RESUMO
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
RESUMO
BACKGROUND: Plastic surgeons are increasingly involved in the repair of complex ventral hernias. Although this typically involves recurrent incisional hernias, operative strategies can be applied to most abdominal wall defects, including chronic wounds with or without exposed mesh, enterocutaneous fistulas, or hernias associated with significant pannus formation. METHODS: This is a retrospective review of a single institution/single surgeon experience of complex ventral hernia repair performed over a 5-year period. Patients were classified into different hernia types based on their characteristics and underwent hernia repair according to the presented algorithm. RESULTS: A total of 133 patients underwent a complex ventral hernia repair between January 2005 and September 2009. The separation of components technique was used in the majority of cases. Permanent or biologic mesh was added in select patients. Adjunctive procedures were performed as indicated. The majority of short-term (less than 1 year) recurrences occurred in patients expected to have impaired wound healing due to comorbid conditions. In these patients, the recurrence rate was reduced when autologous repair was reinforced with mesh. CONCLUSION: Autologous tissue is the preferred method for reconstruction of complex ventral hernias. In certain instances, such as contamination, use of an acellular dermal matrix mesh is added as a temporizing measure. A subset of patients who will be prone to recurrence remains. Long-term follow-up is needed to confirm reliable and reproducible results.
Assuntos
Hérnia Abdominal/classificação , Hérnia Abdominal/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Telas Cirúrgicas , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Seguimentos , Hérnia Ventral/classificação , Hérnia Ventral/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/efeitos adversos , Recidiva , Reoperação , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Transplante Autólogo , Resultado do Tratamento , Cicatrização/fisiologia , Adulto JovemRESUMO
A case of complete dislocation of the lunate and scaphoid resulting from a fall is reported. We are unaware of any previously reported case of simultaneous dislocation with the scaphoid completely extruded from the wrist at the time of injury. The patient was treated with a proximal row carpectomy.
Assuntos
Luxações Articulares/cirurgia , Osso Semilunar/lesões , Osso Escafoide/lesões , Traumatismos do Punho/cirurgia , Acidentes por Quedas , Adulto , Humanos , Luxações Articulares/diagnóstico por imagem , Osso Semilunar/diagnóstico por imagem , Masculino , Osso Escafoide/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Traumatismos do Punho/diagnóstico por imagemRESUMO
Damage control laparotomy has become an accepted practice in trauma surgery. A number of methods leading to delayed primary closure of the abdomen have been advocated; complications are recognized with all these methods. The approach to staged repair using the Wittmann patch (Star Surgical Inc., Burlington, WI) combines the advantages of planned relaparotomy and open management, while minimizing the rate of complications. The authors hypothesized that use of the Wittmann patch would lead to a high rate of delayed primary closure of the abdomen. The patch consists of two sheets sutured to the abdominal fascia, providing for temporary closure. Advancement of the patch and abdominal exploration can be done at bedside. When the fascial edges can be reapproximated without tension, abdominal closure is performed. Twenty-six patients underwent staged abdominal closure during the study period. All were initially managed with intravenous bag closure. Eighty-three per cent (20 of 24) went on to delayed primary closure of the abdomen, with a mean time of 13.1 days from patch placement to delayed primary closure. The rate of closure using the Wittmann patch is equivalent to other commonly used methods and should be considered when managing patients with abdominal compartment syndrome or severe abdominal trauma.
Assuntos
Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/cirurgia , Laparotomia/métodos , Implantação de Prótese/instrumentação , Telas Cirúrgicas , Cicatrização , Feminino , Seguimentos , Humanos , Masculino , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Índices de Gravidade do Trauma , Resultado do TratamentoRESUMO
BACKGROUND: Previous studies suggest that Dupuytren's disease is caused by fibroblast and myofibroblast contractility. Cell contractility in smooth muscle cells is caused by calcium-dependent and calcium-independent signaling mechanisms. In the calcium-dependent pathway, calcium/calmodulin activates myosin light chain kinase (MLCK). In this study, the effects of calcium/calmodulin inhibition with the FDA-approved drug fluphenazine on Dupuytren's fibroblast contractility and MLCK expression were tested. METHODS: Fibroblast lines from the palmar fascia of patients with Dupuytren's disease were explanted and used for in vitro study. The effect of fluphenazine on Dupuytren's fibroblast migration was determined using a scratch migration assay, and contractility was determined using fibroblast-populated collagen lattice (FPCL) assays. Immunohistochemical staining of MLCK in different samples of Dupuytren's tissue and normal fascia were compared. RESULTS: Fluphenazine demonstrated a dose-dependent inhibition of Dupuytren's fibroblast migration, with the maximum inhibition of migration observed at 20 µM (69.8 ± 1.9%). Fluphenazine also inhibited FPCL contraction in a dose-dependent manner. Maximal inhibition was observed at a fluphenazine concentration of 20 µM (52.5 ± 6.1%). Immunohistological staining illustrated that MLCK was predominantly expressed throughout the cytoplasm of select fibroblasts within Dupuytren's nodules, yet was absent in the fibroblasts of Dupuytren's cords and normal palmar fascia. CONCLUSIONS: Fluphenazine inhibits Dupuytren's fibroblast contractility and migration through inhibition of MLCK in vitro. However, the inconsistent expression of MLCK throughout Dupuytren's tissue suggests that calcium-dependent signaling may not be a primary mode of contracture formation. Fluphenazine inhibition of MLCK is not likely to be a target for the treatment of Dupuytren's disease.
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Bicycle handlebar-related blunt trauma to the femoral vessels with resulting arterial injury has been described previously. However, significant injury to the ileofemoral tree with underlying arterial occlusive disease in the face of handlebar-related trauma has not been reported. We present the case of an all-terrain vehicle accident with isolated injury to the common femoral artery in a patient with underlying atherosclerotic disease.