Superior rectal artery preservation to reduce anastomotic leak rates in familial adenomatous polyposis patients treated with total colectomy and ileorectal anastomosis.

BACKGROUND: Total colectomy with ileorectal anastomosis (TC/IRA) is one of the prophylactic surgical options in patients with familial adenomatous polyposis (FAP). This study investigated the effectiveness of superior rectal artery (SRA) preservation during TC/IRA in reducing anastomotic leakage (AL). METHODS: This retrospective study was based on prospectively collected data (01/2000 - 12/2022) at the National Cancer Institute, Milan, Italy. FAP patients undergoing TC/IRA were enrolled. A 1:1  propensity score matching (PSM) was performed. Associations between SRA preservation and complications were investigated using univariate and multivariate analysis. RESULTS: The study population included 211 patients undergoing TC/IRA (Sex: 106 Male, 105 Female; Age: median 30 yrs, IQR: 20-48 yrs), 82 with SRA preservation (SRA group) and 129 without SRA preservation (controls). After PSM, 75 patients were considered for each group. SRA preservation was associated with fewer complications (OR 0.331, 95% CI 0.116; 0.942) in univariate logistic regression analysis. AL events were significantly fewer in the SRA group than in the control group (0 vs 12, p = 0.028). The SRA group had fewer overall surgical complication and pelvic sepsis rates (p = 0.020 and p = 0.028, respectively). Median operative time was significantly longer in the SRA group (340 min vs 240 min, p<0.001), and median hospital stay was significantly shorter (6 vs 7 days, p=0.017). Twenty-seven patients in the SRA group experienced intraoperative anastomotic bleeding, which was controlled endoscopically. Superimposable results were obtained analyzing the whole patient cohort. CONCLUSIONS: SRA preservation can be considered an advantage in this patient population, despite adding a further technical step during surgery and thereby prolonging the operative time. Intraoperative endoscopic checking of possible anastomotic bleeding sites is recommended.

Extensive rhabdomyoma of the head and neck region: a case report and a literature review.

Rhabdomyomas are rare mesenchymal benign tumors of striated muscle origin that can be classified into cardiac and extracardiac types. Cardiac rhabdomyomas are considered as hamartomatous lesion because of their association with phacomatosis. Extracardiac type is further classified into adult, fetal and genital form, depending on the individual tumor's degree of differentiation. Adult head and neck rhabdomyomas are rare pathologies of adult patients, with a male predominance. The occurrence of multifocality is a rare manifestation of this uncommon lesion. Presenting symptoms are related to the location and dimension of the tumors and they include upper airway obstruction, Eustachian tube dysfunction, dysphagia and mucosal and neck mass. Because of their high rate of recurrence, radical resection is the treatment of choice of this kind of tumors. In this article is reported a rare and particularly large case of head and neck adult rhabdomyoma, presenting with an history of sleep apnea and night-time stridor.

Surgical access to condylar fractures in panfacial traumas.

AIM: Surgical access to the condyle in panfacial fractures is a delicate and debated issue. The aim of the study was to propose a protocol which would apply in the treatment of panfacial fractures requiring access to the condyles. METHODS: A case series of 10 patients (8 males and 2 females) with panfacial fractures consisting of 16 extracapsular mandibular condylar fractures associated with 3 symphyseal, 7 parasymphyseal, 1 mandibular angle, 6 Le Fort II, 3 orbitomaxillomalar, 5 zygomatic arch fractures were included in this study. Reduction and fixation were achieved using the mini-retromandibular access in 6 patients with 10 extracapsular condylar fractures while in 4 patients with 6 extracapsular condylar fractures access to the condyles consisted in a face-lift-type preauricular access, as a caudal extension of a coronal or hemicoronal incision required for the reduction and fixation of other fractures of the upper and middle thirds. RESULTS: A good morphological and functional outcome was achieved in all patients. No surgical complication associated with access to the condyles or treatment of the condylar fractures was registered. CONCLUSION: The proposed protocol could be used as a guide in choosing access to the condyles in panfacial traumas.

Repair of a perforated sinus membrane with a palatal fibromucosal graft: a case report.

The sinus lift procedure in association with dental implant placement and autologous bone grafting enables clinicians to achieve the prosthetic rehabilitation of the posterior edentulous maxilla, when the vertical height of the atrophic crest is reduced. The most commonly reported intraoperative complication of sinus augmentation is membrane perforation, which may lead to infection, with the risk of graft loss or resorption, and acute or chronic sinusitis. We present a technique for repairing a perforated Schnei-derian membrane with a de-epithelialized fibromucosal graft harvested from the palate of a 50-year-old man. In the postoperative period, no wound infections, sinusitis, or bleeding were observed. This technique allowed good prosthetic rehabilitation 3 months postoperatively. This technical procedure is a quick and easy way to treat this surgical complication, allowing repair of the Schneiderian membrane perforation with autologous tissue, without other surgical accesses or need to modify the existing surgical access. In addition, our procedure causes no patient discomfort or adds significant morbidity, with only a moderate increase in surgical time compared to the planned procedure.

Miniretromandibular access for mandibular condyle biopsies.

AIM: Mandibular condylar biopsy is an important tool in defining various condylar lesions and it could become necessary in establishing a correct diagnosis to plan the adequate treatment of the condylar lesions. METHODS: From May to June 2009, two patients affected by a miofibroma and an osteoma of the condyle underwent an open-field biopsy through a mini-retromandibular access. The approach was devised to be curative in case of benign lesion or just diagnostic in case of malignant or doubtful hystology. RESULTS: In both cases, mandibular condyle biopsies were diagnostic and curative at the same time, allowing both the hystologic diagnosis and the complete removal of the bony lesions. CONCLUSION: The present technique seems to be a valid and ideal technique, because ease and quick while simultaneously leaves little esthetic reliquates.

Lingual nerve lesion during ranula surgical treatment: case report.

Iatrogenic lingual nerve (LN) injuries are quite common in oral surgery both in maxillo-facial surgery and in oral surgery. LN runs superficially into the lateral mouth floor just beneath the mucous layer and this position enhances damage frequency. This article lists the different aetiologies of iatrogenic LN injuries and it almost focuses on lesions due to surgical treatment of ranulas. In the case report a LN lesion due to oral ranula excision is discussed; the patient experienced anaesthesia and hyperpatia in the corrisponded tongue side. It was treated with a microneurosugical anastomosis of LN, after amputation neuroma excision. The partial and definitive recovery of perception happened in six months and was deemed satisfying with 70% of functionality restored (results compared with the functionality of the contralateral side). An algorithm for diagnosis and therapy indication for iatrogenic injuries to nerves is also proposed. In case of surgical treatment, funcitonal recovery manifests after 4-6 month; a functional recovery of 70% of total nerve function is possible. The variable that most affects nerve functional recovery is surgical treatment timing; it must be performed as soon as possible.

Ossification of vascular pedicle in fibular free flaps: a report of four cases.

The fibular free flap is the most widely used flap for jaw reconstruction. Flap contouring requires removal of bone excess in the proximal segment by a subperiosteal dissection, preserving vascular connections between the pedicle and the bone and leaving well vascularized periosteum attached to the vascular pedicle. Among about 100 reconstructions with fibular flaps, 4 cases were observed of abnormal ossification along the vascular pedicle. Periosteum preserves its osteogenic capability after transposition, especially in a revascularized flap; this characteristic, together with the direct contact with the bone, allows the possibility of new bone formation along the pedicle. It would appear necessary to change the technique of reducing fibular excess, with removal of periosteum together with the bone, in order to avoid the complication described.

Pilot study on microvascular anastomosis: performance and future educational prospects.

The introduction of microvascular free flaps has revolutionised modern reconstructive surgery. Unfortunately, access to training opportunities at standardised training courses is limited and expensive. We designed a pilot study on microvascular anastomoses with the aim of verifying if a short course, easily reproducible, could transmit microvascular skills to participants; if the chosen pre-test was predictive of final performance; and if age could influence the outcome. A total of 30 participants (10 students, 10 residents and 10 surgeons) without any previous microvascular experience were instructed and tested during a single 3 to 5 hour course. The two microanastomoses evaluated were the first ever performed by each participant. More than the half of the cohort was able to produce both patent microanastomoses in less than 2 hours; two-thirds of the attempted microanastomoses were patent. The pretest predicted decent scores from poor performances with a sensitivity of 61.5%, specificity of 100%, positive predictive value of 100% and negative predictive value of 40%. Students and residents obtained significantly higher scores than surgeons. Since our course model is short, cost-effective and highly reproducible, it could be introduced and implemented anywhere as an educational prospect for preselecting young residents showing talent and natural predisposition and having ambitions towards microvascular reconstructive surgery.

The free fibula flap for treating benign mandibular lesions.

UNLABELLED: A variety of benign lesions that are typically treated conservatively can affect the mandible. The treatment must be radical when these lesions are locally aggressive and involve the perimandibular soft tissues or involve most of the thickness of the mandible. The main treatment is mandibular resection and reconstruction with bone grafts, mainly iliac crest bone grafts for segmental mandibulectomy or a calvaria bone graft for resection without interruption of the mandible body. These grafts are limited due to the possibility of infection and the unpredictable long-term resorption. Free flap surgery, particularly with fibula free flaps, represents a new era in mandibular reconstruction. This technique has similar donor site morbidity, while the transferred bone resists infection and bone resorption. These advantages are achieved at the cost of a procedure that is about 1 h longer when performed by an experienced microsurgical team. We report our experience with mandibular reconstruction following the surgical resection of benign lesions in 7 patients. All the reconstructions had good RESULTS: After reconstruction, the facial morphology showed restored symmetry of the lower third profile in all patients. The functional results were satisfactory, with restored mandibular function in all cases. No signs of recurrence have appeared in any patient after a mean follow-up of 24 months.

Head and neck vascular anomalies. A multidisciplinary approach and diagnostic criteria.

Vascular anomalies represent a heterogeneous group of pathologies of the circulatory system that can affect any type of hematic and /or lymphatic vessel of different diameter or anatomic site. The extreme variability of tissue types and districts involved by these lesions determines a wide heterogeneity of clinical manifestations, resulting in involvement of different medical expertise. In this context, a commonly agreed terminology is crucial for the appropriate evaluation and multidisciplinary management of patients. The ISSVA Classification that has its roots in the previous Classification of Mulliken and Glowacky distinguishes vascular anomalies in two main groups: vascular tumors and vascular malformations. In head and neck, where vascular anomalies are the most common benign lesions of infancy and childhood, correct diagnosis with the use of unequivocal terminology is more crucial for treatment considering the relevance of structures that can be involved. The aim of this work has been to clarify information and knowledges currently available in the field of vascular anomalies. Referring to ISSVA Classification, clinico- histopathological aspects of each entity have been elucidated.

Oral cavity reconstruction with the masseter flap.

The purpose of this report is to highlight how an unusual, outdated, unpopular and overlooked reconstructive method such as the masseter flap can be a reliable, straightforward and effective solution for oral reconstruction in selected cases. We report the transposition of the masseter crossover flap in two previously pre-treated patients presenting a second primary oral squamous cell carcinoma; excellent functional results with satisfactory cosmetic appearance were obtained in both cases. In the literature, only 60 cases of oral cavity and oropharyngeal reconstructions using the masseter flap have been reported. The possible clinical utility of this flap, even in modern head and neck reconstructive surgery, is presented and discussed. We believe that the masseter flap should enter in the armamentarium of every head and neck surgeon and be kept in mind as a possible solution since it provides an elegant and extremely simple procedure in suboptimal cases for microvascular reconstruction.

Head and neck reconstruction with pedicled flaps in the free flap era.

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

Evaluation of behavioral group counseling for parents of learning-disabled children.

The present study evaluated the effectiveness of a behavioral group counseling program for parent members of the Association for Children with Learning Disabilities. Twenty-two mothers were assigned to two treatment groups (N = 5 and N = 6) and a control group (N = 11). Treatment-group mothers received a series of eight weekly 1 1/2-hour sessions in which they were taught basic principles and procedures of behavior modification which they could apply to specific child-rearing problems. Multiple-success criteria (maternal reports, direct observation, frequency counts, and attitudinal measures) were employed to provide a broad-based measurement of outcome. Results indicated that treatment ratings of childrens' conduct and disruption and parental postbehavioral observations of mother-child interactions showed improvement for the behavioral-counseling groups while control-group ratings and behavior observations remained the same. All treatment-group changes were maintained at 3-month follow-up. Consistency of treatment-group data across measures and over time suggests the effectiveness of this approach as a training method. Implications for future research were discussed.

Behavior modification in the home: siblings as behavior modifiers, parents as observers.

It was hypothesized that siblings could function as effective behavior change agent for their behaviorally disturbed brother and sisters within the home environment. Further, it was predicted that parents could be trained to be reliable observers of their children's performance under these circumstances. The results of the study supported both predictions with siblings in two separate families demonstrating their ability to work with their brother or sister within the context of an ABAB reversal design. Parents were also shown to obtain consistently high reliability ratings when compared to outside observers. The judicious use of siblings as behavior modification aides is recommended as a treatment procedure.

Relapse coping and problem solving training following treatment for smoking.

Following an initial smoking program, 33 subjects were randomly assigned to one of four maintenance strategy conditions developed to investigate the Marlatt and Gordon cognitive-behavioral model of relapse. Two out of three components of the model were supported. Abstinent subjects given problem solving training did not show significant relapse while those given an attention placebo control did relapse significantly. Self-efficacy expectations predicted smoking rate up to 5-month follow-up. Contrary to expectations based on the Marlatt and Gordon model, subjects taught to cope with the guilt and sense of personal failure associated with a relapse episode showed considerable relapse.

The saliva thiocyanate analysis: a methodological extension and its relationship to CO and self-report in moderate smokers.

Parameters for the storage and analysis of saliva samples used to measure thiocyanate (SCN) levels among moderate smokers were systematically studied. The variables targeted for study were the temperature of storage (0 to 20 degrees F) and the size of the container (5 ml or 10 ml). Additionally, these same variables were examined, independently under three different temporal delays to laboratory analysis: immediate, 3 days, and 7 days. Results within each of the delay conditions revealed no significant differences in SCN levels and provided support for the reliability of measurement when using these procedures in the study of thiocyanate levels. Self-reported smoking rate and alveolar carbon monoxide (COa) readings of a week prior were found to correlate relatively highly with thiocyanate readings. These findings broaden the support for SCN as a corroborative measure of smoking.

Long-term follow-up (3-4 years) of treatment for smoking reduction.

The present paper reports the 3- and 4-year follow-ups of two smoking reduction clinics (n = 103) employing a comprehensive, non-aversive, behavioral treatment using stimulus control and self-control techniques. Most of the data were gathered via phone contact, while some clients were interviewed in person with corroborative carbon monoxide measurements taken at that time. While the general findings were similar to those reported for other long-term follow-ups of smoking programs, unlike earlier reports, the overwhelming majority of subjects were contacted (an average of 90% for all follow-up periods). The average percentage of baseline for smoking subjects was equal to 56% and average percentage abstinent equal to 24% at final follow-up. Data are also presented which suggest greater attention be paid to the potential efficacy of controlled smoking when assessing the effectiveness of smoking reduction programs.