Cirugía Plástica en emergencias humanitarias: 20 años de experiencia con Médicos del Mundo / Plastic Surgery in humanitarian emergencies: a 20-year-experience period with Médicos del Mundo

En este artículo presento mi experiencia como cirujano plástico de la organización Médicos del Mundo en múltiples misiones de ayuda humanitaria quirúrgica: conflictos bélicos y emergencias tras desastres naturales, describiendo la dinámica de este tipo de misiones desde la movilización inicial hasta el fin de las mismas y desde una óptica tanto personal como de la organización para la que actúo. Las misiones se han llevado a cabo en 10 países de Europa, África y Asia, en las que se intervinieron quirúrgicamente más de 330 pacientes. El equipo quirúrgico desplazado está compuesto habitualmente por anestesista, cirujano ortopédico y cirujano plástico; una combinación adecuada para el tipo de patología encontrada tanto tras terremotos (fracturas abiertas, síndromes por aplastamiento, secuelas de síndromes compartimentales), como en conflictos bélicos (heridas por metralla, por arma de fuego, amputaciones traumáticas, quemaduras y pérdidas de sustancia). Todo ello sirve también para analizar la diferente ayuda humanitaria que la comunidad internacional ofrece en ambos escenarios (AU)

In this paper I present my experience as plastic surgeon working for Médicos del Mundo organization in multiple humanitarian aid surgical missions: war conflicts and emergencies after natural disasters, describing the dynamics of such missions from the initial mobilization until its final from both, a personal perspective and the organization for which I act. Missions were conducted in 10 countries of Europe, Africa and Asia, and more than 330 patients were operated. The displaced surgical team usually consists of anesthesiologist, orthopedic surgeon and plastic surgeon; a suitable combination for the type of pathology founded after earthquakes (open fractures, crush syndrome, sequelae of compartment syndrome) and war (shrapnel wounds, gunshot wounds, traumatic amputations, burns and loss of substance). The existing difference between the humanitarian aid given by the international community in both scenarios is also analyzed (AU)

Infliximab como opción terapéutica en pioderma gangrenoso mamario bilateral postquirúrgico refractario / Infliximab use as a therapeutic option in bilateral breast refractory postoperative pyoderma gangrenosum

El pioderma gangrenoso es una rara enfermedad cutánea ulcerada no infecciosa, perteneciente a las dermatosis neutrofílicas. Su etiopatogenia no está bien definida hasta el momento, barajándose un mecanismo inmunológico. La localización mamaria de la afectación es inusual, apareciendo tras cirugía en la mayoría de casos en relación con el fenómeno de patergia, pero también puede ser de aparición espontánea. Presentamos un caso de paciente con carcinoma de mama izquierda sometida a mastectomía radical con reconstrucción que desarrolla un pioderma gangrenoso bilateral postquirúrgico. Se diagnosticó erróneamente como dehiscencia de herida quirúrgica, procediéndose a múltiples desbridamientos que exacerbaron el problema y retrasaron el diagnóstico más de un año. Tras múltiples tratamientos, se decide inicio de terapia con infliximab debido a la refractariedad del proceso, evolucionando satisfactoriamente. La presentación de este caso tiene como objetivo el reconocimiento y abordaje precoz de esta entidad para aprender a prevenir su morbilidad física y psicológica (AU)

Pyoderma gangrenosum is a rare, non-infection, ulcerating skin disease, included into neutrophilic dermatosis. The pathogenesis of pyoderma gangrenosum has not been determined yet, but it might be related to the immunologic mechanism. The breast localization is unusual, appearing after surgery in most of cases due to the phatergy phenomenon but it can also appear unexpectedly. We report a case of bilateral postsurgical pyoderma gangrenosum of the breast in a patient with breast cancer subjected to mastectomy with reconstruction. The case is wrongly diagnosed as surgical wound dehiscence leading to several debridements that exacerbate the problem and delay the diagnosis by more than one year. After several treatments, it was decided to start with infliximab therapy due to the refractoriness of the process, evolving satisfactorily. The aim of investigating this case is to be able to detect the disease early, to prevent physical and psychological harm (AU)

Actinomicosis primaria de pared abdominal simuladora de sarcoma de partes blandas / Primary abdominal wall actinomycosis sarcoma simulator

La actinomicosis es una patología poco frecuente y su manifestación en la pared abdominal es más infrecuente aún. Está causada por Actinomyces israeli, una bacteria filamentosa, anaerobia estricta, gram positiva, que es comensal en el organismo y que en su forma patógena produce fibrosis, tejido de granulación y abscesos. La forma más frecuente es la cérvico-facial. Presentamos un caso de actinomicosis de pared abdominal diagnosticado postoperatoriamente, con sospecha prequirúrgica de proceso tumoral, por lo que queremos hacer especial mención acerca de la importancia del diagnóstico diferencial de actinomicetoma ante la presencia de una masa abdominal (AU)

Actinomycosis is an uncommon disease, and abdominal wall actinomycosis is rare. It is caused by Actinomyces israeli, a filamentous, gram-positive, anaerobic bacteria that lives in our organism and when the infection progresses, granulomatous tissue, extensive reactive fibrosis and necrosis, abscesses are formed. Infection involving the cervicofacial area is most common. We report a case of abdominal wall actinomycosis diagnosed postoperativerly with preoperative suspected tumor process, so we want to make special mention in the differential diagnosis of actinomycetoma with an abdominal mass (AU)

Conservación de la rodilla con colgajo libre plantar en sarcoma de miembro inferior. Caso clínico / Knee preservation with free plantar fillet flap in lower limb sarcoma. Case report

La cirugía conservadora del miembro es el objetivo ideal a lograr en el tratamiento del sarcoma de extremidades. La tasa de amputaciones en este tipo de tumores se ha reducido considerablemente. La combinación de cirugía conservadora de miembro y radioterapia proporciona los mismos resultados oncológicos con la ventaja de preservar el miembro y su función. A pesar de esto, todavía existen indicaciones de amputación de extremidades, como cuando se trata de masas que afectan al eje neurovascular principal del miembro, entre otras. En estos casos, puede ser útil el uso de colgajos fileteados para preservar la longitud del miembro o para cubrir estructuras nobles. Presentamos el caso clínico de un paciente con sarcoma fusocelular de alto grado de la rodilla en el que empleamos un colgajo libre plantar fileteado para preservar la articulación (AU)

Limb sparing surgery is a desirable goal in the treatment of lower limb sarcoma. Amputation rates in the treatment of this kind of tumours have showed a dramatically reduction. The combination of limb sparing surgery and radiotherapy achieve the same oncological results with the advantages of extremity and function preservation. Despite this fact there are still indications of limb amputation as mass involvements of the major neurovascular structures of the limb, among others. In those cases, fillet flaps may be used to preserve additional length or cover vital structures. We report a case of a patient with high-grade fusocellular sarcoma where the use of a free plantar fillet flap allows us to preserve the knee-joint (AU)

Sentinel lymph node biopsy for cutaneous melanoma: a 6 years study.

BACKGROUND: The aim of this study was to evaluate the results of sentinel lymph node biopsy (SLNB) in cutaneous melanoma at our institution. MATERIALS AND METHODS: 128 patients with primary cutaneous melanoma who underwent SLNB between April, 2004, and August, 2010 were studied. Univariate and multivariate analysis was performed to explore the effect of variables on mortality and sentinel node status. Survival analysis was performed using the Kaplan-Meier approach. RESULTS: Positive SLNB were detected in 35 (27.3%) of 128 cases. Mean Breslow depths were 3.7 mm for SLNB positive patients and 1.99 mm for SLNB negative patients. False negative rate was 1%. The recurrence rate was 40% for positive patients and 6.5% for negative patients (odds ratio 9.7 [confidence interval 95 % 3.3-28.1]). 33 patients (29%) had an ulcerated melanoma, 12 (10.5%) in the positive group and 21 (18.5%) in the negative group. The disease recurred in a 48.5% of patients with ulcerated melanoma, but only in a 2.5% of patients with non-ulcerated melanoma. Upon multivariate analysis, only Breslow thickness (P = 0.005) demonstrate statistically significance for SLNB status. Multivariate analysis for clinicopathologic predictors of death demonstrate statistically significance for Breslow thickness (P = 0.020), ulceration (P = 0.030) and sentinel node status (P = 0.020). CONCLUSIONS: This study confirms that the status of the sentinel node is a strong independent prognostic factor with a higher risk of death and lower survival. Patients with ulcerated melanoma are more likely to develop recurrence, and also higher risk of death than patients with non-ulcerated melanoma.

Effects of clonality on the genetic variability of rare, insular species: the case of Ruta microcarpa from the Canary Islands.

Many plant species combine sexual and clonal reproduction. Clonal propagation has ecological costs mainly related to inbreeding depression and pollen discounting; at the same time, species able to reproduce clonally have ecological and evolutionary advantages being able to persist when conditions are not favorable for sexual reproduction. The presence of clonality has profound consequences on the genetic structure of populations, especially when it represents the predominant reproductive strategy in a population. Theoretical studies suggest that high rate of clonal propagation should increase the effective number of alleles and heterozygosity in a population, while an opposite effect is expected on genetic differentiation among populations and on genotypic diversity. In this study, we ask how clonal propagation affects the genetic diversity of rare insular species, which are often characterized by low levels of genetic diversity, hence at risk of extinction. We used eight polymorphic microsatellite markers to study the genetic structure of the critically endangered insular endemic Ruta microcarpa. We found that clonality appears to positively affect the genetic diversity of R. microcarpa by increasing allelic diversity, polymorphism, and heterozygosity. Moreover, clonal propagation seems to be a more successful reproductive strategy in small, isolated population subjected to environmental stress. Our results suggest that clonal propagation may benefit rare species. However, the advantage of clonal growth may be only short-lived for prolonged clonal growth could ultimately lead to monoclonal populations. Some degree of sexual reproduction may be needed in a predominantly clonal species to ensure long-term viability.

Angiosarcoma en linfedema crónico (síndrome de Stewart-Treves) / Angiosarcoma in Chronic Lymphedema (Stewart-Treves Syndrome)

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Tratamiento local de metástasis cutánea facial de cáncer de colon mediante colgajo submentoniano / Local management of colon carcinoma metasasis in the face with a submental flap

Las metástasis cutáneas de los tumores del aparato digestivo son lesiones infrecuentes que aparecen en pacientes con estadíos avanzados de la enfermedad, frecuentemente ya intervenidos del tumor primario. Son lesiones que aparecen de novo, de características variables y crecimiento rápido; suelen localizarse en tronco o extremidades inferiores y se diagnostican precozmente, lo que hace fácil su extirpación y el cierre directo del defecto. Presentamos el caso de un paciente con cáncer de colon en estadío avanzado con lesión metastásica facial de 6 cm de diámetro en mejilla derecha. Esta lesión ulcerada y maloliente, precisaba curas diarias y empeoraba la calidad de vida del paciente. Se procedió a su extirpación y para cobertura realizamos un colgajo submentonianoipsilateral con excelente resultado. Este colgajo proporciona un tejido muy parecido al del defecto, creando mínimas secuelas de la zona donante que queda oculta en el área de sombra submandibular, por lo que representa una alternativa terapéutica ideal en defectos faciales de tamaño medio (AU)

Cutaneous metastasis of the digestive tract are infrequent lesions appearing in patients with advanced disease. Most of these patients have been already operated of their primary tumour. Lesions are variable in aspect, arising de novo and evolving with rapid growth. They usually lie in the trunk or lower extremities thus facilitating an early diagnosis and management with simple extirpation and direct closure. A case-report of a patient with advanced colonic canceris here presented. At admission he presented a cutaneous matastasic lesion in the right cheek; it was a 6 cm ulcerated, bad -smelling lesion which needed daily dressings affecting patient’s normal life. The lesion was removed using successfully a submental flap as coverage. The submental flap provides a very similar tissue to facial defects, leaving no donor area sequelae which is in addition well hidden, being consequently a good tool for midsize facial defects (AU)

Postoperative mediastinitis in open heart surgery patients. Treatment with unilateral or bilateral pectoralis major muscle flap?

AIM: the treatment of mediastinitis, after median sternotomy, in open heart surgery operated patients, remains an important and challenging problem in cardiac surgery. The management of this severe complication by means of surgical debridement of the sternum followed by mediastinal closure with pectoralis major muscle flaps, represents one of the best effective and most common modalities of treatment. The aim of the present publication is to demonstrate the good and comparable result in the mediastinal closure by using a single pectoralis muscle flap instead of two pectoralis muscle flaps. METHODS: in our hospital, between July 1998 and December 2004, 32 patients with mediastinitis were treated after adult open heart surgery with sternal debridement and pectoralis major muscle flaps. In 19 cases the sternal closure was performed with a single pectoralis muscle (group U) and in 13 cases with both pectoralis muscles (Group B). RESULTS: comparing the group U and group B, we did not found statistical differences in the variables of age, sex, associated diseases, previous myocardial infarction, kind of cardiac surgery undertaken, quality of the sternum, type of germen, number of previous sternal debridement performed and time of hospitalization. Patients in group U showed a statistically significant (P=0.001) shorted plastic reconstructive surgery time, an earlier extubation time (non statistically significant) and less need of blood transfusion (non statistically significant). The morbidity and hospital mortality in group U and B did not show any statistical differences. There were three cases of flap related complications in group B and two in group U. One death was recorded in group U (7.69%) and another in group B (5.26%). CONCLUSION: mediastinal infection after cardiac surgery can be effectively managed by surgical debridement followed by plastic coverage with a single pectoralis muscle flap. In our experience, this unilateral pectoralis muscle flap technique showed similar results to the classic closure with both pectoralis muscle flaps. The unilateral technique represents a relative low aggressive operation and preserves intact the contralateral pectoralis muscle. Comparing the single pectoralis muscle flap technique with the bilateral pectoralis musle technique, the former is faster, the extubation is earlier and there is less need of postoperative blood transfusions.

Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgery.

OBJECTIVE: To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release. METHODS: A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed. RESULTS: Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed. CONCLUSION: Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release.

Usefulness of clinical findings, nerve conduction studies and ultrasonography to predict response to surgical release in idiopathic carpal tunnel syndrome.

OBJECTIVES: To assess the usefulness of clinical findings, nerve conduction studies and ultrasonography performed by a rheumatologist to predict success in patients with idiopathic carpal tunnel syndrome (CTS) undergoing median nerve release. METHODS: Ninety consecutive patients with CTS (112 wrists) completed a specific CTS questionnaire and underwent physical examination and nerve conduction studies. Ultrasound examination was performed by a rheumatologist who was blind to any patient's data. Outcome variables were improvement >25% in symptoms of the CTS questionnaire and patient's overall satisfaction (5-point Likert scale) at 3 months postoperatively. Success was defined as improvement in both outcome variables. Receiver operating characteristics (ROC) curves and logistic regression analyses were used to assess the best predictive combination of preoperative findings. RESULTS: Success was achieved in 63% of the operated wrists. Utility parameters and area under the ROC curve (AUC) for individual findings was poor, ranging from 0.481 of the nerve conduction study to 0.634 of the cross-sectional area at tunnel outlet. Logistic regression identified the preoperative US parameters as the best predictive variables for success after 3 months. The best predictive combination (AUC=0.708) included a negative Phalen maneuver, plus absence of thenar atrophy, plus less than moderately abnormalities on nerve conduction studies plus a large maximal cross-sectional area along the tunnel by ultrasonography. CONCLUSION: Although cross-sectional area of the median nerve was the only predictor of success after three months of surgical release, isolated preoperative findings are not reliable predictors of success in patients with idiopathic CTS. A combination of findings that include ultrasound improves prediction.

Mediastinitis postesternotomia media en cirugía cardiaca / Mediastinitis after median sternotomy in cardiac surgery

Se presenta una revisión actualizada de aspectos epidemiológicos, clínicos, diagnóstico y tratamiento de las mediastinitis tras esternotomía media en cirugía cardiaca

An actualized review on deep mediastinal infection alter cardiac surgery is presented. Epidemiological, clinical, diagnostic and therapeutac aspects are exposed

Mionecrosis masiva por salmonella enteritidis en paciente inmunodeprimido / Massive salmonella enteritidis myonecrosis in inmunodeficient pacient

Salmonella enteritidis es un microorganismo que raramente afecta al componente muscular. Recogemos el caso de un paciente varón con Síndrome de Inmunodeficiencia Adquirida (SIDA), que tras un episodio de gastroenteritis aguda debida a Salmonella enteritidis presenta, varios meses después, una necrosis muscular masiva en los miembros inferiores, que le llevó al shock séptico y posteriormente a la muerte (AU)

Salmonella enteritidis is a microorganism which rarely affects muscles. We report a case of a male patient with AIDS, who suffered an episode of acute gastroenteritis due to Salmonella enteritidis, months ago. After this incident, the patient presented massive muscular necrosis in the lower limbs which led to septic shock and subsequent death (AU)

Fibrohistiocitoma maligno / Malignant fibrous histiocytoma

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Hidrosadenitis axilar severa: opciones quirúrgicas / Severe axilar hidrosadenitis: surgical options

En los cuadros severos de hidrosadenitis ( hidradenitis supurativa) axilar con un área infeccioso inflamatoria extendida y retracciones secundarias que limitan la capacidad funcional articular del hombro, la mejor solución pasa por el desbridamiento radical de todo el área afecta y su posterior cobertura con tejido de buena calidad. Los colgajos locales basados en perforantes torácico laterales y toracodorsales con distintos diseños y los derivados de la arteria circunfleja escapular con la Variante bilobulada escápulo - paraescapular para los casos extremos, ofrecen posibilidades locales de muy buena calidad para defectos de todas las dimensiones. Se presentan cinco casos de hidrosadenitis axilar mostrando las posibilidades de cobertura con los colgajos citados (AU)

Traumatismo torácico penetrante que afecta a una prótesis mamaria / Penetrating chest wound affecting a breast prosthesis

No disponible