscle, which is supplied by a muscular branch of the same perforator, can be included in the flap. The flap is elevated as an island based on the profunda femoris artery and accompanying venae comitantes. A substantial soft-tissue mass can be transposed easily to the perineum. Standard latex injection techniques were used in 12 fresh cadaver dissections prior to use of this flap in 16 clinical cases. Selective india ink injections into the third perforator of the profunda femoris artery in 6 cadavers confirmed the perfusion of the overlying skin territory. Recurrent ischial and perineal wounds were closed successfully with this musculocutaneous flap in all 16 clinical cases.

Posterior interosseous reverse forearm flap: experience with 80 consecutive cases.

The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)

Correction of the secondary nasal tip and of alar and/or columellar collapse.

The authors present their surgical technique for the correction of the secondary nasal tip with alar and/or columellar collapse. They employ a cartilage autograft in the form of an anchor or half an anchor which is taken from the auricular concha and is designed according to the requirements of the pathology to be corrected. In their experience, they have observed neither complications with the use of these grafts nor unacceptable scars in the columellar incision.

Ear replantation.

The authors' tactical and technical contribution to this type of microsurgical replantation can be summarized in three main points: (1) direct sutures to the superficial temporal vessels, when these are undamaged, which simplifies the operation and makes it safer; (2) use of Kunlin's technique to make up for the great difference in diameter between the arterial vessels; and (3) deepithelialization of the posterior auricular skin to allow for creation of venous drainage channels during the first postoperative days and the enlargement of the area of contact with the recipient bed, which also helps to better immobilize the amputated part.

Mammary construction and reconstruction in one surgical stage.

The authors' personal technique for mammary reconstruction, including the nipple-areola complex, is presented. The technique is simple and effective and is performed in only one surgical stage. It is applicable to mammary construction in the case of congenital absence as well as to reconstruction after mastectomy.

Correction of the secondary nasal tip.

A technique used concomitantly with Rethi's incision to reach and treat the secondary nasal tip is described. The technique involves removing the cartilage remnants of both domes and placing a shaped cartilage autograft that is immobilized by sutures. No hypertrophic scarring has been observed in the 546 patients treated.

Neighboring flaps and cartilage grafts for correction of serious secondary nasal deformities.

When the secondary nasal deformity is so serious that it presents loss of the soft structures, often its correction requires a neighboring flap besides the cartilage auto-grafts. In such serious cases, which are fortunately infrequent, the surgeon must resort to reconstructive techniques that typically provide very good results. Such is the case with the midforehead Indian flap, which rotated 180 degrees, allows reconstruction of the columella in the same surgical stage. In the same manner, Denonvilliers' flap may be employed to restore contour of the nasal ala, since its scar sequel is very acceptable, and Dieffenbach's flap may be used to reconstruct the columella. The flap of labial mucosa (which other authors have employed to correct septal perforations) is rotated 90 degrees to appose with another similar contralateral flap and is used to correct the seriously retracted columella. In this paper we present some cases that demanded the application of these techniques.