RESUMEN
PURPOSE: Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach. METHODS: We performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed. RESULTS: 27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects. CONCLUSIONS: A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.
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Evisceración Orbitaria , Procedimientos de Cirugía Plástica , Humanos , Estudios Retrospectivos , Colgajos Quirúrgicos , Reino UnidoRESUMEN
AIM: Case payment mechanisms have become the principle means of remunerating hospitals in many countries. We analysed the reimbursement for different types of autologous tissue transfer in five European countries. METHODS: We looked at common surgical options for breast reconstruction and flaps at other body regions. The principle diagnosis was systematically modified and processed with national grouper software to identify the relevant Diagnosis-Related Groups. RESULTS: The mean difference in payment was 4509 in breast reconstruction versus only 2599 in other locations. According to the underlying diagnosis for reconstruction, procedures after resection of malignant breast cancer showed higher reimbursement (mean 8319 ) than of other body parts (mean 6454 ). Sweden had the highest mean reimbursement (9589 ) followed by Austria (8032 ), Germany (7259 ), Italy (6667 ) and the UK (6037 ). Austria, Italy and the UK showed significant differences of reimbursement between pedicled flaps of the breast and other parts of the body. CONCLUSION: International data for the benchmarking and refinement of a national compensation system can be a useful instrument in identifying ways of improving each system. Across a spectrum of European countries, reimbursement for the reconstruction of the breast and other body parts was analysed and characteristics were identified. As rationalisation of healthcare becomes widespread in European countries, the need for individualised reimbursement which correlates accordingly is becoming ever more important.
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Reembolso de Seguro de Salud/estadística & datos numéricos , Mamoplastia/economía , Colgajos Quirúrgicos/economía , Brazo/cirugía , Neoplasias de la Mama/cirugía , Quemaduras/cirugía , Nalgas/cirugía , Grupos Diagnósticos Relacionados , Europa (Continente) , Femenino , Cabeza/cirugía , Humanos , Pierna/cirugía , Mamoplastia/métodos , Neoplasias/cirugía , Especificidad de Órganos , Mecanismo de Reembolso , Torso/cirugíaRESUMEN
The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.
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Implantación de Prótesis Vascular , Isquemia/cirugía , Recuperación del Miembro , Extremidad Inferior/irrigación sanguínea , Diálisis Renal , Venas/trasplante , Adulto , Anciano , Amputación Quirúrgica , Femenino , Oclusión de Injerto Vascular , Humanos , Isquemia/complicaciones , Isquemia/mortalidad , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Pronóstico , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Breast pain is a common complaint which usually subsides with simple reassurance or sometimes medication. This paper describes the case of a 41-year-old woman suffering from severe non-cyclical breast pain that had proved resistant to a battery of medical treatments. The pain was so disabling that it drove the patient to contemplate suicide. At the patient's request, a bilateral subcutaneous mastectomy with immediate implant reconstruction was performed, resulting in a complete resolution of the pain. Non-cyclical breast pain is less common than cyclical breast pain and tends to be more difficult to treat. This case suggests that mastectomy may be an appropriate option of last resort in the treatment of severe intractable breast pain.
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Enfermedades de la Mama/cirugía , Mastectomía , Dolor/cirugía , Procedimientos de Cirugía Plástica , Adulto , Enfermedades de la Mama/psicología , Implantes de Mama , Femenino , Humanos , Dolor/psicología , Calidad de Vida , Índice de Severidad de la Enfermedad , Intento de SuicidioRESUMEN
AIMS: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. METHODS: We analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. RESULTS: The mean reimbursement was 5593 for pedicled flaps, 9149 for free flaps and 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. CONCLUSIONS: Across a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.
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Mamoplastia/economía , Mecanismo de Reembolso/economía , Dermis Acelular/economía , Adulto , Anciano , Austria , Enfermedades de la Mama/economía , Enfermedades de la Mama/cirugía , Implantación de Mama/economía , Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Grupos Diagnósticos Relacionados , Planes de Aranceles por Servicios/economía , Femenino , Alemania , Humanos , Italia , Tiempo de Internación , Mamoplastia/métodos , Persona de Mediana Edad , Mecanismo de Reembolso/estadística & datos numéricos , Colgajos Quirúrgicos , Suecia , Reino UnidoRESUMEN
BACKGROUND: Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects. METHODS: A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups. RESULTS: Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups. CONCLUSIONS: Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.
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Colgajos Tisulares Libres , Recuperación del Miembro , Terapia Neoadyuvante/efectos adversos , Radioterapia Adyuvante/efectos adversos , Sarcoma/terapia , Neoplasias de los Tejidos Blandos/terapia , Adulto , Anciano , Fraccionamiento de la Dosis de Radiación , Colgajos Tisulares Libres/efectos adversos , Supervivencia de Injerto , Hematoma/etiología , Humanos , Extremidad Inferior , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/etiología , Trasplante de Tejidos , Extremidad Superior , Cicatrización de Heridas/efectos de la radiaciónRESUMEN
INTRODUCTION: The provision of a complex lower-limb trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. METHODS: We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex lower limb trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. RESULTS: A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12792 ± £970 SEM (SFT) and £10953 ± £650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p < 0.05). CONCLUSIONS: Our study highlights the considerable disparity between the cost of managing patients with severe lower-limb trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral.
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Tiempo de Internación/economía , Extremidad Inferior/cirugía , Procedimientos de Cirugía Plástica/economía , Colgajos Quirúrgicos/economía , Fracturas de la Tibia/economía , Adulto , Codificación Clínica , Femenino , Costos de la Atención en Salud , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Estudios Prospectivos , Procedimientos de Cirugía Plástica/métodos , Fracturas de la Tibia/cirugíaRESUMEN
INTRODUCTION: Trauma is a significant part of the workload in plastic surgery. There are currently wide variations in the available resource for dealing with these patients. Delays to treatment currently exist and may result in poorer clinical outcomes. METHOD: Data was collected prospectively in 4 centres (Cork University Hospital, John Radcliffe Hospital, Stoke Mandeville Hospital and Salisbury District Hospital) assessing delays to theatre. We assessed time to theatre, both from injury and from review, cancellation rate, starvation time and patient satisfaction. RESULTS: 424 patients were audited over an 8-week period. The average time from review to theatre was 15.7 h and the average injury-to-theatre time was 58.6 h. The average starvation time was 10 h; the mean cancellation rate was 25%. Patients are satisfied overall with the service provided with 83% rating the service as excellent or good, and 63% feeling that there wait was not too long. CONCLUSIONS: Despite an increase in provision of emergency plastic surgery trauma lists, the average wait for emergency plastic surgery is increasing. Despite this patients remain, on the whole, satisfied with the service that they are receiving.
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Tratamiento de Urgencia/estadística & datos numéricos , Auditoría Médica , Cirugía Plástica/estadística & datos numéricos , Listas de Espera , Heridas y Lesiones/cirugía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/métodos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Prospectivos , Factores de Tiempo , Reino Unido , Carga de Trabajo , Heridas y Lesiones/diagnósticoRESUMEN
BACKGROUND: The free anterolateral thigh flap (ALT) is now used as a 'workhorse flap'. The donor site morbidity is thought to be minimal, although most evidence derives from questionnaire-based studies rather than rigorous objective clinical assessment. In particular, robust quantitative data on thigh sensibility and quadriceps function is lacking. The aim of this study was to provide a comprehensive clinical assessment of donor site morbidity. METHODS: We performed a prospective study of consecutive free ALT perforator flaps performed at Salisbury Foundation Trust between March 2008 and April 2010. The donor site was assessed at six months including a questionnaire (symptoms, function), scar analysis (Vancouver Scar Scale, VSS), and evaluation of quadriceps power and lateral thigh sensibility (compared with the contralateral unoperated thigh). RESULTS: One hundred ALT flaps were performed on 97 patients (mean age 46.8 years). The donor site was closed directly in 88 cases and using a split skin graft in 12 cases. At follow-up (n=68), tingling was the most common reported symptom (59%), whereas pain, itching and muscle herniation were reported infrequently. Donor site scars were mostly flat, pale and soft but widened. Pathological scarring was rare. Sensibility was reduced in donor thighs (p<0.001) and correlated with flap width but peak quadriceps contraction was similar between donor and unoperated thighs. CONCLUSIONS: There was a high throughput and diverse application of ALT flap reconstructions during the study period. Reduced sensibility was common around the scar but rarely troublesome. Quadriceps function was not affected even when dissection of intramuscular perforators was required. The ALT is a versatile flap that can deliver a large skin paddle with minimal impact on thigh function.
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Músculo Cuádriceps/fisiología , Colgajos Quirúrgicos , Muslo/fisiología , Sitio Donante de Trasplante , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Contracción Muscular/fisiología , Dinamómetro de Fuerza Muscular , Estudios Prospectivos , Sitio Donante de Trasplante/fisiología , Adulto JovenRESUMEN
Absence of flexor digitorum superficialis function in the little finger is a relatively common congenital anomaly that can complicate assessment of little finger injuries. We reviewed the prevalence of unilateral and bilateral absence of superficialis function in the published literature. In appropriate studies identified (1352 people), the anomaly was unilateral in 92 individuals (6.8%) and bilateral in 81 (6.0%). If superficialis function is absent in one little finger, the probability of absence in the opposite hand is 0.64. If superficialis function is present, the probability of absence in the other little finger is 0.02 (1 in 50). Absence of little finger superficialis function in one hand is therefore not a reliable indicator of this function in the opposite hand.
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Dedos/anomalías , Tendones/anomalías , Traumatismos de los Dedos/diagnóstico , HumanosRESUMEN
INTRODUCTION: The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England. SUBJECTS AND METHODS: We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge. RESULTS: The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ± 1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days. CONCLUSIONS: Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.
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Fracturas Abiertas/cirugía , Fracturas de la Tibia/cirugía , Accidentes de Tránsito , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Inglaterra , Femenino , Fijación de Fractura/métodos , Fracturas Abiertas/etiología , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Auditoría Médica , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos , Fracturas de la Tibia/etiología , Índices de Gravedad del Trauma , Resultado del Tratamiento , Gales , Adulto JovenRESUMEN
Mechanical tension and contracture are two related facets of tissue biology. This study assessed the effect of ilomastat, a broad-spectrum matrix metalloprotease (MMP) inhibitor, on generation of tension by Dupuytren's disease fibroblasts. Nodule and cord-derived fibroblasts were isolated from five patients with Dupuytren's disease; flexor retinaculum acted as the control. A culture force monitor (CFM) provided an in vitro model of tissue organization to assess development of mechanical tension, lattice contraction and spatial remodelling by fibroblasts. Responses to ilomastat were compared to treatment with a control peptide. Nodule and cord-derived fibroblasts exhibited a two-fold increase in tension compared with flexor retinaculum. Ilomastat significantly inhibited development of tension by nodule and cord but not flexor retinaculum derived fibroblasts at 100 microM. These results imply that MMP activity mediates regulation of tensile strength by Dupuytren's disease fibroblasts and may be an important therapeutic target in patients with Dupuytren's disease.
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Contractura de Dupuytren/patología , Inhibidores Enzimáticos/farmacología , Fibroblastos/efectos de los fármacos , Indoles/farmacología , Inhibidores de la Metaloproteinasa de la Matriz , Células Cultivadas , Citocalasina D/farmacología , Humanos , Ácidos Hidroxámicos , Inhibidores de la Síntesis del Ácido Nucleico/farmacologíaRESUMEN
Individual finger tourniquets are appropriate to the management of a wide range of conditions presenting to an accident and emergency department. They are simpler and more comfortable to use than upper arm pneumatic tourniquets and commercially available digital tourniquets are not readily available in the accident and emergency unit. However, if a finger tourniquet is overlooked, ischaemia of the digit results, and gangrene may follow if the problem is not defused early enough, leading to potential disaster. We present one case where a digit was salvaged after 4 days of tourniquet application, using medicinal leeches.
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Traumatismos de los Dedos/terapia , Dedos/irrigación sanguínea , Isquemia/terapia , Aplicación de Sanguijuelas/métodos , Torniquetes , Heridas no Penetrantes/terapia , Adolescente , Animales , Hirudo medicinalis , Humanos , Masculino , Terapia Recuperativa/métodosRESUMEN
Although metachronous colorectal tumours are relatively common, they seldom occur at stomasites. We present the case of a 57-year-old woman who developed a colostomy site malignancy. Possible associations and risk factors are discussed.