RESUMO
BACKGROUND: In this report, we described the use of hypoglossal-facial neurorrhaphy with end-to-side coaptation between the jump interpositional nerve graft and the hypoglossal nerve for facial reanimation and analyzed the relationship between the outcome of surgery and duration of preoperative paralysis. METHODS: We performed hypoglossal-facial neurorrhaphy with the jump interpositional nerve graft on nine men and 10 women with unilateral complete facial paralysis. The patients, with a mean age of 39.7 ± 18.1 years (range, 8-65 years) at the time of surgery, experienced preoperative paralysis ranging from 1 to 150 months (mean, 16.9 ± 34.9 months). The movement of the corners of the mouth was evaluated 12 months after surgery using a unique method based on the House-Brackmann grading scale. RESULTS: The mean follow-up was 5.6 ± 1.6 years (range, 3-9 years). The movement of the corners of mouth was classified as excellent in two cases, good in seven cases, fair in two cases, and poor in eight cases. Nine of the 11 cases with preoperative paralysis of 6 months or less had excellent or good results, whereas none of the eight cases with preoperative paralysis of 7 months or longer yielded excellent or good results, showing a significant difference (P = 0.01). CONCLUSIONS: To achieve successful reanimation of the corners of the mouth, hypoglossal-facial neurorrhaphy with end-to-side coaptation between the jump interpositional nerve graft and the hypoglossal nerve should be performed within 6 months after the onset of facial nerve paralysis. © 2015 Wiley Periodicals, Inc. Microsurgery 36:460-466, 2016.
Assuntos
Nervo Facial/cirurgia , Paralisia Facial/cirurgia , Nervo Hipoglosso/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adolescente , Adulto , Idoso , Criança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: No mouthpiece has been designed to control salivary flow during endoscopic procedures. A new continuous suction mouthpiece (CSM) was developed, and its usefulness for percutaneous endoscopic gastrostomy (PEG) was evaluated. PATIENTS AND METHODS: Seventy-two patients who were scheduled to undergo PEG or the exchange of a gastrostomy button or tube were assigned to one of two groups: the group using the CSM and the group using the conventional mouthpiece. Aspiration pneumonia, procedure duration, extent of salivary flow, frequency of saliva suction, and number of choking episodes during the procedures were evaluated and compared between the two groups. RESULTS: The same number of patients was randomly allocated to each group. There were no significant differences between the two groups in sex, age, procedure type, duration of procedure,depth of sedation, and indication for the procedure. The grade of salivary flow was significantly lower in patients with the CSM than in patients with the conventional mouthpiece (P < 0.001). Significantly fewer suctions and choking episodes were observed in patients with the CSM than in patients with the conventional mouthpiece (P = 0.013, and P = 0.015, respectively). Aspiration pneumonia and other significant adverse events were not observed in either group. CONCLUSIONS: CSM reduced the number of episodes associated with salivary flow in PEG-related procedures. The device is expected to reduce complications such as aspiration not only in PEG but in other upper endoscopic procedures.
Assuntos
Gastroscopia/métodos , Gastrostomia/métodos , Saliva/metabolismo , Sucção/instrumentação , Idoso , Idoso de 80 Anos ou mais , Nutrição Enteral/métodos , Feminino , Gastrostomia/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Boca , Estudos Prospectivos , Medição de Risco , Resultado do TratamentoRESUMO
We present herein a case of massive arterial thrombosis of a free rectus abdominal musculocutaneous flap used for reconstructive surgery of gingival carcinoma that could not be rescued. A 54-year-old woman underwent the operation. She had experienced two miscarriages in her 20s, but medical history was otherwise uneventful. Intraoperatively, the anastomosed artery often showed massive arterial thrombosis, and the flaps had become necrotic after bilateral flaps were used. Laboratory findings, 7 days postoperatively, showed high levels of immunoglobulin G anticardiolipin antibody. This value normalized by 2 months postoperatively after using chemotherapy. This case does not match the criteria for antiphospholipid syndrome, but some English-language reports have shown rising antiphospholipid antibody levels, particularly anticardiolipin antibodies, in patients with neoplasm. In those cases, levels have normalized after successful therapy. Antiphospholipid antibody levels should be examined before surgery to identify risks of hypercoagulability.
Assuntos
Anticorpos Anticardiolipina , Arteriopatias Oclusivas/imunologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Gengivais/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Trombofilia/imunologia , Carcinoma de Células Escamosas/complicações , Feminino , Neoplasias Gengivais/complicações , Humanos , Mandíbula/cirurgia , Pessoa de Meia-Idade , Esvaziamento Cervical , Procedimentos de Cirurgia Plástica , Reto do Abdome/irrigação sanguínea , Reto do Abdome/transplante , Reoperação , Trombose/imunologiaRESUMO
BACKGROUND: The safety and efficacy of laparoscopic sleeve gastrectomy followed by biliopancreatic diversion with duodenal switch for morbid obesity has been well established. We previously recommended 2-stage laparoscopic biliopancreatic diversion with duodenal switch for super-super obese patients. In the 2-stage version, these patients undergo laparoscopic sleeve gastrectomy as a first-stage procedure, followed by laparoscopic biliopancreatic diversion with duodenal switch as the second stage for more definitive treatment of their obesity. However, short-term weight regain may occur owing to gastric dilation after initial laparoscopic sleeve gastrectomy. The aim of this study was to prevent gastric dilation after sleeve gastrectomy. We designed a sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh. METHODS: Eleven Yorkshire pigs weighing 20-25 kg underwent sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh (wrapping group) or sleeve gastrectomy only (control group) to compare the weight loss. The animals were weighed weekly postoperatively. Necropsy was performed 8 weeks postoperatively to confirm the wrapping by pathologic report. RESULTS: Four pigs died because of staple line failure or strangulation; no perioperative complications occurred in the other pigs. The operative time for the control group was 198 +/- 60 minutes and for the wrapping group was 181 +/- 86 minutes (P = NS). The average weight of the removed stomach was 123.3 +/- 5.8 g in the control group and 140.3 +/- 69.9 g in the wrapping group (P = NS). The postoperative weight gain at 8 weeks was significantly slower in the wrapping group than in the control group (P <.0001). The pathologic necropsy report noted that the mesh was well attached to the stomach wall at 9 days postoperatively, with no unexpected deaths. CONCLUSION: Sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh is feasible, and weight gain was reduced in the porcine model.
Assuntos
Gastrectomia/métodos , Politetrafluoretileno , Telas Cirúrgicas , Análise de Variância , Animais , Dilatação Patológica/prevenção & controle , Laparoscopia , Modelos Animais , Obesidade Mórbida/cirurgia , Projetos Piloto , SuínosRESUMO
Dietary and behavioral modifications have resulted in limited long-term success in curing morbidly obese patients, and surgery remains the only effective treatment. Of the surgical procedures that are the most commonly offered, Roux-en-Y gastric bypass (RYGB) appears to offer the best long-term results. However 5-15% of patients will not achieve successful weight loss after RYGB. There are many reports showing that the patients who underwent gastric bypass surgeries regain weight over time. The cause for this remains unclear. Several factors may contribute, including dilation of the gastric pouch and the gastrojejunal anastomosis. However, the data to support the link is sparse. The objective of this paper is to describe the surgical technique of wrapping the gastric pouch with a polytetrafluoroethylene (PTFE) mesh to prevent gastric pouch dilatation. In specific, we created a 20-30 ml gastric pouch and subsequently, the gastrojejunostomy was performed with a circular stapler. Afterwards, the mesentery was dissected and the gastric pouch was wrapped with the PTFE mesh. We have performed this procedure on three cadavers with an average operative time of 75 minutes. We found that the procedure of wrapping the gastric pouch was not particularly difficult. As a result, the gastric pouch, gastrojejunal anastomosis and the stump of the jejunum are all totally wrapped within the mesh. It may be effective in the prevention of dilatation.
Assuntos
Cirurgia Bariátrica/efeitos adversos , Dilatação Gástrica/etiologia , Dilatação Gástrica/prevenção & controle , Gastroplastia , Obesidade Mórbida/cirurgia , Telas Cirúrgicas , Idoso , Idoso de 80 Anos ou mais , Cadáver , Feminino , Humanos , Masculino , PolitetrafluoretilenoRESUMO
We performed a new procedure for reconstruction of donor site of a deltopectoral (DP) flap. A 58-year-old man presented with a wide subcutaneous abscess, which was caused by acute mandibular osteomyelitis due to dental caries. On admission, the patient received a neck incision for drainage. However, necrosis of the neck skin was observed after drainage. The patient had an 8 × 10 cm skin and soft-tissue defect, which we covered with a DP flap (15 × 7 cm). The DP flap donor site was reconstructed using a 16 × 8 cm pedicled thoracodorsal artery perforator (TDAP) flap. There was no flap necrosis, abscess formation, or scar contracture of the DP region. Debulking of the TDAP flap was not required. The pedicled TDAP flap is useful for the reconstruction of the donor site of DP flap. In this report, we describe our operative procedure.
RESUMO
BACKGROUND: Decreased absorption of nutrients results in weight loss. Apart from a surgical bypass or restriction, or pharmacological manipulations, novel approaches include endoluminal devices placed inside the stomach or intestine which could be used to achieve weight loss. Our goal is to verify the technical feasibility of an Endoluminal Duodeno-Jejunal Tube (EDJT) in reducing weight gain in a living porcine model and its safety in a short to medium survival. METHODS: 8 45-kg Yorkshire pigs were used for this study. 4 pigs were used as controls, whereas 3 pigs had a 180-cm and 1 had a 360-cm EDJT implanted and fixed to the first part of the duodenum proximal to the ampulla of Vater with a solenoid circumferential suture by way of a duodenotomy. The EDJT is a 25-mm diameter and 0.05-mm thickness polyethylene tube. The intent was to avoid the mixing of food and biliopancreatic juice for its entire length. RESULTS: Each pig was evaluated daily for symptoms of distress and weighed weekly for 7 weeks. No major complications were observed. The percentage weight changes 7 weeks after surgery in the control group, 180-cm group, and 360-cm group were 22.5%, 6%, and -2.8%, respectively. The EDJT groups (180-cm, 360-cm) had significantly slower weight gains than the control group (P=0.005). CONCLUSION: Use of an EDJT is safe; no major complications, such as obstruction, intussusception, or pancreatitis occurred. The EDJT slowed weight gain dramatically in a porcine model when compared to the controls. A trend of reduced weight gain was obtained with a longer tube.
Assuntos
Absorção Intestinal , Próteses e Implantes , Aumento de Peso , Animais , Duodeno/patologia , Duodeno/cirurgia , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Jejuno/patologia , Jejuno/cirurgia , Modelos Animais , Mucosa/patologia , Polietilenos , SuínosRESUMO
BACKGROUND: Morbid obesity has become a major global health problem. Surgery remains the only effective treatment for patients with severe obesity, because diet reduction methods and pharmacologic agents have not resulted in long-term weight reduction. Gastric bypass (GBP) can provide adequate weight loss, but after some years, dilatation of the gastric pouch and outlet may lead to weight regain by allowing the patient to increase food intake. METHODS: 2 groups of 6 pigs underwent laparoscopic GBP. In the first group, a non-adjustable silicone band (Proring-band, IOC, Innovative Obesity Care, Saint Etienne, France) was positioned 1 cm proximal to the gastrojejunal anastomosis. In the second group, the device used to stabilize the gastric pouch was an adjustable silicone band (Mid-band, Medical Innovation Developpement, Villeurbanne, France). Weight loss, complications and histological reaction were evaluated after 3 months. RESULTS: Mortality rate was 25% (cardiac arrythmia in 2 pigs). Conversion rate was 25%. The positioning of the band was more difficult with the Mid-band because of its larger size and the presence of the catheter. The average weight change in the Proring group was 15.8 kg (3.5-25.1 kg), and in the Mid-band group was 12.0 kg (6.2-15.1 kg). Morbidity consisted of one intragastric migration of the Proring band into the gastrojejunal anastomosis, and one infection of the port in the Mid-band group treated by removal of the port and antibiotics. CONCLUSION: Use of silicone devices may be safe and effective in the prevention of pouch or outlet dilatation after GBP.
Assuntos
Dilatação Patológica/prevenção & controle , Balão Gástrico , Derivação Gástrica/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Anastomose em-Y de Roux , Animais , Modelos Animais de Doenças , Desenho de Equipamento , Segurança de Equipamentos , Estudos de Viabilidade , Feminino , Derivação Gástrica/efeitos adversos , Laparoscopia/efeitos adversos , Masculino , Obesidade Mórbida/mortalidade , Distribuição Aleatória , Fatores de Risco , Sensibilidade e Especificidade , Silicones , Taxa de Sobrevida , SuínosRESUMO
We did a simultaneous reconstruction of the upper lip and the supportive columella for a midface deformity caused by the wide resection of a squamous cell carcinoma of the nasal vestibule. It was reconstructed with an Abbe flap combined with a periosteally-vascularised outer layer of mandibular bone, which give an aesthetically and functionally acceptable result.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Face/cirurgia , Neoplasias Nasais/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Idoso , Humanos , Lábio/cirurgia , Masculino , Mandíbula/transplante , Resultado do TratamentoRESUMO
BACKGROUND: Pegylated interferon (PEG-IFN) plus ribavirin therapy is still recommended for elderly and/or cirrhotic patients. This study examined whether sustained virological response (SVR) to low-dose PEG-IFN-α2a plus ribavirin therapy for elderly and/or cirrhotic patients could be predicted based on viral reduction within 2 weeks after therapy initiation or interleukin IL-(28B) polymorphism and viral mutations. METHODS: Participants comprised 115 elderly (≥65 years) and/or cirrhotic patients with genotype-1b and high viral load. Reduced doses of PEG-IFN-α2a (90 µg/kg/week) and ribavirin (400-800 mg/day) were administered for 48-72 weeks based on virological response of each patient. RESULTS: SVR was achieved in 34% (39/115), and treatment was discontinued in 15% (17/115). Univariate analysis identified age, α-fetoprotein, fibrosis marker, interferon sensitivity-determining region (ISDR), IL-28B polymorphism and level of viral reduction within 2 weeks as factors contributing significantly to SVR. However, no significant differences were noted in core amino acid substitutions. Multivariate analysis identified age, hyaluronic acid, ISDR and viral reduction as factors independently associated with SVR. Positive predictive value (PPV) and negative predictive value (NPV) of SVR based on the level of viral reduction at 2 weeks (cutoff level, 1.7 log IU/ml) were 83% and 84%, respectively. The PPV of SVR based on IL-28B major and ISDR mutant was 70%, and the NPV of SVR based on IL-28B minor and wild-type ISDR was 89%. CONCLUSIONS: Evaluations of viral reduction at 2 weeks or both IL-28B and ISDR are useful to predict SVR to low-dose PEG-IFN-α2a plus ribavirin therapy for elderly and/or cirrhotic patients.
Assuntos
Antivirais/uso terapêutico , Hepacivirus/genética , Hepatite C Crônica/complicações , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/uso terapêutico , Cirrose Hepática/etiologia , Polietilenoglicóis/uso terapêutico , Ribavirina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Antivirais/administração & dosagem , Antivirais/efeitos adversos , Feminino , Genótipo , Hepatite C Crônica/virologia , Humanos , Interferon-alfa/administração & dosagem , Interferon-alfa/efeitos adversos , Interferons , Interleucinas/metabolismo , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/administração & dosagem , Polietilenoglicóis/efeitos adversos , Estudos Prospectivos , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Ribavirina/administração & dosagem , Ribavirina/efeitos adversos , Fatores de Risco , Resultado do Tratamento , Carga ViralRESUMO
BACKGROUND/AIMS: The present study aimed to clarify whether virological response within 2 weeks after therapy initiation can predict a null response to pegylated interferon α-2b plus ribavirin therapy in patients with high viral load genotype 1b hepatitis C. METHODS: The participants consisted of 72 patients with high viral load genotype 1b. The dynamics of viral load within 2 weeks were measured. RESULTS: Significant differences between null responders and nonnull responders were noted for interleukin (IL)-28B genotype, amino acid 70 substitution, α-fetoprotein, low-density lipoprotein cholesterol, hyaluronic acid, and viral response. The area under the curve (AUC) for the receiver operating characteristic curve of the hepatitis C virus (HCV) RNA level decline at 2 weeks (AUC=0.993) was the highest among the factors predicting the null response. When the cutoff value for the HCV RNA level decline at 2 weeks was set at 0.80 log, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in predicting a null response were 82%, 96%, 82%, 96%, and 94%, respectively. In comparison, values for the non-TT and mutant type of amino acid 70 substitution were similar to those for HCV RNA level decline at 2 weeks. CONCLUSIONS: Virological response at 2 weeks or the combination of IL-28B and amino acid 70 substitution are accurate predictors of a null response.
Assuntos
Antivirais/administração & dosagem , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/administração & dosagem , Polietilenoglicóis/administração & dosagem , Ribavirina/administração & dosagem , Administração Oral , Adulto , Idoso , Área Sob a Curva , Quimioterapia Combinada , Feminino , Genótipo , Hepatite C Crônica/genética , Humanos , Injeções Subcutâneas , Interferon alfa-2 , Masculino , Adesão à Medicação , Estudos Prospectivos , RNA Viral/metabolismo , Proteínas Recombinantes/administração & dosagem , Resultado do Tratamento , Carga Viral , Adulto JovemRESUMO
Facial defect after an extended total maxillectomy is one of the most difficult deformities to reconstruct aesthetically, because the defect is not only large but also three-dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colour match and poor texture match are major problems. The contracture and displacement of the reconstructed eyelids and eye socket are also serious matters. To resolve these problems, we have performed a three-step reconstruction using a free rectus abdominis myocutaneous (RAM) flap and an expanded cervicofacial flap with cartilage grafts. In the first step, a free RAM flap was transplanted to the defect after extended total maxillectomy. In the second step, tissue expanders were placed under the skin of the cheek and neck a year after the RAM flap transplantation. After expansion of the cheek and neck skin, the third step was performed. The inferior part of the external skin island of the RAM flap was raised and sutured to the superior margin of the skin island to create a pouch for the eye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominence, and auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cervicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neo-eyelids were divided to form the lid fissure. We performed the three-step reconstruction on six cases after extended total maxillectomy. In all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids and cheek were natural in appearance with good colour and texture match without conspicuous scars. To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there are five points that should be formed; the eye socket, the groundwork of the eye socket, the orbital floor and malar prominence, the tarsal plates and the surface of the eyelids and cheek. We do not reconstruct the palate to set prosthetic dentures and to clean the surface of the skin island in the nasal cavity. To reconstruct the indispensable five points and achieve satisfying results, we propose this three-step reconstruction.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Cartilagem/transplante , Maxila/cirurgia , Neoplasias Maxilares/cirurgia , Neoplasias Nasais/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Reto do Abdome/transplante , Retalhos Cirúrgicos , Adulto , Idoso , Carcinoma de Células Escamosas/terapia , Bochecha/cirurgia , Terapia Combinada , Pálpebras/cirurgia , Feminino , Humanos , Masculino , Neoplasias Maxilares/terapia , Pessoa de Meia-Idade , Neoplasias Nasais/terapia , Órbita/cirurgia , Expansão de Tecido/métodos , Resultado do TratamentoRESUMO
The transverse rectus abdominis myocutaneous (TRAM) flap can create a good breast shape, however, the patchwork-like scar obviously shows that the breast has been reconstructed. To reconstruct a breast without the patchwork-like appearance, we used a two-stage procedure using a tissue expander before transplanting a de-epithelialised TRAM flap. In addition, to avoid fat necrosis and resorption in a large TRAM flap, we performed two vascular enhancement procedures, surgical delay and supercharging microvascular anastomosis. The surgical delay, which consisted of an extended skin island delay and a vascular delay, was performed when the tissue expander was placed under the breast skin in the first stage. As the extended skin island delay, zones 3 and 4 of the TRAM flap were elevated and silicone sheets were laid under the flaps. As the vascular delay, the deep inferior epigastric vessels (DIEV) on the pedicle side were ligated. In the second stage, the de-epithelialised TRAM flap was transferred into the expanded breast skin pocket. The flap was double pedicled with supercharging microvascular anastomosis between DIEV on the contra-pedicle side of the flap and the thoracodorsal vessels of the recipient site. This surgery was performed on 20 post modified radical mastectomy patients to reconstruct large breasts without patchwork-like scars, and every TRAM flap survived perfectly without fat necrosis or resorption. All patients were satisfied with the reconstructed breasts and the abdominal contour without abdominal wall hernia or any other complications.