Endoscopic endoluminal therapy with the Eso-SPONGE® system for the treatment of spontaneous esophageal perforation with associated paraoesophageal collection.

We present the case of a 92-year-old woman with no relevant history, who consulted for sore throat, progressive dysphagia to solids and fever. A cervical-thoraco-abdominal CT was performed with the finding of a paraesophageal collection at the level of C3-T1 without a clear solution of continuity, although with passage of oral contrast to the collection, exerting a mass effect on the esophageal lumen, suggestive of contained esophageal perforation, of cause not clarified. A gastroscopy was performed, in which three esophageal fistulous orifices were observed, two 4-5 mm, and a third 10 mm deeper, located 22cm from the dental arch, septate, with perilesional purulent material and bubbling.

Upper gastrointestinal bleeding secondary to late gastric metastasis of renal cell carcinoma.

Clear cell renal cell carcinoma is the most common renal neoplasm in adults. It has a relatively slow growth pattern that delays diagnosis until the onset of local, paraneoplastic or metastasis-related manifestations, and an unpredictable behavior ranging from aggressive tumors with poor short-term prognosis to late recurrence cases where metastases are identified years after nephrectomy, the latter scenario being the subject of the case we herein report.

Ethmoidal metastasis as an uncommon presentation and diagnostic form of hepatocellular carcinoma.

Nasopharynx metastases are an extremely rare cause of hepatocarcinoma debut. We report the case of a 71 year old man who presented symptoms of nosebleed and diplopia event, diagnosed by imaging and biopsy of ethmoidal metastasis of hepatocarcinoma.

Diagnosis of biliary papillomatosis with a Spyglass® cholangioscope.

We report the case of a 78-year-old woman with dyspepsia for several years and a history of cholecystectomy, informed by pathology as calculous cholecystopathy, where CT revealed a left-sided intrahepatic bile duct dilation. Cholangio-MRI confirmed a size increase in the distal intrahepatic bile duct on the left side, with T2-hyperintense contents with scarce contrast enhancement, which resulted in the observed dilation. . A Spybite® forceps was used to obtain a biopsy sample, which showed a benign papillary growth compatible with biliary papillomatosis. Biliary papillomatosis or intraductal papillary neoplasm of the biliary tract is a rare, uncommon condition characterized by intraductal papillary growth of the biliary epithelium. It has a tendency towards malignization, hence must be considered a premalignant condition . Major symptoms include jaundice, abdominal pain, and repeat cholangitis, with imaging studies being key for diagnostic suspicion . The development of cholangioscopy with biopsies allows an early diagnosis of malignant precursor lesions of the bile duct, thus allowing early treatment.

Endoscopic submucosal dissection of gastric plexiform fibromyxoma, an alternative to the traditional approach.

We report the case of a 62-year-old woman with no history of interest who presented with dyspepsia of 2 years' standing. Gastroscopy revealed a subepithelial lesion at the greater antral curvature with irregular surface and preserved mucosal and vascular pattern, 15 mm in diameter. Because of clinical persistence a radial endoscopic ultrasonogram (EUS) was performed, which showed a well-delimited hypoechoic lesion with heterogeneous areas that was dependent on the muscularis mucosae layer. A biopsy was obtained using the "bite-on-bite" technique, which provided no pathological findings. With these findings an endoscopic submucosal dissection (ESD) procedure was performed with wide margins and no complications. Pathology found low-grade mesenchymal fusicellular proliferation dependent on the muscularis mucosae with immunohistochemistry positive for smooth-muscle vimentin and actin, consistent with plexiform fibromyxoma.

Autologous Tragal Perichondrium Graft for Vocal Fold Scar and Sulcus Vocalis.

Between 2006 and 2016 in a Tertiary Academic Center, 11 patients underwent phonomicrosurgery with tragal perichondrium graft placement in Reinke's space for the treatment of sulcus (Ford type 2) and vocal fold scar. A total of six patients out of 11 had an additional autologous fat implantation in order to improve the glottic closure. We evaluated the functional outcome using the Spanish validated version of the VHI- 30 before and 6 months after the surgery. We also measured the subjective appreciation of the obtained outcome, a perceptual voice evaluation using GRBAS scale, and changes in videostroboscopy examinations concerning mucosal wave and glottic closure. In the VHI-30 questionnaire, we observed an improvement in all patients (six of which showed an improvement of 50% or more) with statistically significant results (P = 0.003), and no significant differences between sulcus (Ford type 2) and vocal cord scar patients (P = 0.7579). The results obtained from the single question assessing changes in voice quality showed a high improvement in seven patients. According to the GRBAS scale, all cases improved. Concerning the results of the videostroboscopy, two patients obtained very favorable results, eight of them presented a moderate recovery and only one improved slightly. The following complications were identified: two granulomas, a graft extrusion and a tragal infection. The tragal perichondrium used as an autograft in Reinke's space appears to be a safe and satisfactory choice, comparable to other grafts such as temporalis fascia or autologous fat.

Active search for hepatitis C patients in primary care.

INTRODUCTION: undiagnosed active hepatitis C virus (HCV) infections are an obstacle to achieve the WHO (World Health Organization) hepatitis C elimination goal by 2030. One of the possible strategies to identify these patients is the active search for patients in primary care (PC). METHODS: patient medical records in PC were reviewed with a "hepatitis C" open case in the last five years. Cases with an incomplete diagnostic study (due to the absence of active infection confirmation) or those who did not start or finish treatment were included. A blood analysis was recommended to prove the existence of an active infection. The one-step diagnosis (OSD) was implemented to assess viremia in all patients with a new serologic diagnosis. RESULTS: of 253 cases with a "hepatitis C" open case in their medical records, 24.1 % (61) did not finish the diagnostic study or did not follow the treatment. Four were not suitable candidates to finish the study. Of the other 57, 92.9 % accepted the diagnostic test. Active infections were confirmed in 40 patients (75.4 %) and the treatment was completed in all of them. CONCLUSIONS: active searching for patients with hepatitis C in PC together with the OSD are effective measures to detect hidden infections and to increase the number of treatments, thus contributing to the elimination of hepatitis C.

Mucinous ascites secondary to peritoneal pseudomyxoma of an uncertain origin.

Peritoneal pseudomyxoma (PP) is a rare malignant tumor, which is characterized by the presence of mucinous ascites. Abdominal ultrasound as the first diagnostic method of this entity allows the visualization of ascites on the one hand and its analysis through a diagnostic paracentesis on the other.

Reconstrucción mediante colgajos basados en el sistema de la arteria facial. Un sistema vascular para múltiples usos en cirugía reconstructiva de cabeza y cuello / Reconstruction using facial artery system-based flaps. One vascular system for multiple purposes in head and neck reconstructive surgery

INTRODUCCIÓN: El objetivo del siguiente trabajo es la revisión de las modificaciones y avances en cirugía reconstructiva de tejidos blandos de la cavidad oral basándonos exclusivamente en los principales colgajos que dependen de arterias nominadas del sistema de la arteria facial. MÉTODOS: Revisión de la literatura y la experiencia propia respecto a reconstrucciones de cavidad oral basadas en colgajos del sistema de la arteria facial. DISCUSIÓN: La reconstrucción de la cavidad oral basada en colgajos dependientes del sistema de la arteria facial ofrece resultados satisfactorios y permite realizar reconstrucciones limitadas evitando la utilización de colgajos pediculados regionales o de colgajos libres. CONCLUSIONES: El conocimiento de las opciones reconstructivas utilizando el sistema de la arteria facial en cirugía de la cavidad oral permitirá a los cirujanos de cabeza y cuello ampliar las opciones de reconstrucción, adaptar de forma efectiva las reconstrucciones a los defectos quirúrgicos, permitiendo un abordaje de alta calidad, seguro y con menor consumo de recursos

INTRODUCTION: to review the modifications and advances in reconstructive surgery of the soft tissues of the oral cavity exclusively based on flaps that depend on the facial artery system. METHODS: review of the literature regarding oral cavity reconstructions based on main facial artery system flaps. DISCUSSION: The reconstruction of the soft tissues of the oral cavity, based on facial artery system flaps, offers satisfactory results and allows limited reconstructions avoiding the use of pedicled regional flaps or free flaps. CONCLUSIONS: Knowledge of reconstructive options using the facial artery system in oral cavity surgery allows expanding reconstructive options for head and neck surgeons, enabling safe, high quality and effective reconstructions, with limited resources consumption

Reconstruction using facial artery system-based flaps. One vascular system for multiple purposes in head and neck reconstructive surgery. / Reconstrucción mediante colgajos basados en el sistema de la arteria facial. Un sistema vascular para múltiples usos en cirugía reconstructiva de cabeza y cuello.

INTRODUCTION: to review the modifications and advances in reconstructive surgery of the soft tissues of the oral cavity exclusively based on flaps that depend on the facial artery system. METHODS: review of the literature regarding oral cavity reconstructions based on main facial artery system flaps. DISCUSSION: The reconstruction of the soft tissues of the oral cavity, based on facial artery system flaps, offers satisfactory results and allows limited reconstructions avoiding the use of pedicled regional flaps or free flaps. CONCLUSIONS: Knowledge of reconstructive options using the facial artery system in oral cavity surgery allows expanding reconstructive options for head and neck surgeons, enabling safe, high quality and effective reconstructions, with limited resources consumption.

Porcine experimental model for gracilis free flap transfer to the head and neck area with novel donor site description.

INTRODUCTION: Functional free tissue transfer in the form of muscle free flap is a challenging surgical procedure and needs a steep learning curve. A porcine model for free muscle transfer and insetting in a distant area is of great interest in reconstructive microsurgery due to the experience and learning curve necessary to perform these surgeries. The aim of this study was to assess the feasibility of a swine model for gracilis muscle free transfer and to describe the donor site anatomy. METHODS: Ten gracilis free flap transfer surgery models were performed under general anesthesia in a porcine model, based on a vascular pedicle depending of the external iliac vessels and a branch of the obturator nerve with microsuture mediated connection to head and neck nerves and vessels. RESULTS: The gracilis myocutaneous or muscle-only free flap was successfully transferred in all cases using as receptors the vagus nerve, the common carotid artery, and the external or internal jugular veins. In two cases, nervous connection had to be redone. All vascular anastomoses were correctly functioning. CONCLUSIONS: Despite the anatomical and design variations, porcine gracilis free flap transferred to the head and neck area with microvascular anastomosis and nerve connection provides a suitable training model for functional reconstructive microsurgery.

Terapia endoscópica endoluminal con sistema Endo-Sponge(R) en el manejo de dehiscencia de anastomosis tras cirugía colorrectal / Endoluminal endoscopic therapy with Endo-Sponge(R) system in the management of anastomotic dehiscence after colorectal surgery

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Porcine experimental model for perforator flap raising in reconstructive microsurgery.

BACKGROUND: Perforator free flap-based reconstruction of the head and neck is a challenging surgical procedure and needs a steep learning curve. A reproducible mammal large animal model with similarities to human anatomy is relevant for perforator flap raising and microanastomosis. The aim of this study was to assess the feasibility of a swine model for perforator-based free flaps in reconstructive microsurgery. METHODS: Eleven procedures were performed under general anesthesia in a porcine model, elevating a skin flap vascularized by perforating musculocutaneous branches of the superior epigastric artery to evaluate the relevance of this model for head and neck reconstructive microsurgery. RESULTS: The anterior abdominal skin perforator-based free flap in a swine model irrigated by the superior epigastric artery was elevated in eleven procedures. In six of these procedures, we could perform an arterial and venous microanastomosis to the great vessels located in the base of the neck. CONCLUSIONS: The porcine experimental model of superior epigastric artery perforator-based free flap reconstruction offers relevant similarities to the human deep inferior epigastric artery perforator flap. We could demonstrate this model as acceptable for perforator free flap training due to the necessity of perforator and pedicle dissection and transfer to a distant area.

Utilidad y versatilidad del colgajo en isla de la arteria supraclavicular en reconstrucción de cabeza y cuello / Utility and versatility of the supraclavicular artery island flap in head and neck reconstruction

Introducción: El colgajo supraclavicular en isla es un colgajo rotacional pediculado que puede presentar ciertas ventajas en reconstrucción de cabeza y cuello en pacientes donde una reconstrucción microvascularizada no sea factible o aconsejable. Material y métodos: Presentamos nuestra experiencia durante el año 2016 en 5 casos con la aplicación de este colgajo, como alternativa a una reconstrucción microvascularizada tras resección de distintos tumores de cabeza y cuello. En 2 casos se utilizó para reconstrucción del faringostoma quirúrgico tras laringectomía total con faringectomía parcial. En un caso para reconstrucción facial lateral tras resección parcial de temporal. En un caso para reconstrucción de un defecto cutáneo tras laringectomía total ampliada y en otro para cobertura cutánea tras el cierre primario de una fístula faringocutánea. No hubo complicaciones del colgajo y el resultado final fue satisfactorio en todos los casos. Resultados: El colgajo supraclavicular en isla presenta una utilidad y es muy versátil en reconstrucciones de cabeza y cuello. El tiempo quirúrgico en pacientes de riesgo se reducirá respecto a colgajos libres microvascularizados. Su técnica quirúrgica es relativamente sencilla y se adapta perfectamente a reconstrucciones mucosas o cutáneas. Conclusión: El colgajo supraclavicular en isla es una opción recomendable en reconstrucción de cabeza y cuello, su uso parece estar incrementándose y supone una alternativa segura y sobre todo rápida a los colgajos libres microvascularizados en pacientes seleccionados (AU)

Introduction: The supraclavicular island flap is a rotational pedicled flap and may have some advantages in head and neck reconstruction compared with free-tissue transfer when this kind of reconstruction is not affordable or recommended. Material and methods: We present our experience during the year 2016 in the application of the supraclavicular island flap in five cases as an alternative to microvascular reconstruction in several defects after resection of head and neck tumours. In two patients, the flap was used to close the surgical pharyngostoma after total laryngectomy with partial pharyngectomy. In one patient, it was used in lateral facial reconstruction after partial resection of the temporal bone. In one case, it was used to close a skin defect after total laryngectomy with prelaryngeal tissue extension. And in the last case to close a neck skin defect after primary closure of a pharyngo-cutaneous fistula. There were no flap complications, and the result was satisfactory in all cases. Results: The supraclavicular artery island flap is useful and versatile in head and neck reconstruction. Operating room time in aged patients or those with comorbidities will be reduced compared to free flaps. The surgical technique is relatively easy and can be used for skin and mucosal coverage. Conclusion: The supraclavicular island flap could be a recommended option in head and neck reconstruction, its use seems to be increasing and provides a safe and time-saving option to free flaps in selected patients (AU)

Aplicación de la biopsia por endoscopia flexible en el diagnóstico de la patología tumoral en otorrinolaringología / Application of flexible endoscopy-based biopsy in the diagnosis of tumour pathologies in otorhinolaryngology

Introducción y objetivos: La endoscopia intervencionista nos permite actuar sobre la patología del paciente con mínimas molestias, bajos costes y alta eficiencia. Evaluamos la validez de la biopsia por endoscopia flexible en nuestro hospital, en las lesiones sospechosas de malignidad en el espacio rinofaringolaríngeo. Material y método: Estudio retrospectivo de los pacientes con patología sospechosa de malignidad valorados en el periodo 2006-2016 en nuestro centro. Valoramos la eficacia, la tolerancia y número de complicaciones. Calculamos la reducción de costes frente a la laringoscopia directa en quirófano. Comparamos nuestra muestra con otras de características similares descritas en la bibliografía. Resultados: Treinta pacientes fueron estudiados mediante biopsia por endoscopia flexible en ese período. Diecinueve pacientes obtuvieron resultados positivos que permitieron iniciar el tratamiento de su patología. Siete casos, sin evidencia de malignidad, requirieron nueva biopsia bajo anestesia general que confirmó el diagnóstico de carcinoma. Dos muestras descartaron malignidad, dato que se confirmó tras microcirugía de laringe. Un caso mostró inflamación y la lesión se resolvió tras antibioterapia. En un caso la toma de muestra resultó imposible. Obtenemos de esta forma niveles de sensibilidad del 73% con una especificidad del 100%. No se produjeron complicaciones. La reducción de costes en nuestra muestra fue superior al 80%. Conclusiones: La biopsia por endoscopia flexible aporta ventajas sobre la laringoscopia directa que resultan de interés en el diagnóstico de patología oncológica en otorrinolaringología (AU)

Introduction and objectives: Interventional endoscopy allows us to act on the pathology of the patient with minimal discomfort, low costs and high efficiency. We assessed the validity of flexible endoscopic biopsies in our hospital, in lesions suspected of malignancy in the rhino-pharyngo-laryngeal space. Subjects and methods: Retrospective study of patients with a pathology suspected of malignancy assessed between 2006-2016 in our centre. We evaluated the effectiveness, the tolerance and the number of complications. We calculated the cost reduction in comparison with direct laryngoscopy in the operating room. We compared our sample with others of similar characteristics described in the literature. Results: Thirty patients were studied with a flexible endoscopic biopsy during that period. Nineteen patients obtained positive results which allowed them to start treatment for their pathology. Seven cases had no evidence of malignancy and required another biopsy under general anaesthesia, which confirmed the carcinoma diagnosis. Two samples ruled out malignancy which was confirmed by laryngeal microsurgery. One case showed inflammation and the lesion was cured after antibiotherapy. It was impossible to collect the sample in one case. Thus, we obtained sensitivity levels of 73% with a specificity of 100%. There were no complications. The cost reduction in our sample was above 80%. Conclusions: Flexible endoscopic biopsy has advantages over direct laryngoscopy that are relevant in the diagnosis of oncological pathology in otorhinolaryngology (AU)