Vasoespasmo en microcirugía: revisión de la literatura y recomendaciones para su manejo / Vasospasm in microsurgery: literature review and clinical recommendations

Introducción y objetivo: Los colgajos libres microquirúrgicos se han convertido en una herramienta indispensable en Cirugía Reconstructiva. El vasoespasmo es una entidad que puede producir fallo del colgajo. El objetivo de este trabajo es evaluar las distintas medidas terapéuticas para la prevención y tratamiento del vasoespasmo y proponer un algoritmo de manejo para esta complicación. Material y método: Revisión bibliográfica de estudios de diseño experimental o cuasi experimental que evalúen el efecto de distintas intervenciones para la prevención y el tratamiento del vasoespasmo. Resultados: Incluimos 31 estudios experimentales, de los cuales 5 analizan intervenciones no farmacológicas y 26 intervenciones farmacológicas. Todos los estudios experimentales fueron realizados en modelos animales. Dentro de las intervenciones no farmacológicas estudiadas, la adventicetomía y el adecuado control de la hemostasia mostraron ser medidas efectivas para la prevención del vasoespasmo. Dentro de las intervenciones farmacológicas tópicas, la lidocaína, la papaverina, el sulfato de magnesio al 10% y el verapamilo demostraron consistentemente su efectividad en la prevención y tratamiento del vasoespasmo. Dentro de las intervenciones farmacológicas sistémicas, la pentoxifilina y la prostaglandina E1 fueron las más efectivas para el manejo del vasoespasmo. Otros fármacos mostraron evidencia controvertida: nifedipino, nicardipino y prostaglandina E1 (todos de aplicación tópica); nicardipino, nifedipino y verapamilo (todos de aplicación sistémica). Conclusiones: La evidencia actual respecto a la efectividad de medidas orientadas al manejo del vasoespasmo en microcirugía se basan principalmente en estudios animales. El algoritmo de manejo del vasoespasmo que presentamos se sustenta en la experiencia clínica acumulada y la mejor evidencia actualmente disponible...

Background and objective: Microsurgical free flaps have become an indispensable tool in Reconstructive Surgery. Vasospasm is an entity that can cause flap failure. Our objective is to evaluate the different therapies for vasospasm prevention and treatment and to propose a management algorithm for this complication. Methods: Bibliographic review of studies of experimental or quasi-experimental design that assesed the effect of interventions for the prevention and treatment of vasospasm. Results: Thirty one experimental studies were included, of which 5 analyzed non-pharmacological interventions and 26 pharmacological interventions. All experimental studies were performed in animal models. Among the non-pharmacological interventions studied, adventicetomy and adequate control of hemostasis proved to be effective measures for the prevention of vasospasm. Within topical pharmacological interventions, lidocaine, papaverine, 10% magnesium sulfate, and verapamil consistently demonstrated their effectiveness in the prevention and treatment of vasospasm. Within the systemic pharmacological interventions, pentoxifylline and prostaglandin E1 were the most effective interventions for the management of vasospasm. Other drugs showed controversial evidence: nifedipine, nicardipine and prostaglandin E1 (topicallys); nicardipine, nifedipine and verapamil (systemics). Conclusions: The current evidence regarding the effectiveness of measu-res aimed at managing vasospasm in microsurgery is based mainly on animal studies. The vasospasm management algorithm presented is based on accumulated clinical experience and the best currently available evidence. Having this therapeutic strategy makes it possible to standardize management in clinical practice for rapid decision-making. Level of evidence 5c Therapeutic.(AU)

Extremity reconstruction with superficial circumflex iliac artery perforator free flap: Refinements and innovations after 101 cases.

INTRODUCTION: The superficial circumflex iliac artery perforator flap is based on perforators originated on the superficial circumflex iliac artery. This flap is thin and pliable, of moderate size, and has a concealed donor site. The authors report their experience, innovations, and refinements in both planning and execution, and the outcomes obtained after 101 extremity reconstruction consecutive cases. PATIENTS AND METHODS: A total of 101 superficial circumflex iliac artery perforator flaps were prospectively reviewed and followed up for at least one year at Hospital del Trabajador. The flaps were used for both upper (n = 21) and lower limbs (n = 80), planned with computed tomography angiography/augmented reality, and raised above the superficial fascia using a standardized approach. Demographic data, anatomy of the flap, surgical technique, and the results were assessed. RESULTS: Average flap size was 90.5 cm2, ranging from 25 to 212 cm2. Total flap loss occurred in 6 flaps (5.9%). Four patients developed complications at the donor site. Debulking surgery was performed in 7 patients (6.9%). The average follow-up period was 850 days (range, 370-1405 days). CONCLUSIONS: The superficial circumflex iliac artery perforator flap is versatile, thin, and pliable, suitable for covering even large defects in either the upper or lower extremities, obtaining a shallow contour and optimal esthetics results. The elevation can be standardized, but requires training and proper planning. This is the largest series in a Western country reporting the experience, refinements, and innovation that allows for better results in limb reconstruction.

Coledocolitiasis múltiples y colangitis en paciente con quiste de colédoco: a propósito de un caso / Multiple choledocholithiasis and cholangitis in a patient with choledochal cyst: a case report

INTRODUCCIÓN: El quiste de colédoco (QC) es una patología infrecuente, caracterizada por una dilatación de vía biliar intra o extrahepática. Constituye una lesión congénita, representado 1% de las lesiones biliares benignas. Tiene una incidencia de 1 en 100.000 a 150.000 habitantes. Es más frecuente en mujeres, y su etiología es desconocida. En adultos los síntomas son inespecíficos; predominando dolor abdominal e ictericia. PRESENTACIÓN DEL CASO: Mujer de 61 años con cólico abdominal en hipocondrio derecho de tres días, vómitos e ictericia. Al ingreso hospitalario presentaba leucocitosis, hiperbilirrubinemia, aumento de fosfatasa alcalina, transaminasas y amilasa. Se plantearon los diagnósticos de ictericia obstructiva, pancreatitis y quiste hidatídico complicado, por lo que se realiza tomografía computada (TC) de abdomen evidenciando dilatación sacular intra y extrahepática, compatible con QC tipo IV-a. Se realizó colecistectomía y coledocostomía con sonda T de urgencia por evolución a colangitis con resultados favorables. DISCUSIÓN: Los QC son una causa rara de ictericia obstructiva. En Chile existen escasos datos estadísticos al respecto. Se manifiesta con una sintomatología inespecífica, sobretodo en adultos. El diagnóstico se realiza con hallazgos de laboratorio concordantes con ictericia colestásica, donde los estudios imagenológicos como ultrasonido y TC tienen un rol importante, pese a que en algunas ocasiones pueden pasar inadvertido. Es primordial un alto índice de sospecha para el diagnóstico y un tratamiento oportuno debido a su importante riesgo de progresión a colangiocarcinoma

INTRODUCTION: Choledochal cysts (CCs) is a rare disease characterized by dilatation of the intrahepatic or extrahepatic bile duct, which is about 1% of all benign biliary lesions. Its incidence is 1:100,000 to 150,000 habitants. It is more common in females, and its etiology is unknown. In adults the symptoms are nonspecific, predominantly abdominal pain and jaundice. CASE REPORT: 61 year old female patient with three days of severe abdominal colic in the right upper quadrant, whit both vomiting and jaundice. On admission, she presents leukocytosis, hyperbilirubinemia, and increased levels of alkaline phosphatase, transaminases and amylase. Diagnosis of obstructive jaundice, pancreatitis and complicated hydatid cyst arising. The abdominal CT Scan reveals intra and extrahepatic saccular dilatations, compatible with a type IV-a CCs. Both cholecystectomy and T-tube choledochotomy were done by evolution to cholangitis with favorable results and satisfactory postoperative. DISCUSSION: CCs is a rare cause of obstructive jaundice, and in this regard, there are few data described in Chile, Its diagnosis requires a high index of suspicion because of its nonspecific symptoms found mostly in adults. Despite this, the diagnosis is determined with laboratory findings consistent with cholestatic jaundice and support diagnostic imaging such as ultrasound, CT Scan, among others. Although the imaging findings, it may not be detected. A correct diagnosis and appropriate treatment is essential because of its high risk of progression to cholangiocarcinoma. Currently the patient is waiting for resection of extrahepatic bile duct and Roux-en-Y hepatic jejunostomy which is the optimal treatment.