Estudo anatômico do ramo angular da artéria tóracodorsale suas implicações no transplante ósseovascularizado do ângulo da escápula / An anatomical study of the angular branch of the thoracodorsal artery and its implications in microsurgical bone transplantation of scapula’s angle

Introdução: A reconstrução dos defeitos ósseos complexos é dificultada pela escassez de áreasdoadoras para transplantes ósseos vascularizados. A versatilidade dos transplantes baseadosnos vasos subescapulares e seus ramos (circunflexa da escápula e tóraco-dorsal), associada àevolução das técnicas microcirúrgicas nos levaram ao estudo da área como potencial doadora.O objetivo do trabalho foi determinar o padrão anatômico que permita a utilização clínica desseretalho. Método: Para avaliação das relações anatômicas dos vasos com origem no sistema subescapular,com ênfase no ramo angular da artéria tóraco-dorsal, foram dissecados 15 cadáveresfrescos. Resultados: A artéria circunflexa da escápula apresentou anatomia constante, medindoem média 4,4 cm (3,2 - 6,5 cm) e irrigando a porção lateral superior da escápula. Dentre osvasos estudados, a artéria circunflexa da escápula apresentou anatomia mais constante. Em 14casos estudados, observou-se a presença do ramo angular da artéria tóraco-dorsal (93%), sendoque em 13 deles origina-se da artéria serrátil anterior. A trifurcação da artéria tóraco-dorsal foiverificada em apenas um caso. Conclusão: A constância anatômica do ramo angular da artériatóraco-dorsal (incidência de 93%) e a possibilidade de retalhos compostos e bipediculadosdevem encorajar cirurgiões ao uso mais frequente do retalho escapular.

Introduction: The reconstruction of major bone defects is hampered by the scarcity of bonegrafts. The flaps based on the subscapular blood vessels and their branches (circumflex scapularand thoracodorsal) are versatile and show great promise. The objective of the study is to usethe information obtained to arrive at an anatomical standard that enables the clinical use of thisgrafts. Methods: Fifteen fresh cadavers were dissected to evaluate the anatomical relationshipsof the blood vessels from the subscapular system, focusing primarily on the angular branch ofthe thoracodorsal artery. Results: The circumflex scapular artery presented consistent anatomy,measuring on average 4.4 cm (3.2 - 6.5 cm) and irrigating the superior lateral portion of thescapula. Among those studied, this blood vessel presented the most consistent anatomy. In 14cases studied, the presence of the angular branch of the thoracodorsal artery (93%) was observed,and 13 of them originated from the anterior serratus artery. Only once was a trifurcation of thethoracodorsal artery found. Conclusion: The anatomical consistency of the angular branch ofthe thoracodorsal artery (incidence of 93%) and the availability of compound and bipedicledgrafts should encourage surgeons to use scapular grafts more frequently.

Effect of IIb-IIIa glycoprotein inhibitors in a partial limb amputation model submitted to warm ischemia in rats.

Viability and functional results of a segment replantation depend on the prevention of deleterious effects of ischemia. Prolonged ischemia leads to alterations in the microcirculation: thrombosis, edema, production of oxygen free radicals, and platelet aggregation. The effect of IIb-IIIa glycoprotein inhibitors was tested in a partial limb amputation model submitted to warm ischemia. The male Wistar rats were divided into four groups: G1 with 0 hours of ischemia and saline ( N = 20), G2 with 6 hours of ischemia and saline ( N = 24), G3 with 6 hours of ischemia and abciximab ( N = 23), and G4 with 6 hours of ischemia and tirofiban ( N = 29). The limbs were observed for 7 days and classified as viable or nonviable. Viability and mortality rates were obtained and analyzed by Q-square and Fisher exact tests ( P < 0.05). The viability rates were 100% (G1), 30% (G2), 77.78% (G3), and 80.95% (G4). G2 was statistically different from G1, G3, and G4. G1, G3, and G4 were not statistically different. Transoperative and postoperative mortalities were not statistically different. The administration of abciximab and tirofiban improved limb salvage after ischemia and reperfusion and did not modify mortality rates significantly.

[Effects of streptokinase and hyperbaric oxygen therapy on venous occlusion after limb reimplantation in rats]. / Estreptoquinase e oxigênio hiperbárico em congestão após reimplante de membro.

OBJECTIVE: The effectiveness of streptokinase and hyperbaric oxygen therapy on venous occlusion after limb reimplantation was tested in rats. METHODS: Amputation with preservation of vessels and nerves of the right hind limb was carried out in 140 rats. Groups MG0, MG1, MG2, MG3 and MG4 were submitted to 0, 1, 2, 3 and 4 hours of venous occlusion. MG3 was elected as control for the experimental groups. Groups EG1 and EG2 were submitted to 3 hours of venous occlusion and were treated with streptokinase and hyperbaric oxygen therapy. Limbs were observed for 7 days and their mortality and survival rates were studied. RESULTS: Trans-operatory mortality rates in groups MG0, MG1, MG2, MG3 and MG4 were 0, 10, 15, 30 and 60% respectively and the postoperative mortality rates were 5; 11.1; 11.7; 14.2 and 100% respectively. The limb survival rates were 100%, 87.5%, 80% and 66.67% respectively and 76.9% and 100% in EG1 and EG2. Model groups were statistically different, except for MG1 and MG2 in trans-operatory mortality rates. There were no statistical differences in postoperative mortality rates between model groups except for MG3 and MG4. Model groups were statistically different, with the exception of MG1 and MG2, in limb survival rates. EG1 and MG3 showed no statistical difference in limb survival and EG2 had a better limb survival than MG3. CONCLUSION: Results suggest that the administration of streptokinase does not change effects of venous occlusion and that hyperbaric oxygen therapy may decrease the effects of venous occlusion in limbs.

Surgical treatment of lymphedema of the penis and scrotum.

PURPOSE: Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region. MATERIALS AND METHODS: Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface. RESULTS: Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema. CONCLUSIONS: The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.

Study of warm ischemia followed by reperfusion on a lower limb model in rats: effect of allopurinol and streptokinase.

UNLABELLED: Prolonged tissue ischemia leads to changes in microcirculation and production of oxygen free radicals. The event eventually responsible for tissue death is the no-reflow phenomenon and its management is a challenge for the surgeon dealing with replantation or transplantation. We introduce a model of warm ischemia and reperfusion of the lower limb of rats with which we studied the effect of allopurinol and streptokinase. METHOD: Section of the lower limb with preservation of vessels and nerves was performed in 110 rats. Femoral vessels clamped for periods of 0, 2, 4, 6, and 8 hours of ischemia were allowed to reperfuse (groups M0, M2, M4, M6, and M8 respectively). Other groups, E1, E2, and E3, received streptokinase, allopurinol, or a combination of the two drugs after 6 hours of ischemia. RESULTS: Viability rates of the ischemic limbs after 7 days were 100% (M0), 80% (M2), 63.6% (M4), 50% (M6), and 20% (M8). In the experimental groups, E1, E2, and E3, viability rates were 67% (E1), 70% (E2), and 70% (E3). Groups M0, M2, M4, M6, and M8 differed among themselves except for groups M4 and M6. Group E1 had a higher rate of limb viability than M6 (control group) but not than M4. Groups E1, E2 and E3 had higher rates of limb viability than M6 but not than M2 or M4. DISCUSSION: The results suggest that increased viability of limbs after 6 hours of ischemia occurs when allopurinol or streptokinase is used. The combination of the two drugs does not appear to produce any additional effect.