Crystallographic, spectroscopic and thermal studies of 1-(4-bromophenyl)-5-(2,5-dimethyl-1H-pyrrol-1-yl)-3-methyl-1H-pyrazole.

The new title pyrrole-pyrazole derivative, C16H16BrN3, was synthesized through a citric acid-catalyzed Paal-Knorr reaction between acetonylacetone and 1-(4-bromophenyl)-3-methyl-1H-pyrazol-5-amine under mild reaction conditions. This synthetic protocol is noteworthy for its utilization of stoichiometric amounts of the reactants, an ecofriendly solvent and a cost-effective, non-toxic and biodegradable organocatalyst. A comprehensive understanding of the molecular structure was gained through spectroscopic, thermal and X-ray crystallographic analyses. The crystal structure is characterized by weak interactions, where only C-H...π connections contribute to the hydrogen-bond contacts. The supramolecular assembly is controlled by dispersion forces. However, the energy frameworks demonstrate that these forces act in three dimensions, providing enough stability, as observed in TGA-DSC (thermogravimetric analysis-differential scanning calorimetry) studies.

Resección vascular mayor por adenocarcinoma pancreático ductal: reporte del primer caso registrado en Paraguay / Major vascular resection for pancreatic ductal adenocarcinoma: case report, of first case reported in Paraguay

El adenocarcinoma pancreático ductal (APD) es la cuarta causa de muerte por cáncer y se proyecta que para el 2030 ocupe el segundo lugar. El pronóstico es sombrío, siendo la sobrevida menor a 9% en 5 años. Se consideró durante mucho tiempo a la resección quirúrgica como el único tratamiento curativo, sin embargo, sólo el 15 a 20% de los pacientes pueden ser beneficiados con la misma. La clasificación pre terapéutica más utilizada es la del National Comprehensive Cáncer Network (NCCN), basada en la relación del tumor con estructuras vasculares, clasificándolos en tumores "resecables", de resección límite "Borderlines" y "localmente avanzados". Se presenta el primer caso registrado en Paraguay de APD con infiltración de la Vena Mesentérica Superior (VMS) tratado con duodenopancreatectomía cefálica (DPC) asociada a resección vascular mayor.

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer death and is projected to rank second by 2030. The prognosis is bleak, with survival being less than 9% in 5 years. For a long time, surgical resection was considered the only curative treatment, however, only 15 to 20% of patients can benefit from it. The most widely used pre-therapeutic classification is that of the National Comprehensive Cancer Network (NCCN), based on the relationship of the tumor with vascular structures, classifying them into "resectable", "borderline" and "locally advanced" tumors. We present the first registered case in Paraguay of PDA with infiltration of the Superior Mesenteric Vein (SMV) treated with cephalic duodenopancreatectomy (CPD) associated with major vascular resection.

Presentaciones atípicas de COVID-19: Serie de casos / COVID-19 atypical presentations: Case series

Resumen El objetivo del presente trabajo fue presentar una serie de casos de COVID-19 con manifestaciones atípicas de la enfermedad. Los casos fueron atendidos por un equipo interdisciplinario de personal de la salud de una clínica de cuarto nivel en Barranquilla, Colombia, y posteriormente los investigadores tomaron los datos de las historias clínicas. Se evaluaron tres casos: el primero tuvo evolución tórpida y coinfección con virus de la influenza H1N1 y los otros dos, manifestaciones gastrointestinales como debut de la enfermedad; todos tuvieron desenlace satisfactorio. La pandemia por SARS-CoV-2 cada día cobra más vidas, por lo que para identificar oportunamente a los infectados y tomar medidas tanto terapéuticas como de prevención y así evitar la propagación de la enfermedad y lograr su control, es necesario realizar reportes de caso en donde se evidencie la diversa variedad de presentaciones de COVID-19.

Abstract The objective of this work is to present a series of cases of COVID-19 with atypical manifestations of the disease. The cases were evaluated by an interdisciplinary team of health personnel from a fourth-level clinic in Barranquilla, Colombia, and the data was subsequently taken from the clinical history of each patient. Three cases were evaluated, initially the first case with torpid evolution, coinfection with H1N1 influenza virus, however, with satisfactory outcome, and cases two and three with gastrointestinal manifestations as disease debut, with satisfactory evolution. The SARS-CoV-2 pandemic takes more lives every day, so it is necessary to describe the cases and their diverse variety of presentation, to identify the infected and take both therapeutic and preventive measures. To prevent the spread of the disease and achieve its control.

Patients with abdominal-based free flap breast reconstruction a decade after surgery: A comprehensive long-term follow-up study.

BACKGROUND: Abdominal-based free flap has increasingly become the gold standard for breast reconstruction, however long-term evidence of the aesthetic outcome and quality of life is lacking. The present study aims to gain an overview of patients with abdominal-based free flap breast reconstructions in a long-term perspective. METHODS: Seventy-five patients who received abdominal-based free flap breast reconstructions between 2000-2007 in Uppsala, Sweden were invited back for photographs, 3D imaging and questionnaires. A retrospective chart review was conducted. Patient satisfaction with appearance and quality of life were assessed using the Breast-Q questionnaire. A layman panel and a professional panel rated the aesthetic appearance of the reconstructed breast from photographs and 3D images. RESULTS: Fifty-five patients participated with a mean age of 52 ±â€¯8 years at the time of reconstruction and a mean follow-up time of 11.4 ±â€¯1.8 years completed the study. The majority of the patients had received unilateral (85%), delayed reconstructions (73%) with prior radiation (55%). There were 53 patients with DIEP flaps, one with free TRAM flap and one with SIEA flap. Breast-Q scores in the cohort were comparable to normative values of women without breast cancer (p < 0.001). There was a high level of agreement for the aesthetic results of the reconstructions between patient, professionals and layman panels (0.89 ICC, 95% CI: 0.83  - 0.93). CONCLUSION: Abdominal-based free flap reconstructions were effective in achieving a lasting positive aesthetic result and a high quality of life in patients a decade after surgery.

Tipo de derivación urinaria en el paciente llevado a cistectomía radical, participación del urólogo y tasa de filtración de la anastomosis intestinal / Type of urinary diversion in the patient led to a radical cystectomy, participation of the urologist, and filtration rate of intestinal anastomosis

Objetivo Conocer la prevalencia de cistectomías radicales que se realizan en centros especializados en Colombia, definiendo tipo de derivación intestinal, participantes en su creación, segmento intestinal utilizado y tasa de filtración. Materiales y métodos Se realizó una encuesta a instituciones de salud colombianas que realizan cistectomías radicales de manera rutinaria, se analizaron variables como número de procedimientos por año, segmento intestinal utilizado, tipo de especialidad participante en la anastomosis intestinal y la tasa de filtración de esta. Resultados Quince instituciones colombianas respondieron la encuesta, el número de cistectomías realizadas por año fue: 5/15 (33,3%) más de 15 cirugías al año, 4/15(26,6%) entre 11 y 15 procedimientos al año, 3/15 (20%) entre 5 y 10 y otro 3/15 (20%) entre 1 y 5 cistectomías al año. El 93,3% de las instituciones realizan Bricker como derivación más común; solo una institución (6,7%) lleva a cabo ureterostomías cutáneas. Con respecto a los participantes en la creación de la anastomosis de las 14 instituciones, en 9 (64,2%) es realizada por cirujano general, en 4 (28,5%) la lleva a cabo un urólogo y en una (7,4%) la derivación es realizada por coloproctólogo. La gran mayoría de los centros tiene una incidencia baja de filtración intestinal. Conclusiones En la gran mayoría de las instituciones colombianas el cirujano general y en menor medida el urólogo participan en la creación de la anastomosis intestinal como parte del protocolo de la institución. La filtración es una complicación poco frecuente pero con alta morbimortalidad. Se requiere de entrenamiento por parte del urólogo en formación para lograr mejores resultados.

Objective To determine the prevalence of radical cystectomies that are performed in specialist centres in Colombia, defining the type of intestinal derivation, participants in its creation, intestinal segment used, and filtration rate. Materials and methods A survey was conducted in Colombian health institutions that routinely perform radical cystectomies. An analysis was made of the variables, such as number of procedures per year, intestinal segment used, specialty participating in the intestinal anastomosis, and the rate of filtration. Results A total of 15 health institutions responded to the survey. The number of cystectomies performed per year was; 5/15 (33.3%) with greater than 15 surgeries per year, 4/15 (26.6%) with between 11 and 15 procedures per year, 3/15 (20%) between 5­10/year, and another 3/15 (20%) between 1­5 cystectomies per year. Most (93.3%) of the institutions performed a Bricker as the most common derivation, with only one institution (6.7%) performing cutaneous ureterostomies. As regards the participants in the creation of the anastomosis of the 14 institutions, 9 (64.2%) were performed by a general surgeon, by a urologist in 4 (28.5%), and a coloproctologist performed the shunt in one (7.4%). The vast majority of centres have a low incidence of intestinal filtration. Conclusions In the great majority of Colombian institutions, the general surgeon, and to a lesser extent the urologist, participate in the creation of intestinal anastomosis as part of the protocol of the institution. Filtration is a rare complication, but with a high morbidity and mortality. Training by the urologist during training is required to achieve better results.

Race and socioeconomic disparities in national stoma reversal rates.

BACKGROUND: Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. METHODS: Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. RESULTS: The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001). CONCLUSIONS: Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.

Factores de riesgo cardiovascular (FRCV) en una comunidad aborigen Pilagá de la localidad de Campo del Cielo, Provincia de Formosa, Argentina / Cardiovascular risk factors (CVRF) in an Pilagá aboriginal community in the town of Campo del Cielo, Province of Formosa, Argentina

Se realizó un estudio observacional descriptivo de corte transversal con el objetivo de determinar algunos factores de riesgo en la comunidad aborigen pilagá asentada en la localidad del Campo del Cielo (Departamento Patiño, Provincia de Formosa, Argentina) en el mes de noviembre del año 2012. Se evaluaron a 67 individuos sobre un total de 96 personas mayores de 18 años miembros de la comunidad. En orden decreciente, los factores de riesgo que se observaron fueron: sedentarismo 74.2%, pre-hipertensión arterial 55.2%; sobrepeso y obesidad 52.2%; ICC (índice cintura cadera) elevado 47.7%; obesidad central 40.30%; hipertensión 31.3%; antecedentes familiares 26.87%; tabaquismo 3% y diabetes 0%. Entre las mujeres, los dos factores más prevalentes fueron el sedentarismo 86.1% y el ICC elevado 83.3%, entre los hombres, la obesidad y sobrepeso 48.4% y la pre-hipertensión 48.4%. En la comunidad pilagá, la prevalencia de HTA, sobrepeso y obesidad, obesidad central e ICC fueron muy similares a la media nacional y provincial pero se comprobó también la inexistencia de hábito tabáquico y DBT2 (factores de riesgo mayores). Esto permite concluir con que el riesgo cardiovascular en la comunidad pilagá es más bajo que en el resto de la población, pero no inexistente. Ante esta situación que no sólo se observa en estas comunidades originarias sino también en buena parte de la comunidad formoseña, es necesario implementar programas preventivos basados en la prevención y la promoción de estilos de vida saludables. Palabras claves: Factores de riesgo cardiovascular, etnia Pilagá, Formosa

SUMARY We conducted an observational cross-sectional descriptive study in order to determine some risk factors from the Pilagá Aboriginal community settled in the town of Campo del Cielo (Department of Patiño, Formosa Province, Argentina). The work was performed in November 2012. Sixty seven individuals were evaluated on a total of 96 people over 18 years available to the community. In decreasing order of the risk factors that were observed are: sedentary (74.2%), pre-hypertension (55.2%), overweight and obesity (52.2%); ICC high (47.7%), central obesity (40.30%), hypertension (31.3%), family history (26.87%), smoking (3%) and diabetes (0%). Among women the two most prevalent factors were physical inactivity (86.1%) and the ICC high (83.3%) and among men were obesity and overweight (48.4%) and pre-hypertension (48.4%). In pilagá community, the prevalence of hypertension, overweigh and obesity, central obesity and ICC were very similar to the national and provincial average but there was also found the lack of smoking and type 2 diabetes mellitus (higher risk factors). This leads to the conclusion that the cardiovascular risk in the community pilagá is lower than in the rest of the population, but not nonexistent. In this situation not only observed in these indigenous communities but largely in Formosa´s community, it is necessary to implement preventive programs based on prevention and promotion of healthy lifestyles. Key words: Cardiovascular risk factors - ethnic Pilagá ­ Formosa

Estenosis benigna de la vía biliar principal / Benign bile duct strictures

El manejo de las estenosis benignas de los conductos biliares es uno de los problemas más difíciles de la cirugía abdominal. El diagnóstico no siempre es evidente a partir de la historia clínica, y la intervención quirúrgica para restablecer el flujo normal de bilis en el tracto gastrointestinal, presenta muchos problemas técnicos y requiere del mayor ingenio por parte del cirujano.Se presenta el caso de un paciente de sexo masculino de 58 años de edad, que presentaba una estenosis del tracto biliar distal de etiología indeterminada, al cual se le realizó una duodeno pancreatectomía cefálica, descartándose la patología maligna.

The management of benign bile duct strictures is one of the most difficult problems in abdominal surgery. Diagnosis is not always clear from the history, and surgical intervention to restore the normal bile flow in the gastrointestinal tract presents many technical issues and it requires the surgeon’s ingenuity. We report the case of a 58 year old male patient who presented with distal biliary tract stenosis of unknown etiology and underwent pancreaticoduodenectomy, which discarded malignancy.

Resección segmentaria duodenal por tumor estromal en la tercera porción / Duodenal segmental resection for third portion stromal tumor

Los GIST son tratados preferentemente de manera quirúrgica. La localización duodenal de los mismos corresponde al 4,5% de los casos pero el tratamiento de los tumores en esta localización no está estrictamente definido. Se reporta el caso de una mujer de 59 años con antecedentes de cólicos biliares y melena. El estudio ecográfico demostró litiasis vesicular y una lesión redondeada de 4 cm diámetro de localización retroperitoneal. La tomografía abdominal ubicó a la masa en la tercera porción duodenal (confirmada por la duodenoscopía) con aspecto sugerente de tumor estromal. Fue sometida a laparotomía, donde se realizó colecistectomía y resección segmentaria de la tercera y cuarta porción duodenal con anastomosis duodeno-yeyunal. Durante la internación presentó ictericia pasajera y fuga anastomótica de bajo débito que cerró espontáneamente. El alta se realizó al 16° día postoperatorio. El estudio anatomopatológico reveló un tumor de bajo grado con células características del estroma intestinal. La inmunohistoquímica confirmó la estirpe estromal intestinal del tumor (CD117+).

GISTs are preferably treated surgically, duodenal location corresponding to 4.5 % of cases but the treatment of the tumors in this location is not strictly defined. We report the case of a 59 year old woman with a history of biliary pain, and an episode of melena. Ultrasound examination showed gallstones and a retroperitoneal lesion of almost 4 cm diameter. The TAC placed the mass in the third portion of the duodenum (confirmed by duodenoscopy) with characteristical aspect of a stromal tumor. At the laparotomy was performed segmental resection of the third and fourth portion of the duodenum with duodenal- jejunal anastomosis. During hospitalization the patient presented temporary jaundice and low flow anastomotic leak that closed spontaneously and she went home on the 16th postoperative day. The pathological study revealed low-grade tumor with intestinal stromal cell characteristics. The immunohistochemistry confirmed the intestinal stromal tumor lineage (CD117 +). The duodenum - pancreatectomy is not always necessary for the treatment of tumors of the duodenum.

The pectoralis major myocutaneous flap.

INTRODUCTION: The pectoralis major myocutaneous flap (PMMF) is a workhorse flap for head and neck reconstruction and a flap of choice for anterior chest wall reconstruction. METHODS: A thorough review of the literature was undertaken, exploring the full range of designs, variations, indications, and outcomes of the PMMF. RESULTS: Numerous modifications have been documented since it was first described in 1968. Complication rates vary greatly in the literature, but most institutions describe significant success with the PMMF. It is fast, versatile, reliable, and a good alternative when microsurgical flap failure occurs. A classification system of skin paddles is presented. CONCLUSION: In the era of free tissue transfer, the PMMF still has its advantages and continues to command an important place in the reconstructive surgeon's armamentarium.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects.

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases.

UNLABELLED: Defects of the Achilles tendon and the overlying soft tissue are challenging to reconstruct. The lateral-arm flap has our preference in this region as it provides thin pliable skin, in addition, the fascia and tendon can be included in the flap as well. The aim of this report is to share the experience the authors gained with this type of reconstruction. The authors report the largest series in the published reports today. PATIENTS AND METHODS: A retrospective review was performed of all patients treated between January 2000 and January 2009 with a lateral-arm flap for a soft-tissue defect overlying the Achilles tendon. RESULTS: In the reviewed period, 16 soft-tissue defects overlying the Achilles tendon were reconstructed, with a mean follow-up of 63 months. In three cases, tendon was included into the flap and in two, a sensory nerve was coapted. Fifteen cases (94%) were successful, one failed. In seven cases, a secondary procedure was necessary for thinning of the flap. CONCLUSION: The lateral-arm flap is a good and safe option for the reconstruction of defects overlying the Achilles tendon.

Enfermedad hipertensiva del embarazo y el calcio / Pregnancy hypertensive disease related to calcium

Actualmente se pueden esperar cifras mundiales de preeclampsia de 143 667 casos y 431 000 de gestosis grave, muertes maternas mundiales de 20 000 pacientes y hasta 86 000 muertes perinatales. Esta afección es responsable de complicar entre el 2 y el 8 por ciento de los embarazos. En países desarrollados, la eclampsia es rara y afecta alrededor de 1 por cada 2 000 partos, mientras que en los países en vías de desarrollo esta cifra varía desde 1 en 100 hasta 1 en 1700. La hipertensión inducida por el embarazo es un factor mayor en la morbilidad y mortalidad materna y perinatal. Aunque esta enfermedad es relativamente común, su etiopatogenia es desconocida. Nuevas evidencias epidemiológicas, experimentales y clínicas en personas no embarazadas y en embarazadas, indican que el calcio puede desempeñar un rol importante en la regulación de la presión arterial. Son muchos los autores que señalan la importancia de suministrar el calcio durante el embarazo como elemento preventivo de la hipertensión arterial

Nowadays, it is possible to expect world figures of pre-eclampsia of 143 667 cases and 431 000 severe gestosis, global mother deaths of 20 000 patients and up to 86 000 perinatal deaths. This affection accounts for the complication between the 2 and the 8 percent of pregnancies. In developed countries, the pre-eclampsia is a rare entity and involves about 1 per each 2 000 labors, whereas in the developing ones, this figure fluctuates from 1 in 100 up to 1 in 1700. The high blood pressure induced by pregnancy is a major factor in the mother and perinatal morbidity and mortality. Although this disease is relatively common, its pathogenesis is unknown. New epidemiologic, experimental and clinical evidences in pregnant and non pregnant persons, suggest that calcium may play a significant role in the regulation of the blood pressure. Many authors emphasize on the significance of to supply calcium during the pregnancy as a preventive element of the high blood pressure

Enfermedad hipertensiva del embarazo y el calcio / Pregnancy hypertensive disease related to calcium

Actualmente se pueden esperar cifras mundiales de preeclampsia de 143 667 casos y 431 000 de gestosis grave, muertes maternas mundiales de 20 000 pacientes y hasta 86 000 muertes perinatales. Esta afección es responsable de complicar entre el 2 y el 8 por ciento de los embarazos. En países desarrollados, la eclampsia es rara y afecta alrededor de 1 por cada 2 000 partos, mientras que en los países en vías de desarrollo esta cifra varía desde 1 en 100 hasta 1 en 1700. La hipertensión inducida por el embarazo es un factor mayor en la morbilidad y mortalidad materna y perinatal. Aunque esta enfermedad es relativamente común, su etiopatogenia es desconocida. Nuevas evidencias epidemiológicas, experimentales y clínicas en personas no embarazadas y en embarazadas, indican que el calcio puede desempeñar un rol importante en la regulación de la presión arterial. Son muchos los autores que señalan la importancia de suministrar el calcio durante el embarazo como elemento preventivo de la hipertensión arterial(AU)

Nowadays, it is possible to expect world figures of pre-eclampsia of 143 667 cases and 431 000 severe gestosis, global mother deaths of 20 000 patients and up to 86 000 perinatal deaths. This affection accounts for the complication between the 2 and the 8 percent of pregnancies. In developed countries, the pre-eclampsia is a rare entity and involves about 1 per each 2 000 labors, whereas in the developing ones, this figure fluctuates from 1 in 100 up to 1 in 1700. The high blood pressure induced by pregnancy is a major factor in the mother and perinatal morbidity and mortality. Although this disease is relatively common, its pathogenesis is unknown. New epidemiologic, experimental and clinical evidences in pregnant and non pregnant persons, suggest that calcium may play a significant role in the regulation of the blood pressure. Many authors emphasize on the significance of to supply calcium during the pregnancy as a preventive element of the high blood pressure(AU)

The deep inferior epigastric artery perforator flap for autologous reconstruction of large partial mastectomy defects.

BACKGROUND: Breast conservation surgery in the treatment of early stage breast cancer has become increasingly utilized as a means to avoiding mastectomy. While partial mastectomy defects (PMDs) may often be cosmetically acceptable, some cases warrant consideration of reconstructive options, and while several reconstructive options have been described in this role, a series of deep inferior epigastric perforator (DIEP) flaps has not been reported to date. METHODS: A cohort of 18 patients undergoing PMD reconstruction with a DIEP flap were included. Patient-specific data, operation details, cosmetic results, and complication rates were assessed. Oncologic outcomes, in particular recurrence rates, were also evaluated. RESULTS: In our series there were no cases of partial or total flap necrosis, and overall complications were low. There were two cases of wound infection (both had undergone radiotherapy), managed conservatively, and one case of reoperation due to hematoma. There were no cancer recurrences or effect on oncologic management. Cosmetic outcome was rated as high by both patients and surgeon. The results were thus comparable with other reconstructive options. CONCLUSION: Although autologous reconstruction has an established complication rate, our results suggest that the DIEP flap may be of considerable value for delayed reconstruction of selected larger partial mastectomy defects.

Sutured attachment of the implantable Doppler probe cuff for large or complex pedicles in free tissue transfer.

The Cook-Swartz implantable Doppler probe (Cook Medical(®), Cook Ireland Ltd., Limerick, Ireland) has evolved as a useful option for postoperative free flap monitoring. For placement, the probe either is left unattached around the venous pedicle or is secured. In our experience with over 300 applications, we typically secure the cuff with two small microclips, or use fibrin glue. These techniques require redundant silicone cuff for apposition; however, we have encountered some vessels that are of sufficiently large diameter as to not provide enough cuff to employ these methods. The first technique comprises the application of two interrupted sutures through the cuff ends to mimic the technique of microclips. The sutures can be tightened to the desired tension and can be used in cases where the cuff ends are not in direct apposition. A second technique is to excise a segment of silicone cuff and either clip or suture the excised segment to the cuff ends, effectively elongating the cuff diameter. All four techniques (nonattachment, microclip fixation, suture fixation, silicone cuff elongation) have been used effectively, and none have resulted in any complications. Of note, the technique of nonattachment was associated with an increased rate of false-positive results, as migration away from the vessel was postulated to have occurred. There are a range of techniques for attachment of the implantable Doppler probe, and each contributes to the range of options for cuff attachment in difficult cases, with each technique worthwhile in particular settings.

The pedicled 'propeller' deep inferior epigastric perforator (DIEP) flap for a large abdominal wall defect.

The deep inferior epigastric perforator (DIEP) flap has become a popular free flap for use in breast reconstruction, providing a versatile volume of tissue with low donor site morbidity and in particular its ease of direct donor site closure. While its use in free tissue transfer has been widely reported, its use as a local pedicled flap has been more scarcely described. Limited reports include its use for hip and groin defects and in penile reconstruction. A long and robust vascular pedicle is ideal for islanded local advancement or so-called 'propeller' rotation to adjacent abdominal wall defects, with Seyhan and Borman (2008) describing such a technique for coverage of the lower abdominal wall, and we have described such a technique to aid closure of the lower abdominal wall during contralateral DIEP flap harvest. Having been presented with a large central-lower anterior abdominal wall defect, we describe a further application of the pedicled 'propeller' DIEP flap.