Keystone Flap Type IV in Breast Reconstruction: A Case Report.

OBJECTIVE: The objective of this paper is to present and document a specific case of breast reconstruction using an adapted Type IV Keystone Flap technique, with a droplet-shaped design with a reduced flap ratio, and to identify the qualities of this method. CASE REPORT: A 41-year-old woman, with a history of myocardial infarction and low ejection fraction, underwent a lumpectomy, resulting in a lower medial quadrant deficit in her left breast. After she developed skin and tissue necrosis and infection, implementing the Type IV Keystone Flap effectively addressed the deficit, ensuring sufficient coverage. The flap extended dropwise beneath the deficit, progressing anteriorly towards the upper rectus abdominis, with a ratio of 2.5:1. The flap's novel droplet shape allowed for the utilization of fewer perforators, while ensuring adequate blood supply and tissue coverage, leading to improved perfusion and aesthetic outcome. CONCLUSION: The application of the adapted Type IV Keystone Flap highlights its capacity as a versatile and effective method for breast reconstruction post-lumpectomy. With the advantages of a short learning curve, easy execution, and acceptable risk profile, it offers a valuable alternative for patients who may not be suitable for more complex surgeries. Further research is recommended to confirm its broader applicability and to conduct a comparative analysis with other techniques.

Anatomical Variations in the Celiac Trunk: A Short Review.

OBJECTIVE: The objective of the current study was the examination of possible variants of the celiac trunk. METHODS: An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table. RESULTS: The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients. CONCLUSION: Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants.

The Coexistence of the Superficial Brachial Artery With the Common Origin of the Posterior Circumflex Humeral Artery and the Deep Brachial Artery.

The brachial artery (ΒΑ) represents the axillary artery's extension as it distally progresses to the teres major muscle or beneath the tendon of the latissimus dorsi muscle. Throughout its course, the BA maintains continuous proximity to the median nerve. Occasionally, an artery located in front of the arm muscles may exhibit a slightly more lateral position than the BA, following a convoluted path, referred to as the superficial brachial artery (SBA). SBA variants are not uncommon and can impact neural structures as well. In the course of routine dissection on a formalin-embalmed donated cadaver through the Body Donation Program, the following notable findings were identified: a) a BA bilateral trifurcation, below the tendon of the latissimus dorsi muscle; b) a posterior circumflex humeral artery of low origin (brachial artery); c) the coexistence of an SBA with the main BA; d) a subscapular artery of high origin (second part of the axillary artery); e) an anterior circumflex humeral artery duplication. These BA variants, particularly those related to the SBA, hold significance in upper limb surgery and everyday clinical practice. In such cases, meticulous surgical dissection is crucial to prevent arterial injury, and in complex situations, preoperative imaging might be advisable. Additionally, it's important to note that concurrent neural variants may also be present, potentially complicating the surgical approach.

The Aberrant Origin of the Suprascapular Artery May Hide Neural Covariants: A Cadaveric Finding.

The axillary artery is the continuation of the subclavian artery. Occasionally, some of the subclavian artery's distal branches may atypically originate from the axillary artery, such as the suprascapular artery. The suprascapular artery's distal (low) origin from the axillary artery, instead of the subclavian artery, may also be characterized as an aberrant suprascapular artery. The current cadaveric report describes the coexistence of an aberrant suprascapular artery (of axillary origin), variant course, and termination with atypically formatted nerves originating from the cervical (the phrenic nerve) and the brachial (the long thoracic and the median nerves) plexus. An unusual interconnection between the phrenic and the long thoracic nerves was also described. The aberrant suprascapular artery had an atypical termination below the superior transverse scapular ligament, along with the suprascapular vein and nerve. Except for the atypically formatted phrenic and long thoracic nerves, the aberrant suprascapular artery coexisted with an atypical passage of the anterior ramus of the C6 spinal nerve, through the middle scalene muscle, before the long thoracic nerve formation, and a variant formation of the median nerve. Understanding neurovascular variants is crucial for interventionists and surgeons who work in the supra- and infraclavicular areas. Being aware of the different origins of the brachial plexus branches, in the supraclavicular part, may help reduce the occurrence of iatrogenic axillary injury. Efforts should be made to expand the number of cadaveric studies that investigate the origin, course, interconnection, and branching patterns of these nerves and related covariants, in a systematic way, thus unifying their study and comprehension.

A Bilateral Symmetric Accessory Coracobrachialis Muscle Combined With an Interconnection of the Musculocutaneous Nerve With the Median Nerve.

This report describes a bilateral symmetric accessory coracobrachialis muscle variant coexisting with a unilateral interconnection of the musculocutaneous nerve and the median nerve. An 80-year-old female cadaver was dissected. The bilateral coracobrachialis muscle variant consisted of three heads: two superficial heads and one deep head. One superficial head arose from the tip of the coracoid process, while the other originated from the short head tendon of the biceps brachii. The deep head of the coracobrachialis muscle emerged from the base of the coracoid process. The musculocutaneous nerve bilaterally coursed between the superficial and deep heads. On the right side, the three-headed coracobrachialis muscle coexisted with an ipsilateral interconnection of the musculocutaneous nerve and the median nerve, located at the lower third of the arm. While the presence of a unilateral three-headed coracobrachialis muscle is not rare (with a prevalence range of 0-22.2%), as well as the distal interconnection between the musculocutaneous nerve and the median nerve at the lower third of the arm (with a prevalence range of 1.8-53.6%), the coexistence of the current bilateral three-headed coracobrachialis muscle variant with the distal interconnection of the musculocutaneous and median nerves is quite unusual. A similar report underscores the finding of the bilateral coracobrachialis muscle variant.

Lingual and Facial Artery Fusion: A Cadaveric Report With Clinical Significance.

The external carotid artery (ECA) anterior branches, including the superior thyroid, the lingual, and the facial artery (STA, LA, and FA) present variability among cadaveric studies. These arteries may usually originate as isolated branches from the ECA anterior surface and atypically migrate proximally or distally and/or fused into trunks with the most common fusion that of the LA with the FA, into the linguofacial trunk (LFT), and the rarer ones those of the thyrolingual and thyrolinguofacial trunks. The current report describes a case of a bilateral fusion of the LA with the FA into an LFT and another case of a unilateral origin of the FA from the LA (aberrant FA).  In a 75-year-old donated male cadaver, a bilateral symmetrical LFT coexisted with a right-sided STA origin from the ECA proximal origin, at the level of the common carotid artery (CCA) bifurcation. In an 82-year-old donated female cadaver, at the left side, the atypical origin of the FA from the LA proximal origin coexisted with a common trunk of the left CCA with the brachiocephalic artery, and an atypical origin of the STA from the CCA, 3.65 mm inferior to the CCA bifurcation. This report provides a detailed description of the abnormal origin of the ECA anterior branches, the potential fusion of these branches, their exact location, and the existence of an unusual origin proximal or distal to the CCA bifurcation. Aberrant origin and course remain important in surgical and interventional approaches. A thorough understanding of the typical and variable anatomy of the ECA anterior branches ensures safe and successful intervention. Careful preoperative staging and precise dissection are essential components of this process.

The Coronoid Anatomical Variation of the Masseter Muscle: A Case Report.

INTRODUCTION: Masseter muscle is considered to consist of two layers: the superficial and the deep parts. However, in the literature a few cases have been reported of a third layer of the masseter muscle, which is called the coronoid part. The aim of this study is to present such a rare case of the coronoid part of the masseter muscle. MATERIAL AND METHODS: In our study, a case report is presented and enhanced by searching the existing literature in PubMed for other similar cases that recorded the coronoid part of the masseter muscle. RESULTS: The coronoid part of the masseter muscle was found in a male cadaver of Greek origin that was dissected in the Department of Anatomy, Medical School Athens, Greece. CONCLUSIONS: Good knowledge of anatomy and variations of the masseter muscle are of paramount importance due to their clinical and functional applications as well as during surgical procedures in this anatomical region.

Partial Superficial Parotidectomy Versus Extracapsular Anatomical Dissection for the Treatment of Benign Parotid Tumors.

OBJECTIVES: Superficial benign parotid tumors are a common neoplasm of the salivary glands. Different surgical procedures have been applied for partial superficial parotidectomy (PSP) and extracapsular dissection (ECD), which are the two predominant surgical techniques. Our study aimed to evaluate PSP versus ECD for benign parotid tumors, in relation to post-operative complications and recurrence rates. MATERIALS AND METHODS: 266 patients who underwent parotidectomies of benign superficial parotid tumors were evaluated retrospectively. The first group (PSP group) was composed of 143 patients who underwent PSP, and the second group (ECD group) was composed of 123 patients who underwent ECD. RESULTS: In the ECD group the rate of patients presenting with total postoperative permanent facial nerve paralysis, House-Brackmann grade III, was 0.8%, whereas in the PSP group it was 1.4%. Frey's syndrome was only reported in the PSP group. Salivary fistula occurred in both groups at similar rates. Sensation dysfunction due to greater auricular nerve division occurred in 72% patients in the PSP group and 10.6% in the ECD group. No statistical difference regarding recurrence rates was found between the two groups. CONCLUSIONS: Both ECD and PSP procedures are safe surgical options for superficial parotidectomy in the treatment of benign tumors, with similar recurrence rates and post-surgical complications, apart from sensation abnormalities due to more extensive auricular nerve division.

Anatomical Variations of Vascular Anatomy in Meckel's Diverticulum.

OBJECTIVE: The objective of the current study was to describe the anatomical variations of vessels observed in patients with Meckel's Diverticulum. METHODS: A narrative review of the literature was undertaken by means of the PubMed database, using the terms: "Meckel's Diverticulum AND vessels", "Meckel's Diverticulum AND anatomical variation" and "Meckel's Diverticulum variation". Classical anatomical textbooks were also used for normal anatomy. Additional articles provided useful information in relation to the aim of this review. Hence, the articles that met the inclusion criteria were included in this review, and the collected data were categorized into a single table. RESULTS: The majority of studies indicated the presence of an abnormal vitelline artery. Other angiographic findings concerned variations of the ileal and the iliac arteries. However, the literature revealed the presence of vascular variations without the existence of Meckel's Diverticulum, whereas a remnant of the vitelline vein may be present, but it is very rare. CONCLUSION: The detection of vascular variations accompanying Meckel's Diverticulum is not always easy and requires the correct choice of imaging method to prevent misdiagnosis.

The postoperative redox status of patients with diabetes mellitus: a mini review.

The human organism is exposed to variable endogenous and exogenous factors that result in the induction of free radicals. Surgeries are associated with increased inflammation and production of free radicals through various mechanisms, including ischemia, hemolysis, or endogenous antioxidant depletion. Importantly, a more oxidized redox status could lead to the condition known as "oxidative stress," which is related to alterations in insulin signaling and may lead to insulin resistance and diabetes mellitus. Therefore, patients with diabetes who undergo surgery could be more vulnerable compared with healthy individuals. Thus, this review focuses on the currently available literature regarding the link between the redox status and diabetes complications after surgery and the methods used to assess the redox status of patients, which is the first step to designing an appropriate treatment strategy. To this end, we queried PubMed for novel works published up to May 2020.

Precaution Measures for the Safety of the Personnel in the Surgical Wards during the COVID-19 Pandemic.

Coronavirus disease-19 has affected million of people worldwide, constituting the biggest social, economic, and health crisis since World War 2. During this pandemic, the hospitals have become hot zones for the treatment of patients. Therefore, it is important to take the appropriate protective measures and ensure the physician's health and, especially, those who work in the intensive care units and in operating rooms. In this letter, we are trying to make a discussion regarding the measures that should be considered by the healthcare workers who are facing this invisible enemy during their effort to provide their services in the surgery rooms.

Erectile Dysfunction Treatment Using Stem Cells: A Review.

Erectile dysfunction (ED) is a disorder that affects the quality of life and the sexual relations of more than half of the male population aged over 40 years. The prediction regarding the incidence of ED is devastating as it is expected that this disorder will affect more than 300 million men in the next five years. Several studies have suggested the use of stem cells for the treatment of ED and showed that this type of treatment is promising in terms of damaged tissue repair as well as of clinical efficacy; however, there are several gaps in the knowledge and evidence is lacking. In order to highlight a few of them in this review, we performed a research of the literature focusing on currently available clinical studies regarding the clinical efficacy of stem cell administration for the treatment of ED. We reviewed the methods of administration, the cell types used in the performed clinical trials and the safety and efficiency of such procedures. We conclude that there are rapidly expanding and promising results from the reported clinical studies indicating that stem cells could indeed be a potential treatment for patients with ED although more studies are necessary.

Ethical Issues in Intensive Care Units during the COVID-19 Pandemic.

Coronavirus disease-2019 (COVID-19) outbreak began in December 2019 in China and has spread rapidly across the world. The healthcare system of each country has been affected from this situation. Undoubtedly, during this period several ethical issues have been raised. In this commentary, we aimed to make a discussion regarding the ethical issues that could be raised in the treatment of patients in the intensive care units during the COVID-19 pandemic. The objective of this article is to contribute to the wide current discussion regarding the appropriate measures that should be taken to protect the health and ensure the safety of the staff that comes in close contact with patients who are suspected or confirmed of having COVID-19. How to cite this article: Karampelias V, Spanidis Y, Roussakou E. Ethical Issues in Intensive Care Units during the COVID-19 Pandemic. Indian J Crit Care Med 2020;24(9):855-856.

The Effects of Ascorbic Acid and U-74389G on Renal Ischemia-Reperfusion Injury in a Rat Model.

BACKGROUND/AIM: U-74389G and ascorbic acid protect the cells from oxidation. This study aimed to depict their role in ischemia-reperfusion injury in a renal rat model. MATERIALS AND METHODS: Sixty Wistars rats were randomized into six groups of 10 animals each. Group A Ischemia 30 min, reperfusion 60 min; Group B Ischemia 30 min, reperfusion 120 min; Group C Ischemia 30 min, ascorbic acid administration, reperfusion 60 min; Group D Ischemia 30 min, ascorbic acid administration, reperfusion 120 min; Group E Ischemia 30 min, U-74389G administration, reperfusion 60 min; Group F Ischemia 30 min, U-74389G administration, reperfusion 120 min. We then collected tissue and blood samples. RESULTS: Histology and the significantly decreased malondialdehyde and tumor necrosis factor-α levels indicated that ascorbic acid was superior to U-74389G, at pre-defined time intervals. CONCLUSION: Ascorbic acid and U-74389G ameliorated renal damage induced by ischemia-reperfusion injury, suggesting a therapeutic effect.

Superior mesenteric artery syndrome: a rare case of upper gastrointestinal obstruction.

Superior mesenteric artery (SMA) or Wilkie's syndrome is a rare clinical entity of partial or complete duodenal obstruction. The pathogenic mechanism is an acute angulation of the SMA which leads to compression of the third part of the duodenum between the SMA and the aorta. This is commonly due to loss of fatty tissue as a result of a variety of debilitating conditions. Its treatment is initially conservative and in case of failure, surgical therapy is unavoidable. We present a case of a 68-year-old female patient who presented in our Department with symptoms of dehydration after persistent vomiting for months. After complete radiologic workup, SMA syndrome was diagnosed and was successfully treated operatively. SMA syndrome might be a diagnostic challenge and must be always included in the differential diagnosis of upper gastrointestinal obstruction. Consequently, this paper aims to increase the awareness of a rare entity of duodenal obstruction.

Laparoscopic abdominoperineal resection for the treatment of a mucinous adenocarcinoma associated with an anal fistula.

Mucinous adenocarcinoma associated with an anal fistula is a rare oncologic entity which may pose diagnostic and therapeutic challenges for Surgeons and Medical Oncologists. Few reported cases without definite therapeutic guidelines exist. It represents 2-3% of all gastrointestinal malignancies and arises from chronic anal fistulas, ischiorectal or perianal abscesses. We report a case of perianal mucinous adenocarcinoma in a 65-year-old male initially surgically treated multiple times for a recurrent fistula in ano of 5 years duration. He presented with an ischiorectal and a perianal fistula. Incisional biopsy from fistulotomy revealed mucinous adenocarcinoma. Contrast enhanced computed tomography scan and magnetic resonance imaging showed a localized perianal growth of a tumor which was further evaluated with colonoscopy. With no evidence of metastasis, we performed a laparoscopic abdominoperineal resection (APR). Two years follow-up after APR and without adjuvant chemotherapy there is not any evidence of recurrence or distant metastasis.