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1.
Medicine (Baltimore) ; 98(28): e16395, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31305447

RESUMO

RATIONALE: The main cause of death in melanoma patients is widespread metastases as it can metastasize to almost every organ. However, melanoma skeletal muscle metastases (MSMM) are exceptional, and only a few cases of MSMM to the rectus abdominis muscles have been previously described. And our case maybe the first reported case in Asia region. PATIENT CONCERNS: A 45-year-old man with history of right scalp melanoma, pT3aN0M0, stage IIA status post wide excision with 2 cm safe margin and right neck lymph node dissection at 5 years before. He had an almost 5 years disease-free period but presented to our clinic due to intermittent abdominal sharp pain for 1 to 2 months, with a palpable soft tissue mass over his right abdomen. Metastatic melanoma to rectus abdominis muscles was highly suspected. INTERVENTIONS: The patient subsequently underwent radical en-block extraperitoneal 15 cm segmental resection of the right rectus abdominis muscle including tumor mass. The resected tumor was a black-gray colored solid mass, and the final histologic study showed a metastasis of melanoma. OUTCOMES: Postoperative course of the patient was uneventful, and the right abdominal pain was improved. The patient was referred for further target therapy, but passed away half a year later due to multiple metastasis. LESSONS: Scalp melanoma with isolated rectus muscle metastasis is extremely rare especially for a young aged patient who had an almost 5-year disease-free period. Surgery is a potentially curative therapy for patients with isolated metastatic melanoma. The goal is negative resection margins, in order to avoid local recurrences. Radical compartmental surgery should be considered for selected stage IV melanoma patients with sole rectus abdominis MSMM, whose disease could be amenable to complete resection, in preliminary procedure to prolong disease-free survival time. For oligometastatic disease, surgical resection is sometimes useful in carefully selected patients after systemic therapy; also, it could be performed as symptomatic treatment.


Assuntos
Neoplasias Abdominais/secundário , Neoplasias de Cabeça e Pescoço/patologia , Melanoma/patologia , Neoplasias Musculares/secundário , Neoplasias Cutâneas/patologia , Neoplasias Abdominais/diagnóstico , Neoplasias Abdominais/cirurgia , Evolução Fatal , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Melanoma/diagnóstico , Melanoma/cirurgia , Pessoa de Meia-Idade , Neoplasias Musculares/diagnóstico , Neoplasias Musculares/cirurgia , Reto do Abdome , Couro Cabeludo , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/cirurgia
2.
Plast Reconstr Surg ; 144(1): 1e-8e, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31246793

RESUMO

BACKGROUND: Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction. METHODS: The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI). RESULTS: Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33). CONCLUSION: Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Assuntos
Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/irrigação sanguínea , Mamoplastia/efeitos adversos , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Feminino , Retalhos de Tecido Biológico/efeitos adversos , Humanos , Microvasos , Pessoa de Meia-Idade , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Reto do Abdome/transplante , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
3.
Plast Reconstr Surg ; 144(1): 24-33, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31246794

RESUMO

BACKGROUND: Revision procedures address contour irregularities and aesthetic concerns following autologous breast reconstruction. Mental health diagnoses are known to influence patient satisfaction with reconstruction. The authors aimed to identify oncologic, reconstructive, and demographic factors, including mental health diagnoses, associated with the number of revisions after autologous breast reconstruction. METHODS: The medical records of all adult women undergoing abdominal free flap-based breast reconstruction at a major academic institution between 2011 and 2016 were reviewed. Multivariate logistic regression was used to identify factors associated with receipt of revisions. Negative binomial regression was used to identify characteristics associated with number of revisions received. RESULTS: Of 272 patients identified, 55.2 percent received one revision, 23.2 percent received two revisions, and 10.3 percent received three or more revisions after autologous breast reconstruction (median, one; range, zero to five). After adjustment on multivariate analysis, anxiety (OR, 4.34; p = 0.016) and bilateral reconstruction (OR, 3.10; p = 0.017) were associated with receipt of any revisions; other oncologic and reconstructive factors including breast cancer stage, receipt of radiation therapy, and type or timing of free flap reconstruction were not associated with revisions. Using univariate negative binomial regression, anxiety (incidence rate ratio, 1.34; p = 0.006), Caucasian race (incidence rate ratio, 1.24; p = 0.02), and bilateral reconstruction (incidence rate ratio, 1.39; p = 0.04) were predictive of increased numbers of revisions received. After stepwise selection on multivariate analysis, anxiety remained the only significant predictor of increased numbers of revisions. CONCLUSIONS: Preoperative anxiety significantly influences the number of revisions after autologous breast reconstruction. Further research is necessary to better understand the interplay among mental health, patient preference, and outcomes in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Assuntos
Transtornos de Ansiedade/complicações , Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico , Mamoplastia/psicologia , Adulto , Neoplasias da Mama/psicologia , Transtorno Depressivo/complicações , Feminino , Humanos , Mamoplastia/métodos , Pessoa de Meia-Idade , Satisfação do Paciente , Cuidados Pré-Operatórios , Reto do Abdome/transplante , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Transplante Autólogo
4.
Transplant Proc ; 51(5): 1496-1501, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31155182

RESUMO

OBJECTIVE: This study of living liver transplant donors compared postoperative atrophy of the rectus abdominis after an upper abdominal midline incision vs a Mercedes incision. METHODS: A total of 110 donors underwent left-side donor hepatectomy in our hospital from 2007 to 2016. We analyzed the postoperative computed tomography data of 102 cases 3, 6, and 12 months after surgery. Donors were categorized as having a midline incision (MID group, n = 39) or a Mercedes incision (MER group, n = 63). The rectus abdominis was assessed on computed tomography images, and the percentage of muscle thickness (PMT) was compared in the 2 groups. RESULTS: Patient age, sex, and body mass index did not differ in the 2 groups. Laparoscope-assisted hepatectomy was only performed in the MID group, while open hepatectomy was performed mainly in the MER group. The mean PMT of the rectus abdominis did not change 3, 6, and 12 months after surgery in the MID group but decreased to 80%, 76%, and 72% of the baseline value in the MER group 3, 6, and 12 months after surgery, respectively. The PMT values were significantly lower in the MER group than in the MID group at all 3 time points (P < .001). In the MER group, rectus abdominis atrophy was significantly worse on the right side than on the left. There was no significant difference in morbidity between the 2 groups. CONCLUSION: In living donor liver transplant, the Mercedes incision resulted in significantly greater atrophy of the rectus abdominis in donors compared with the midline incision.


Assuntos
Hepatectomia/efeitos adversos , Hepatectomia/métodos , Doadores Vivos , Reto do Abdome/patologia , Coleta de Tecidos e Órgãos/métodos , Adulto , Atrofia , Feminino , Humanos , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Reto do Abdome/cirurgia
5.
Asian J Surg ; 42(6): 696-701, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31104697

RESUMO

OBJECTIVE: To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. METHODS: We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV. RESULTS: WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively. CONCLUSIONS: This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.


Assuntos
Colo/cirurgia , Enema/métodos , Perfuração Intestinal/diagnóstico por imagem , Perfuração Intestinal/cirurgia , Cuidados Pré-Operatórios/métodos , Reto do Abdome/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Casos e Controles , Serviços Médicos de Emergência , Feminino , Humanos , Perfuração Intestinal/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Solubilidade , Tomografia Computadorizada por Raios X , Água , Adulto Jovem
6.
Plast Reconstr Surg ; 143(6): 1137e-1141e, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31136466

RESUMO

BACKGROUND: Muscle flaps used in reconstructive surgery are known to lose volume over time because of denervation and disuse atrophy. However, there is currently no agreement on a quantitative approach to evaluating volume changes. Here, long-term serial measurement of muscle volume in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has been conducted using the Eclipse treatment planning system. METHODS: This was a retrospective review of the medical records of patients who underwent unilateral immediate breast reconstruction using a pedicled TRAM flap between January of 2004 and December of 2007. Patients who completed three serial follow-up computed tomographic scans and did not have history of recurrence and/or radiation therapy were included. Eclipse software was used for segmentation and three-dimensional reconstruction of the computed tomographic images; the volume of the pedicled rectus abdominis muscle was calculated, and the contralateral side served as the control. RESULTS: Among 451 patients undergoing TRAM flap surgery during the study period, 35 met the inclusion requirements. Serial measurement of rectus abdominis muscle volume of the flap showed a mean volume ratio of 27.1 percent, 22.1 percent, and 19.8 percent at 15, 30, and 51 months, respectively. The extrapolated volume ratio finally converged at 19.4 percent. Contralateral muscle volume did not change significantly over time. CONCLUSIONS: The muscle of a TRAM flap loses more than 70 percent of its volume in the first 15 months, ultimately reducing to approximately 20 percent of its original size. Eclipse can be used retrospectively for volume measurement after a variety of reconstructive procedures using computed tomographic or magnetic resonance images. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Mamoplastia/métodos , Reto do Abdome/transplante , Retalhos Cirúrgicos , Neoplasias da Mama/cirurgia , Feminino , Humanos , Tamanho do Órgão , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
7.
Plast Surg Nurs ; 39(2): 41-43, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31136556

RESUMO

Given their high rate of complications, radical surgical procedures of anorectal and gynecological tumors require a reliable and individualized reconstruction. The latter is influenced by the frequent indication of adjuvant chemo/radiotherapy that they present. We describe the case of a patient with medical history of vulvar carcinoma that required radical surgery and bilateral inguinal lymphadenectomy. Because of the stage of the tumor, the application of postoperative radiotherapy was clinically indicated; however, after surgery, the patient developed bilateral inguinal ulcers that made postoperative radiotherapy application impossible. Using a radical surgical approach in combination with postoperative radiotherapy increases survival in patients with these types of tumors. Therefore, delaying its use because of wound complications or inadequate reconstruction cannot be justified. The pedicled abdominal rectus flap is an excellent option for this purpose in patients with moderate- to large-sized defects.


Assuntos
Canal Inguinal/cirurgia , Retalhos Cirúrgicos/cirurgia , Neoplasias Vulvares/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/normas , Adulto , Feminino , Humanos , Radioterapia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Reconstrutivos/normas , Reto do Abdome/cirurgia , Resultado do Tratamento
8.
Cochrane Database Syst Rev ; 4: CD009487, 2019 04 24.
Artigo em Inglês | MEDLINE | ID: mdl-31016723

RESUMO

BACKGROUND: A parastomal hernia is defined as an incisional hernia related to a stoma, and belongs to the most common stoma-related complications. Many factors, which are considered to influence the incidence of parastomal herniation, have been investigated. However, it remains unclear whether the enterostomy should be placed through, or lateral to the rectus abdominis muscle, in order to prevent parastomal herniation and other important stoma complications. OBJECTIVES: To assess if there is a difference regarding the incidence of parastomal herniation and other stoma complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy. SEARCH METHODS: For this update, we searched for all types of published and unpublished randomized and non-randomized studies in four medical databases: CENTRAL, PubMed, LILACS, Science Ciation Index, and two trials registers: ICTRP Search Portal and ClinicalTrials.gov to 9 November 2018. We applied no language restrictions. SELECTION CRITERIA: Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality and extracted data. We conducted data analyses according to the recommendations of Cochrane and the Cochrane Colorectal Cancer Group (CCCG). We rated quality of evidence according to the GRADE approach. MAIN RESULTS: Randomized controlled trials (RCT)Only one RCT met the inclusion criteria. The participants underwent enterostomy placement in the frame of an operation for: rectal cancer (37/60), ulcerative colitis (14/60), familial adenomatous polyposis (7/60), and other (2/60).The results between the lateral pararectal and the transrectal approach groups were inconclusive for the incidence of parastomal herniation (risk ratio (RR) 1.34, 95% confidence interval (CI) 0.40 to 4.48; low-quality evidence); development of ileus or stenosis (RR 2.0, 95% CI 0.19 to 20.9; low-quality evidence); or skin irritation (RR 0.67, 95% CI 0.21 to 2.13; moderate-quality evidence). The results were also inconclusive for the subgroup analysis in which we compared the effect of ileostomy versus colostomy on parastomal herniation. The study did not measured other stoma-related morbidities, or stoma-related mortality, but did measure quality of life, which was not one of our outcomes of interest.Non-randomized studies (NRS)Ten retrospective cohort studies, with a total of 864 participants, met the inclusion criteria. The indications for enterostomy placement and the baseline characteristics of the participants (age, co-morbidities, disease-severity) varied between studies. All included studies reported results for the primary outcome (parastomal herniation) and one study also reported data on one of the secondary outcomes (stomal prolapse).The effects of different surgical approaches on parastomal herniation (RR 1.22, 95% CI 0.84 to 1.75; 10 studies, 864 participants; very low-quality evidence) and the occurrence of stomal prolapse (RR 1.23, 95% CI 0.39 to 3.85; 1 study, 145 participants; very low-quality evidence) are uncertain.None of the included studies measured other stoma-related morbidity or stoma-related mortality. AUTHORS' CONCLUSIONS: The present systematic review of randomized and non-randomized studies found inconsistent results between the two compared interventions regarding their potential to prevent parastomal herniation.In conclusion, there is still a lack of high-quality evidence to support the ideal surgical technique of stoma formation. The available moderate-, low-, and very low-quality evidence, does not support or refute the superiority of one of the studied stoma formation techniques over the other.


Assuntos
Hérnia Ventral/etiologia , Hérnia Ventral/prevenção & controle , Reto/cirurgia , Estomas Cirúrgicos/efeitos adversos , Anastomose Cirúrgica , Colostomia/efeitos adversos , Colostomia/métodos , Humanos , Ileostomia/efeitos adversos , Ileostomia/métodos , Prolapso , Ensaios Clínicos Controlados Aleatórios como Assunto , Reto do Abdome
9.
Chirurgia (Bucur) ; 114(1): 109-114, 2019 Jan-Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30830852

RESUMO

Introduction: In 1993 Leblanc published his laparoscopic technique in ventral hernia repair. The procedure has been improved due to deeply change of the paradigm in abdominal wall reconstruction. Placing the mesh into the retrorectus space was initially a big challenge but now the Rives-Stoppa procedure by endoscopic approach extended total extra-peritoneal approach (eTEP) become a well known technique. Method: The total extraperitoneal (TEP) approach used in inguinal hernia repair, is extended cranially into the rectus sheath. Crossover the midline toward the contralateral retrorectus space, being outside the peritoneal cavity, allows bilateral retrorectus dissection, reducing the hernia, restoring the linea alba and placing a polypropylene mesh under the rectus muscles. Results: I applied this technique between 2016 June 2017 December in 63 cases in ventral (primary or incisional) hernia repair having median area 60 sqcm (6 - 300). To close the defect and restore linea alba it was necessary to perform TAR in 19 cases. Median hospitalisation was 1day (1 9). Follow up at 2, 6, 12 months: 1 case with chronic pain and no recurrences until now. Conclusions: Combining the advantages of the Rives-Stoppa procedure with the the advantages of minimally invasive surgery (MIS), the eTEP approach tends to occupy an important place in ventral hernia repair.


Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/métodos , Reto do Abdome/cirurgia , Endoscopia/métodos , Humanos , Peritônio/cirurgia , Polipropilenos , Telas Cirúrgicas , Resultado do Tratamento
10.
Plast Reconstr Surg ; 143(6): 1589-1600, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30907803

RESUMO

BACKGROUND: Breast reconstruction plays a significant role in breast cancer treatment recovery. Introduction of the BREAST-Q questionnaire has facilitated quantifying patient-reported quality-of-life measures, promoting improved evidence-based clinical practice. Information regarding the effects of body mass index on patient-reported outcomes and health-related quality of life is significantly lacking. METHODS: Consecutive deep inferior epigastric perforator (DIEP) flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two points postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision, respectively. Postoperative flap and donor-site complications were recorded prospectively. BREAST-Q scores were compared at all time points and stratified by body mass index group (≤25, >25 to 29.9, 30 to 34.9, and ≥35 kg/m). RESULTS: Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Breast satisfaction and psychosocial and sexual well-being scores increased significantly postoperatively. Chest and abdominal physical well-being scores returned to baseline levels by postoperative point B. Preoperatively, stratified by body mass index, breast satisfaction and psychosocial well-being scores were significantly lower among patients with body mass index of 35 or higher and of more than 30, respectively. After reconstruction, not only were breast satisfaction, psychosocial, and sexual well-being scores significantly improved in all body mass index groups versus baseline, but also between-body mass index group differences were no longer present. Outcome satisfaction, flap, and donor-site morbidity were similar irrespective of body mass index. CONCLUSIONS: Patient-reported outcomes demonstrate significant improvements in breast satisfaction and psychosocial and sexual well-being among patients following DIEP flap reconstruction. Preoperative differences in quality-of-life scores were improved in patients with obesity (body mass index ≥30 kg/m). CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Neoplasias da Mama/cirurgia , Artérias Epigástricas/cirurgia , Mamoplastia/métodos , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Reto do Abdome/transplante , Adulto , Índice de Massa Corporal , Neoplasias da Mama/patologia , Diclofenaco/análogos & derivados , Intervalo Livre de Doença , Feminino , Sobrevivência de Enxerto , Humanos , Estudos Longitudinais , Mastectomia/métodos , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/transplante , Estudos Prospectivos , Reto do Abdome/irrigação sanguínea , Medição de Risco , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
11.
Rev. bras. cir. plást ; 34(1): 143-147, jan.-mar. 2019. ilus
Artigo em Inglês, Português | LILACS | ID: biblio-994620

RESUMO

Introdução: A ressecção de tumores invasivos de cabeça e pescoço pode resultar em defeitos extensos e complexos exigindo reparação imediata. Uma das opções de reparação é a transferência, utilizando técnica de microcirurgia vascular, do retalho musculocutâneo do reto abdominal pediculado nos vasos epigástricos inferiores profundos (TRAM). O presente estudo tem como objetivo registrar um procedimento utilizado no tratamento reparador microcirúrgico de fibrohistiocitoma maligno gigante de face com retalho TRAM. Relato de Caso: Paciente procurou atendimento médico devido a lesão tumoral gigante em hemiface direita. Foi realizada a tomografia computadorizada do crânio revelando volumoso processo expansivo de aspecto vegetante com limites mal definidos. Após os procedimentos básicos no pré-operatório, realizou-se a exérese do tumor que acometia músculos masseter e temporal direito, glândula parótida, assoalho orbitário à direita e osso malar. Posteriormente, retirou-se o retalho microcirúrgico do músculo reto do abdome em conjunto com a artéria epigástrica inferior profunda através de incisão cirúrgica da área hipogástrica. Em seguida, dissecção da artéria e veia facial utilizando microscópio e anastomoses venosa e arterial. Quanto à evolução retalho apresentou-se íntegro, com boa perfusão, sem sinais de infecção. Conclusões: A reconstrução facial microcirúrgica oferece liberdade ao cirurgião de cabeça e pescoço para realizar grandes ressecções tumorais.


Introduction: The resection of invasive tumors of the head and neck can result in extensive and complex defects requiring immediate repair. One repair option is the transfer of a transverse rectus abdominis myocutaneous (TRAM) flap pedicled on deep inferior epigastric vessels using vascular microsurgery. This study aimed to register a procedure used in the microsurgical treatment of giant malignant fibrous histiocytoma of the face using a TRAM flap. Case Report: A male patient sought medical care for a giant tumoral lesion in the right hemiface. Computed tomography of the skull revealed a voluminous expansive process of vegetating aspect with poorly defined borders. The excision of the tumor affected the right masseter and temporalis muscles, parotid gland, and right orbital and malar bones. Subsequently, microsurgical withdrawal of the TRAM flap was performed with the deep inferior epigastric artery through a surgical incision in the hypogastric area. Dissection of the facial artery and vein under microscopy and venous and arterial anastomoses followed. The flap was intact with good perfusion and no signs of infection. Conclusions: Microsurgical facial reconstruction allows head and neck surgeons to resect large tumors.


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Pacientes , Retalhos Cirúrgicos/efeitos adversos , Tomografia Computadorizada por Raios X/métodos , Reto do Abdome/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Histiocitoma Fibroso Maligno/cirurgia , Histiocitoma Fibroso Maligno/diagnóstico , Face/cirurgia
12.
Transplant Proc ; 51(2): 479-484, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30879572

RESUMO

BACKGROUND: Standard of care for postoperative analgesia after pancreas transplant has been thoracic epidural analgesia (TEA). A high incidence of venous graft thrombosis necessitated a change to a more aggressive anticoagulation protocol. To minimize the risk of epidural hemorrhages, we changed from TEA to rectus sheath block (RSB) in 2017. METHODS: From June 2016 to December 2017, a total of 29 consecutive pancreas transplant recipients were included. Sixteen were treated with TEA and 13 were treated with RSB. In the TEA group, the catheter was inserted before induction of general anesthesia, and an epidural infusion was started intraoperatively. An ultrasound-guided RSB was performed bilaterally, and a bolus of local anesthetic was administered before an 18G catheter was inserted. The patients received intermittent local anesthetic boluses every 4 hours in addition to an intravenous patient-controlled analgesia with oxycodone. Both groups received oral acetaminophen and additional rescue opioids. RESULTS: The administered amount of intravenous morphine equivalents (MEQ) was not significantly different between the RSB and TEA groups. The median MEQ consumption per day during the stay at the surgical ward was 23 mg MEQ/d (interquartile range [IQR], 14-33 mg MEQ/d) in the TEA group compared with 19 mg MEQ/d (IQR, 14-32 mg MEQ/d) in the RSB group (P = .4). The duration of the pain catheters was significantly longer in the RSB group. We had no complications related to insertion, use, or removal of the RSB or the TEA catheters, and overall patient satisfaction and comfort was good. CONCLUSION: Compared with TEA, RSB was equally effective and safe for postoperative analgesia in heavily anticoagulated pancreas transplant patients.


Assuntos
Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Transplante de Pâncreas/métodos , Adulto , Idoso , Analgesia Epidural , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Reto do Abdome/efeitos dos fármacos , Reto do Abdome/inervação , Estudos Retrospectivos , Resultado do Tratamento
13.
Anticancer Res ; 39(3): 1383-1389, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30842172

RESUMO

BACKGROUND/AIM: Our hypothesis was that rectus sheath block (RSB) analgesia could enhance satisfaction following midline laparotomy in patients with benign disease and cancer patients. PATIENTS AND METHODS: Initially, 56 patients were randomized into four groups; control group (n=12), single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) RSB analgesia groups. The plasma concentrations of the NT marker were measured just before, immediately after and 24 h after operation. Patient satisfaction at 24 h postoperatively was filed on a 11-point numeric rating scale (SFS24; 0=fully unsatisfied; 10=fully satisfied). RESULTS: The RSB analgesia significantly enhanced the SFS24 scores in the study groups (p=0.001). The median plasma NT concentrations (pg/ml) following surgery (POP1) were significantly lower in patients with cancer versus patients with benign disease (5.3 vs. 7.6, p=0.008). Jitter plots of the individual SFS24 values versus plasma NT concentrations were significantly correlated in benign and cancer patients (r=-0.284, p=0.028). CONCLUSION: The RSB analgesia could significantly enhance patient satisfaction following midline laparotomy. Plasma NT concentrations versus patient satisfaction following surgery are significantly correlated in benign disease and cancer.


Assuntos
Neoplasias/cirurgia , Bloqueio Nervoso , Reto do Abdome , Tirosina/análogos & derivados , Idoso , Analgesia , Feminino , Humanos , Laparotomia , Masculino , Pessoa de Meia-Idade , Neoplasias/sangue , Estresse Nitrosativo , Tirosina/sangue
14.
Surg Technol Int ; 34: 251-254, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30716161

RESUMO

A common technique for ventral and incisional hernia repair is the retrorectus repair (Rives-Stoppa). The posterior rectus sheath is incised bilaterally, and mesh is placed retromuscularly. There is little information on how this component separation technique affects abdominal wall tension. We evaluated abdominal wall tension in patients undergoing retrorectus repair of abdominal wall hernias. Patients undergoing retrorectus repair of their ventral hernias were enrolled in a prospective, Institutional Review Board-approved protocol to measure abdominal wall tension from 8/1/2013 to 8/2/2017. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that were clamped to the fascia and brought together in the midline. Measurements were made before and after incising the posterior rectus sheaths. Data were analyzed with a repeated measures analysis of variance (ANOVA), and differences between individual groups were analyzed by least square differences. Forty-five patients had tension measurements. Average age was 58 years (range 29-81)-78% Caucasian, 51% female, an average body mass index (BMI) of 35 kg/m2 (range 20-62), and 38% recurrent hernias. The average hernia defect was 121.9 cm2, and the average mesh size was 607.8 cm2. There was a significant reduction in tension after bilateral posterior rectus sheath incision (3.1 lbs vs. 5.6 lbs, p<0.0001). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair with retrorectus repair. Transection of the posterior rectus sheath decreases tension during hernia repair and may help guide surgeons regarding when to use this procedure.


Assuntos
Parede Abdominal/fisiopatologia , Hérnia Ventral/fisiopatologia , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Reto do Abdome/fisiopatologia , Reto do Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Telas Cirúrgicas
15.
Plast Reconstr Surg ; 143(4): 992-1008, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30730497

RESUMO

BACKGROUND: Anatomical variations in perforator arrangement may impair the surgeon's ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap. METHODS: A single surgeon's experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange ("APEX") arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion. RESULTS: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps. CONCLUSIONS: This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Abdome/cirurgia , Neoplasias da Mama/cirurgia , Artérias Epigástricas , Mamoplastia/métodos , Retalho Perfurante , Reto do Abdome/transplante , Retalhos Cirúrgicos/irrigação sanguínea , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Reto do Abdome/irrigação sanguínea , Estudos Retrospectivos
16.
Am J Case Rep ; 20: 163-166, 2019 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-30728345

RESUMO

BACKGROUND A clinical condition that is often misdiagnosed, rectus sheath hematoma (RSH) is usually seen in the context of blunt abdominal trauma and/or anticoagulation therapy, rarely occurring spontaneously. We present a case of spontaneous rectus sheath hematoma (SRSH) without obvious risk factors and review the literature regarding diagnosis modalities and management. The aim of this case presentation is to highlight this rare clinical condition and emphasize the role of the physical exam in determining the appropriate treatment approach.   CASE REPORT A 50-year-old woman presented to the emergency room with right-sided pelvic pain for one day. Her medical history was specifically notable for recent coughing due to acute bronchitis, as well as the use of NSAIDs. Physical examination revealed marked tenderness in the hypogastric and right lower quadrant, with guarding and fullness in the same area. Laboratory investigation showed mild anemia and normal coagulation tests. Computed tomography demonstrated a right rectus muscle hematoma measuring 8.5×8.5 cm and extending into the lower abdomen and the extraperitoneal space, without active contrast extravasation. Close monitoring of vital signs and hemoglobin hematocrit levels along with supportive care with fluid resuscitation and pain control were initiated and the patient remained stable throughout her hospital stay. CONCLUSIONS Prompt recognition and management of SRSH are crucial. Physical examination is a key part of this process and imaging is the mainstay of diagnosis. Management remains for the most part supportive, although surgery or vascular embolization is required for uncontrolled hematomas with hemodynamic instability.


Assuntos
Dor Abdominal/etiologia , Hematoma/diagnóstico por imagem , Doenças Musculares/diagnóstico por imagem , Reto do Abdome/diagnóstico por imagem , Bronquite/complicações , Tosse/complicações , Feminino , Hematoma/etiologia , Humanos , Pessoa de Meia-Idade , Doenças Musculares/etiologia , Tomografia Computadorizada por Raios X
17.
Paediatr Anaesth ; 29(3): 280-285, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30609170

RESUMO

BACKGROUND: Single injection ultrasound-guided rectus sheath blocks are used for postoperative analgesia after midline abdominal incisions, but the ultrasonographic spread of medication posterior to the rectus muscle has not been investigated. AIMS: The primary goal of this study was to determine the ultrasound-measured medication spread superiorly and inferiorly after single injection ultrasound-guided rectus sheath blocks and to calculate the incidence of cases with spread up to the subcostal margin and below of umbilicus. The secondary goals were to correlate the spread with the volume of medication administered and with the patient's age, weight, height, sex, and body mass index. METHODS: Pediatric patients who underwent single injection ultrasound-guided rectus sheath blocks and underwent data collection of ultrasonographic information on medication spread along the plane of the posterior rectus sheath were identified retrospectively from an acute pain service database at UPMC Children's Hospital of Pittsburgh. RESULTS: Sixty-eight children, 10.2 ± 4.2 (mean ± SD) years old, 41.7 ± 17.9 kg, 140 ± 24.6 cm, had complete data collection. Mean injected volume of ropivacaine was 8.3 ± 2.8 mL (right) and 8.2 ± 2.8 mL (left). The average spread was measured as 3.9 ± 1.4 cm (right) and 3.4 ± 1.3 cm (left) cranial to the umbilicus, and 1.5 ± 1.6 cm (right) and 1.6 ± 1.4 cm (left) caudal to the umbilicus. Complete spread up to the level of the subcostal margin was observed in 52.9% (n = 36; right) and 36.8% (n = 25; left) of cases. The spread correlated closely with the volume of injected ropivacaine (right: 0.556, P < 0.001; left: 0.541, P < 0.001). The spread below umbilicus was 70.6% (n = 48, right) and 80.9% (n = 55, left). There was a positive strong correlation (P < 0.001) between total medication spread and age (right: 0.608; left: 0.538), weight (right: 0.600; left: 0.540), and height (right: 0.593; left: 0.526). CONCLUSION: After single injection ultrasound-guided rectus sheath blocks, incomplete cephalocaudal medication spread can be expected within the posterior rectus sheath.


Assuntos
Anestésicos Locais/administração & dosagem , Anestésicos Locais/farmacocinética , Bloqueio Nervoso/métodos , Reto do Abdome/efeitos dos fármacos , Ultrassonografia de Intervenção/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Reto do Abdome/diagnóstico por imagem , Estudos Retrospectivos
18.
J Bodyw Mov Ther ; 23(1): 94-98, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30691770

RESUMO

BACKGROUND: Abdominal wall pain is considered as pain that arises from the abdominal muscles rather than the underlying viscera or the spine. It is frequently overlooked and is often misdiagnosed, as these patients continue to suffer with pain. Many such patients would have even been subjected to a psychiatric evaluation in view of the absence of any ostensible clinical cause for the pain. In this study, we describe the role of myofascial trigger points in the abdominal wall pain that could be a cause of chronic pain and present our findings of pain relief by dry needling technique. OBJECTIVES: To report the effect of dry needling treatment for patients who suffer from chronic abdominal wall pain of uncertain etiology and in whom specific myofascial trigger points were identified. METHODS: Twelve patients diagnosed with chronic abdominal wall pain were included in the study. All patients were clinically evaluated and subjected to a combination of imaging techniques. Once categorized as patients suffering from chronic abdominal wall pain, they were subjected to a thorough palpation of the abdominal wall to identify the presence of myofascial trigger points (MTrPs) over the abdominal muscles. All had MTrPs over one or more abdominal muscles either unilaterally or bilaterally. Dry Needling using a standard technique was done based on the side and localization of the myofascial trigger points. Numerical pain rating scale (NPRS) was used to measure pain before and after treatment and at the end of four months. All patients were then seen by the primary clinician and re-evaluated. RESULTS: Eleven out of twelve patients had significant reduction with a mean difference 5.95 in NPRS in their pain levels at four months follow up. Seven patients had complete resolution of the pain. Some patients had improvement in complaints such as Dysmenorrhea, Urinary Frequency and constipation. CONCLUSION: Dry Needling can be a useful adjunct in treating chronic abdominal wall pain especially in those patients in whom Myofascial Trigger Points in the muscles of abdomen are identified by palpation. LEVEL OF EVIDENCE: Level 4.


Assuntos
Parede Abdominal/fisiopatologia , Agulhas , Manejo da Dor/métodos , Terapia de Tecidos Moles/métodos , Pontos-Gatilho/fisiopatologia , Músculos Abdominais Oblíquos/fisiopatologia , Adulto , Idoso , Dor Crônica , Fáscia/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Reto do Abdome/fisiopatologia
19.
Eur J Orthop Surg Traumatol ; 29(2): 285-293, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30649621

RESUMO

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.


Assuntos
Retalhos de Tecido Biológico , Traumatismos da Perna/cirurgia , Microcirurgia/métodos , Adolescente , Angiografia , Músculo Grácil/transplante , Humanos , Masculino , Planejamento de Assistência ao Paciente , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Reto do Abdome/transplante , Transplante de Pele/métodos , Sítio Doador de Transplante/irrigação sanguínea
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