Role Of Intravenous Iron Over Nonsurgical Transfusions In Major Burns.

Anemia is a frequent condition in burn patients due to a mixture of blood loss and chronic inflammation. Transfusions increase the probability of serious infections and reduce overall survival, especially when unrelated to perioperative blood loss. Once the surgical phase in burn patients is completed, the role of parenteral iron administration in the reduction of subsequent transfusions is not well established. Burn patients subjected to at least two surgeries and presenting progressive anemia after concluding the surgical phase, without major symptoms, were selected (n=12). Those patients with confirmed iron deficiency were treated with intravenous (i.v.) ferric carboxymaltose (n=8). Subsequently, these patients were compared with a group of 18 control patients selected from our historical database (n=1375), matching controls by age (±5 years), sex, and TBSA burn (±6%). The objective was to verify if i.v. iron administration reduced the need for blood transfusions after the surgical phase. The analysis concluded that none of the cases treated required transfusions compared to 44% of the controls. There were no side effects related to the i.v. iron infusion. This result suggests that i.v. iron supplementation with ferric carboxymaltose could be an alternative in anemic patients without major symptoms once the surgical phase is completed. Iron deficiency should be assessed and i.v. supplementation must be administered if required in burn patients showing progressive anemia.

L'anémie, à la fois par pertes sanguines et inflammation, est fréquente chez les brûlés. Les transfusions, en particulier lorsque l'anémie n'est pas liée à la chirurgie, sont corrélées à la survenue d'infections sévères et à la mortalité. Une fois la phase chirurgicale terminée, le rôle de la thérapie martiale intraveineuse sur l'épargne transfusionnelle est mal connu. Nous avons évalué 12 patients brûlés, ayant été opérés au moins 2 fois et ne devant plus l'être, qui développaient une anémie progressive bien tolérée. Les 8 patients ayant une carence martiale ont reçu du carboxymaltose ferrique intraveineux. Ils ont été comparés avec 18 patients témoins, sélectionnés dans notre base de données de 1 375 dossiers, appariés sur l'âge +/- 5 ans, le sexe et la surface brûlée +/- 6%, l'objectif étant de vérifier si le traitement permettait effectivement de réduire les transfusions. Effectivement, aucun des patients traités n'a été transfusé, contre 44% des témoins. Aucun effet secondaire n'a été observé après administration de fer. Ceci suggère que des patients brûlés, chirurgie terminée, anémiques pauci- symptomatiques par carence martiale devraient recevoir un traitement martial IV.

Surgical treatment and management of the severely burn patient: Review and update / Tratamiento y manejo quirurgico del paciente gran quemado: revisión y puesta al día

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients (AU)

La escarectomía precoz y la cobertura de la quemadura son fundamentales en la prevención de la infección en el paciente quemado agudo. Mediante un desbridamiento quirúrgico intensivo inicial se retira el tejido no viable. Se han descrito múltiples opciones quirúrgicas para cobertura del lecho cutáneo, aunque los injertos de piel parcial continúan siendo el estándar para una cobertura rápida y permanente de las quemaduras de espesor total. Los grandes avances que han tenido lugar en décadas anteriores han mejorado de forma sustancial los cuidados del paciente quemado de tal forma que parece difícil que pueda haber mejoras importantes en las tasas de supervivencia futuras. Técnicas tales como la investigación en células madre, injertos, biomarcadores, control de la inflamación y rehabilitación contribuirán a mejorar unos planes de cuidados individualizados y a crear nuevas opciones de tratamiento para estos pacientes (AU)

Surgical treatment and management of the severely burn patient: Review and update.

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.

A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital.

BACKGROUND: Postmastectomy breast reconstruction involves the use of large amounts of hospital resources. This study provides comparative data on the clinical results and long-term economic costs of two methods of breast reconstruction in a public hospital. METHODS: A prospective cohort study was performed to evaluate the costs incurred by delayed unilateral breast reconstruction performed using either the two-stage sequence expander/prosthesis (E-P) or autologous deep inferior epigastric flap (DIEP) method during 2005-2013 in 134 patients. The major evaluated variables included previous clinical records, history of radiotherapy, and number of surgical procedures. Total costs accounted for both direct intra- and extra-hospital costs derived from the initial reconstruction and those resulting from associated reoperations due to aesthetic retouches and/or complications. RESULTS: Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction (3.07 vs. 2.32, p < 0.001) and showed higher rates of surgery-related complications (40.29% vs. 32.82%). No statistically significant differences were found between the two surgical methods in terms of total costs (€18857.77 DIEP vs. €20502.08 E-P; p = 0.89). In the E-P cohort, active smoking and history of radiotherapy were statistically significant risk factors of complications. In the DIEP group, only active smoking was significantly associated with complications. CONCLUSIONS: Compared to the E-P method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable aesthetic results. E-P reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.

Coste preciso de la reconstrucción mamaria con colgajo DIEP e implantes en un hospital público del sistema sanitario español / Accurate cost of breast reconstruction with DIEP flap and implants in a public hospital in the spanish healthcare system

La reconstrucción mamaria postmastectomía puede suponer un importante consumo de recursos humanos y económicos para cualquier sistema sanitario. El propósito de este estudio es saber si el peso económico asignado por el Sistema Nacional de Salud Español según codificación mediante Grupos Relacionados con el Diagnóstico a los dos procedimientos principales de reconstrucción mamaria, se ajusta al gasto inferido según el consumo de recursos real de las pacientes. Realizamos un estudio retrospectivo de cohortes para evaluar el coste económico de 134 pacientes intervenidas de reconstrucción mamaria unilateral diferida mediante los procedimientos expansor-prótesis (E-P) y colgajo de perforantes de la arteria epigástrica inferior profunda (DIEP), durante el periodo comprendido entre 2005 y 2013. Los datos analizados e inferidos de las pacientes fueron los costes directos intrahospitalarios y extrahospitalarios tanto de la cirugía inicial de reconstrucción como de los procedimientos secundarios. Las pacientes reconstruidas con E-P precisaron un mayor número de cirugías para completar su reconstrucción, y presentaron mayor porcentaje de complicaciones relacionadas con la cirugía. El porcentaje de cirugías de retoque estético fue superior en la reconstrucción DIEP. No encontramos diferencias significativas en el coste total inferido de las pacientes entre ambas cohortes (18.857,77 Euros DIEP frente a 20.502,08 Euros E-P, p = 0,89). El coste total de la reconstrucción mamaria según Grupos Relacionados con el Diagnóstico fue inferior al coste total inferido de las pacientes para ambas cohortes (11.596,43 Euros frente a 18.857,77 Euros, p < 0,001 DIEP; 13.565,82 Euros frente a 20.502,08 Euros E-P, p < 0,001). El coste de la reconstrucción mamaria está inadecuadamente tarifado por los gestores sanitarios; el coste según Grupos Relacionados con el Diagnóstico es inferior al coste inferido de las pacientes para cualquiera de los dos procedimientos. Consideramos que la reconstrucción con colgajo DIEP es más costeefectiva que la reconstrucción con E-P, pues requiere menos procedimientos quirúrgicos, presenta menor porcentaje de complicaciones y permanece más estable a lo largo del tiempo (AU)

Mastectomy breast reconstruction can be a significant consumption of human and financial resources for any health system. The purpose of this study is whether the economic weight assigned by the Spanish National Health System as encoding by Healthcare Resource Groups to two major breast reconstruction procedures fits true estimate of patients. A retrospective cohort study has been performed to evaluate the economic cost of 134 patients operated on for unilateral breast reconstruction delayed by the expander-prosthesis (E-P) and deep inferior epigastric artery perforator flap (DIEP) procedures during the period between 2005 and 2013. The data analyzed and economic cost estimated of the patients were in-hospital and out-patient direct costs of both the initial reconstruction surgery as secondary procedures. Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction procedure and showed higher rates of surgery-related complications. The percentage of surgery required for aesthetic retouch was higher in patients reconstituted with DIEP flap. No statistically significant differences were found regarding total cost between the two cohorts (18.857,77 Euros DIEP vs 20.502,08 Euros E-P, p = 0,89). Total cost of breast reconstruction according Healthcare Resource Groups was lower than total estimated cost of patients for both cohorts (11.596,43 Euros vs Euros 18.857,77 Euros, p < 0.001 DIEP; 13,565.82 vs 20,502.08 Euros, p < 0.001 E-P). The cost of breast reconstruction is inadequately tariffed by health managers; the cost using Healthcare Resource Groups is less than the estimated cost of the patients to either procedures. We consider that DIEP flap reconstruction is more cost-effective than E-P reconstruction, as it requires less surgical procedures, presents lower complication rate and remains more stable over time (AU)

Reimplante de pulgar. Casuística del Hospital Universitario Virgen del Rocío (Sevilla) entre los años 2005-2010 / Thumb reimplatation. Casuistic at University General Hospital Virgen del Rocío, Seville, Spain (2005-2010)

Las amputaciones de pulgar son indicación de reimplante en todos los casos, ya que el papel de este dedo es crucial para que una mano sea funcional. El objetivo de nuestro estudio es revisar la casuística de reimplantes de pulgar de los últimos 6 años en el Hospital Universitario Virgen del Rocío de Sevilla, España. Revisamos el mecanismo de lesión, el nivel de amputación, el uso de injerto venoso y el tipo de osteosíntesis realizado. La tasa de supervivencia lograda fue del 74,19%. Creemos que es una tasa de supervivencia elevada, que asocia los mejores resultados a las amputaciones sin componente de aplastamiento. El uso de injerto venoso se asocia igualmente a mejores resultados de la cirugía en casos de aplastamiento o arrancamiento como mecanismo de lesión (AU)

Reimplantation is indicated in all cases of thumb amputation as this digit plays a key role in hand function. The aim of the present study is to review all cases of thumb reimplantation carried out during the last 6 years at Virgen del Rocío University Hospital in Seville, Spain. Data regarding the type of injury, the amputation level, the use of venous grafts and the type of osteosynthesis were collected in all cases. Survival rates reached 74.19%. We can conclude that survival rates in patients undergoing thumb reimplantation are high and even a better outcome can be obtained in injuries without crushing lesions. The use of venous grafts is also associated with a better surgical outcome in amputations due to crushing or avulsion mechanisms (AU)

Optimización en el uso del colgajo de segunda perforante intercostal de la arteria mamaria interna / Optimizing the use of the second intercostal perforator flap of the internal mammary artery

El colgajo en isla basado en perforantes de la arteria mamaria interna (colgajo IMAP) se emplea de manera reciente como técnica reconstructiva en cabeza y cuello. El objetivo de esta revisión es corroborar las posibilidades del arco de rotación de dicho colgajo cuando se realiza una amplia disección de su pedículo vascular. Presentamos 4 pacientes de edades comprendidas entre 46 y 75 años, todos ellos varones, con defectos faríngeos parciales, en los que empleamos un colgajo pediculado basado en la segunda perforante de la arteria mamaria interna para reconstrucción del defecto faríngeo. El tamaño medio del defecto a cubrir fue de 3,2 cm (desviación estándar +/- 1,5 cm) en sentido horizontal y 4,5 cm (desviación estándar +/- 2,2 cm) en sentido vertical. En todos los casos se disecó un colgajo en isla con un tamaño medio de 6 X 8 cm. La longitud media del pedículo fue de 5,5 cm (desviación estándar +/- 1,51 cm). En todos los casos fue posible sellar el defecto faríngeo sin necesidad de resecar costilla o de incorporar parte de la arteria mamaria interna correspondiente. El colgajo IMAP es un colgajo rápido de realizar que permite la reconstrucción de defectos faríngeos parciales de la región anterior del cuello y hasta la base de la lengua sin necesidad de resección costal o incorporación parcial de los vasos mamarios (AU)

The island flap based on perforators of the internal mammary artery (IMAP flap) is recently used in reconstruction of head and neck defects. The aim of this review is to verify the possibilities of the arc of rotation of the flap when it's necessary to carry out an extensive dissection of the vascular pedicle. We present reconstruction of partial pharyngeal defects in 4 patients, aged between 46 and 75 years and all men, using a pedicle flap based on the second perforator of the internal mammary artery. The average size of the defect was 3.2 cm (SD +/- 1.5 cm) horizontally and 4.5 cm (SD +/- 2.2 cm) vertically. In all cases, an island flap was dissected with an average size of 6 X 8 cm. The average length of the pedicle was 5.5 cm (SD +/- 1.51 cm). In all cases it was possible the sealing of the pharyngeal defect without rib resection or to incorporate part of the corresponding internal mammary artery. IMAP flap is rapid to dissect and allows coverage in case of partial pharyngeal defects from anterior neck to the base of the tongue without needing rib resection or partial incorporation of the mammary vessels (AU)

Reconstruction of a severe facial defect by allotransplantation in neurofibromatosis type 1: a case report.

BACKGROUND: On January 26, 2010, our team performed a facial transplant for a patient with neurofibromatosis type 1. We detail the perioperative surgical strategies for the composite tissue allograft (CTA) of the lower parts of the face to restore a severe defect after excision of bilateral massive plexiform neurofibromas. The main distinctive feature included an innovative provisional heterotopic transplantation (PHT) technique of the facial allograft to the femoral vessels before its final orthotopic transplantation. CASE REPORT: A 35-year-old Caucasian man received a CTA of the lower two-thirds of the face, including a chin osseous segment. The face was obtained from a non-heart-beating donor. The sequence of microsurgical procedures began by performing a PHT of the CTA to the recipient's femoral vessels in the right thigh. Intraoperatively, he experienced considerable blood loss that required transfusion of 24 units of packed cells. Surgical revision was required at day 7 to remove an extensive hematoma in the right side of the CTA. The maintenance immunosuppressive regimen included steroids, mycophenolate mofetil, and tacrolimus. CONCLUSION: We have reported a case of successful provisional transplantation of a human facial allograft onto the thigh as an alternative technique in human face transplantation. PHT was a reliable alternative procedure to obtain the facial allograft from a cadaveric donor.

The virtual reality tool VirSSPA in planning DIEP microsurgical breast reconstruction.

BACKGROUND: The significant variation in the vascular anatomy of the abdominal wall makes preoperative imaging essential when raising a DIEP (deep inferior epigastric artery perforator) flap due to the potential for maximizing operative success, reducing intraoperative error and minimizing operative complications. Variability in perforator anatomy makes DIEP flap surgery a suitable candidate for computer and virtual reality bio models. In this context, a study was undertaken to determine the feasibility of CTA-guided by VirSSPA application. VirSSPA is a virtual reality tool developed in our Hospital for surgical planning and training. This application allows surgeons to generate the three-dimensional (3D) model of the patient. OBJECTIVE: In this paper, we present a study about VirSSPA tool for virtual reality navigation in DIEP flap surgery and compare findings with operative measurements. METHODS: We recruited 12 consecutive patients planned for an elective DIEP flap for breast reconstruction. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and VirSSPA 3D reconstruction. Imaging findings were compared to operative findings. RESULTS: 3D reconstruction of the abdominal wall with VirSSPA demonstrated a significant good correlation with perforator location compared to operative findings, showing an average error rate of 0.228 cm (95% CI, 0.17-0.30). The Pearson product-moment correlation coefficient was found to be 0.99 (p = 0.01), reflecting an almost linear relationship between the two distances, intraoperative and the one measured in the 3D reconstruction. CONCLUSION: VirSSPA provides additional and potentially more accurate data over conventional CTA with regard to the site of the best perforators and its course through the muscle for DIEP micro-vascular surgery.

Trombosis de miembro superior en neonato homocigótico para la mutación C677T / Upper limb thrombosis in a neonate homozygote for the C677T mutation

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