Treatment for postchemoradiotherapy hypopharyngeal stenosis: Pharyngoesophageal bypass using an anterolateral thigh flap-A case report.

Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature.

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

Staff senior versus staff junior en cirugía tiroidea. Supervisada: resultados y desafíos pedagógicos.

OBJETIVO: En el presente trabajo nos planteamos analizar cuál es la visión del cirujano supervisado que realiza una cirugía tiroidea acerca de qué y cómo se aprende en el ámbito del quirófano y cuáles son las características de este espacio de aprendizaje. Se analizaron las posibles diferencias respecto a la morbilidad posoperatoria del paciente cuando es tratado por un supervisor o un supervisado. MÉTODO: Estudio observacional cualitativo-cuantitativo mediante un cuestionario sin opciones prefijadas, tanto a los supervisores como a los supervisados. También se analizó una base de datos retrospectiva considerando la estadía, los tiempos operatorios y las complicaciones agudas y crónicas según el operador (supervisado o supervisor). RESULTADOS: La experiencia profesional involucra otras acciones complejas que deben visibilizarse para ser enseñadas. Tanto supervisores como supervisados reconocieron al quirófano como un contexto socializador a través de aprendizajes supervisados. No existieron diferencias estadísticas en las complicaciones ni en la estadía hospitalaria entre cirujanos expertos y cirujanos en formación supervisados. CONCLUSIONES: Este trabajo resulta ser un aporte a quienes enfrentan el desafío de facilitar el aprendizaje dentro de la sala de operaciones. Se espera que ayude a inspirar acciones planificadas que jerarquicen y aporten calidad a la tarea educativa ineludible. OBJECTIVE: In the present work we propose to analyze what is the vision of the supervised surgeon who performs thyroid surgery about what and how it is learned in the operating room and what are the characteristics of this learning space. Possible differences regarding the postoperative morbidity of the patient when treated by a supervisor or a supervised person were analyzed. METHOD: Qualitative-quantitative observational study using a questionnaire without predefined options, for both supervisors and supervisees. A retrospective database was also analyzed considering hospital stay, operative times, acute and chronic complications according to operator (supervised or supervisor). RESULTS: Professional expertise involves other complex actions that must be made visible to be taught. Both supervisors and supervisees recognized the operating room as a socializing context through supervised learning. There were no statistical differences in complications and / or hospital stay between expert surgeons and supervised surgeons in training. CONCLUSIONS: This work turns out to be a contribution to those who face the challenge of facilitating learning in the operating room. It is hoped that it will help inspire planned actions that prioritize and add quality to the inescapable educational task.

Head and neck sarcomas: treatment outcomes in a tertiary referral center in Argentina.

PURPOSE: To analyze the clinical findings, management, and results of oncological treatments and to identify prognostic factors in patients diagnosed with head and neck sarcoma. METHODS: We performed a retrospective analysis including 48 adult patients with primary head and neck sarcomas, treated between 2006 and 2018 in a referral center of Argentina. RESULTS: The median follow-up time was 44 months (range: 4-146 months). Five-year overall survival was 68%. On univariate analysis, radiation-induced sarcomas (p=0.038) had worse survival. Five-year disease-free survival was 58% and local recurrence at 2 years was 22.7%. On multivariate analysis, positive/close resection margins (p=0.031), radiation-induced sarcomas (p=0.037), and mandibular and oral cavity location (p=0.002) were independent prognostic factors associated to local recurrence and shorter disease-free survival. CONCLUSION: Head and neck sarcomas are a rare entity. Surgery is feasible in more than 80% of patients, with an acceptable overall and disease-free survival. Radiation-induced sarcomas, location in the mandible and oral cavity, and close margins were significant prognostic factors in our population.

Reconstruction of Hind and Mid-Foot Defects after Melanoma Resection Using the Reverse Sural Flap: A Case Series.

Background Melanoma resection creates important soft tissues defects, which are difficult to manage when located on the weight-bearing heel and mid foot. There is little evidence on the use of the reverse-flow sural flap for this type of reconstruction. Objective This study reports our case series on the reconstructive management of the hind and mid-foot defects after melanoma resection using the reverse sural artery flap. Materials and Methods This is a retrospective study of four consecutive patients treated with resection of melanoma of the feet and reconstruction with reverse sural artery flap from 2006 to 2009. Results The mean age of the patients was 54 years, three were females, and one was male. Three of the defects were located on the weight-bearing heel, the other on the mid-foot dorsum. The melanomas were fully resected with wide margins. Three patients were reconstructed primarily, whereas one patient was reconstructed 4 weeks after the resective surgery. This series revealed 100% flap survival and there was no partial necrosis. Major complications were not observed. The four patients completely recovered the function of the affected limb. Conclusion The reverse sural flap is a viable option for the reconstruction of foot defects after melanoma resection.

Management Issues in the Treatment of an Ameloblastoma with an Atypical Presentation.

Benign ameloblastoma (BA) is the most common tumor arising from the odontogenic epithelium. Surgical resection with adequate margins is the mainstay of treatment due to the high index of tumor recurrence when not completely excised. Although locoregional spread has been described in the literature, it is very uncommon. We describe the treatment and follow-up of a 22-year-old woman with multiple recurrences and locoregional spread of a mandibular ameloblastoma who was referred to our center after several tumor resections with subsequent reconstructions. After a complete macroscopical removal of a new recurrence, the mandible was primarily reconstructed. A local homolateral recurrence and a second lesion in the contralateral maxilla were detected after 1-year follow-up and accordingly treated. After 4 years the patient showed a new tumor in the temporal fossa and was reoperated. The histopathology was consistent with a BA in all cases. Even though it is rare, locoregional spread of BA has been reported previously. Recurrences discovered during follow-up may require further resections. A close follow-up is mandatory, and treatment of these cases may result demanding requiring a multiple team approach, including oncologists and radiotherapists.

Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review.

The aim of the study is to analyze the effectiveness of rigid internal fixation (RIF) for treating edentulous mandibular fractures. Because of the low incidence of fractures in edentulous mandible, there is no consensus of the optimal treatment for it. This study included all edentulous patients with mandibular fracture diagnosis, who were treated with internal fixation at the Hospital Italiano de Buenos Aires from November 1991 to July 2011. Data such as age, gender, etiology and location of fracture, surgical approach, type of osteosynthesis used, and postoperative complications were analyzed. A total of 18 patients, 76.2 years mean age, 12 females (66.6%), presented a total of 35 mandibular fractures. The mandibular body was the most common localization of the fractures. Twenty-five fractures received surgical treatment with RIF, mainly approached extraorally. Reconstruction plates were the most common type of fixation used. Fracture reduction was considered satisfactory in 96.5%, with 22.2% of complications and 11.1% of reoperations needed. Open reduction and RIF demonstrated to be a reliable method for treating edentulous mandibular fractures. Nevertheless, there is lack of high-level recommendation publication to support this.

Pasado, presente y futuro del trasplante facial en el mundo y en la Argentina / Past, present and future of facial transplant in the world and in Argentina

El año 2005 marcó un cambio de paradigma en la reconstrucción facial. En Amiens, Francia, se llevó a cabo con éxito el primer trasplante de cara. Desde entonces, se han planteado varios interrogantes; entre ellos el desafío técnico, el manejo inmunológico y el dilema ético. El presente trabajo es una revisión de la literatura publicada hasta la actualidad. Se analiza la historia, implicaciones, resultados hasta hoy y su futuro. Asimismo, se evalúa la situación actual y factibilidad en la Argentina.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature / Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature.

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

Hemorragia de fosa posterior en el recién nacido de término: una emergencia neuroquirúrgica / Posterior fossa hemorrhage in the term newborn: an neurological emergency

La hemorragia de fosa posterior en el recién nacido de término es una patología de muy baja incidencia cuyos efectos pueden ser letales de no ser reconocida y tratada con presteza,la dificultad diagnóstica asociada a sus síntomas iniciales inespecíficos hacen necesarios un alto índice de sospecha y una actitud agresiva en su tratamiento neuroquirúrgico,antes de que su evolucion comprometa la vida del paciente o provoque lesiones irreparables.Comunicamos el tratamiento de un recién nacido de término con hemorragia de fosa posterior(acompañada de hemorragias supratentoriales de menor volumen en ambas cisternas silvianas)quien luego de un caudro clínico inicial indiferenciado,siguió un curso crítico de hidrocefalia aguda y compresión troncal.El niño fue tratado exitosamente con cirugía.Se debe enfatizar la necesidad del diagnóstico precoz para permitir una oportunidad quirúrgica que mejore las posibilidades pronósticas

Analisis de costos del tratamiento de la hidrocefalia / Cost analysis of hidrocephalus treatment

Objetivo: Evaluar costos de las dos alterantivas quirugicas que se consideran actualmente para el tratamiento de la hidrocefalia: la derivacion ventriculo peritoneal / atrial (DVP) y la ventriculostomia endoscopica del piso del III ventriculo (VE) durante un año de seguimiento en nuestro servicio. El impacto economico de ambas no ha sido establecido en nuestro medio. Metodo: ingresaron en nuestro servicio 59 pacientes con diagnostico de hidrocefalia entre enero de 2000 y agosto de 2002; 9 se excluyeron por no cumplir todos los criterios de seguimiento. Fueron tratados mediante VE: 14 casos y DVP: 36 casos. Veintidos de estos ultimos, con hidrocefalia no comunicante, se agruparon con los sometidos a VE para comparar resultados. Se promediaron: dias de internacion, TAC, IRM, honorarios quirurgicos, anestesicos, costos de protesis y uso de neuroendoscopio en cada grupo. Resultados: el grupo A (DVP) tuvo un promedio de 4,6 dias de internacion para cirugia y 1,05 TAC diagnosticas. Por probable disfuncion: 5 dias de internacion en promedio, 1,05 TAC y 1,66 Rx de control valvular. Veinticuatro TAC ambulatorias. En el grupo B (VE) el promedio fue de 6,92 dias, 10 TAC y 26 IRM durante la internacion para cirugia, 4 fallos requirieron DVP. El costo promedio del primer evento en el grupo A (implante de DVP) fue $3.708,28; en el grupo B (VE) fue $5.742,77. Durante el periodo de control el costo en el grupo A fue $1.542,39 y en el grupo B $2.173,85. Conclusion: Durante el primer año de seguimiento la VE aparece con menor costo respecto de la DVP. El valor de los honorarios quirurgicos representa el 13,36 por ciento del tratamiento en el grupo A y el 8,86 por ciento en el grupo B del costo total durante el primer año, mientras que el costo de la DVP representa el 22,85 por ciento y el uso del Neuroendoscopio el 28,29 por ciento

Hemorragias cerebrales. Parte I: malformaciones arteriovenosas. Analisis sobre 41 casos / brain hemorrhage. Part I: arterial malformations. An analysis of 41 cases

Objetivo: analizar las formas de presentacion, los diferentes abordajes y los resultados quirurgicos de cada malformacion. Metodo: entre diciembre de 1990 y diciembre de 2001 fueron operados en nuestro años (rango 6 dias a 18 años). El debut fue hemorragico en 32, diagnosticadas en el estudio de convulsiones 4; 4 presentaron cefaleas como unica manifestacion previa y 1 fue un hallazgo asintomatico debido a un traumatismo craneoencefalico. Seis pacientes requirieron manejo de su hidrocefalia aguda con ventriculostomia transitoria y 4 necesitaron derivacion permanente. La embolizacion preoperatoria se realizo en 4 pacientes. Veinte pacientes portaban MAV grado I de Spetzler - Martin, 17 grado II y 2 grado III. Dos pacientes de hallazgo intraoperatorio no puedieron ser categorizados. Resultados: La exeresis completa se obtuvo en 40 casos: 2 pacientes con dos procedimientos, uno con tres y un paciente presento "recidiva" de una MAV pericallosa luego de 3 años del control angiografico postoperatorio sin evidencia de malformacion. La aparicion de nuevo deficit postoperatorio se constato en 4 pacientes, no se registraron hemorragias postoperatorias inmediatas ni mortalidad operatoria. El tiempo de seguimiento fue de 6 meses a 10 años

Abordaje interhemisferico transcalloso. Resultados quirurgicos / Interhemispheric transcallosal approach. Surgical results

Objetivos: evaluar aplicaciones y resultados de uso de la via interhemisferica trancallosa. Analizar los detalles del manejo quirurgico obtenido en lesiones de los ventriculos laterales, III ventriculo y cara ventricular talamica. Metodo: Veintitres abordajes transcallosos fueron aplicados en dieciocho pacientes entre enero de 1995 y enero de 2003. Se revisaron las historias clinicas, partes quirurgicos e imagenes obtenidas en el pre y postoperatorio (18 TAC y 13 IRM al diagnostico); se evaluaron la extension de callosotomia y los hallazgos quirurgicos. Se compararon los resultados anatomopatologicos en casos de repeticion del procedimiento. Resultados: la edad promedio fue de : 6 años (3-17 años). Se realizaron 23 procedimientos. En cuatro pacientes se repitio el abordaje (un astrocitoma pilocitico en dos oportunidades, un cavernoma tambien en dos y una MAV en una). Nueve tumores solidos, un quiste coloideo y un craneofaringioma ubicados en el III ventriculo fueron explorados por via transforaminal. Tres tumores talamicos se resecaron desde la cara ventricular, uno con la variante transcoroidea. Dos tumores de la prolongacion frontal fueron resecados desde la callosotomia. En una MAV la callosotomia se utilizo para control y reseccion de grenajes profundos. Anatomia patologica: 7 astrocitomas pilociticos, 3 glioblastomas, 1 papiloma de plexo coroideo, 1 neurocitoma, 1 ependimoma, 1 germinal mixto, 1 cavernoma, 1 quiste coloideo, 1 craneofaringioma y 1 MAV. Se realizaron: 10 resecciones completas, 7 subtotales, 5 parciales. Dos pacientes presentaron deterioro neuropsicologico postquirurgico: uno portador de Astrocitoma talamico; el otro fue un niño con papiloma de plexos coroideos con hidrocefalia persistente. Conclusion: la minima incision neural de la callosotomia permite resecciones amplias sin agregar lesion, aun con la repeticion del procedimiento. La extension de la callosotomia resulto ser mayor en IRM que la estimacion del cirujano. No se necesitaron secciones de fornix ni coagulacion venosa ya que el agradamiento del Foramen de Monro es suficiente para la exploracion

Diferentes tecnicas neuroendoscopicas para el tratamiento de la hidrocefalia en pediatria. Estudio multicentrico en 360 pacientes / Different neuroendoscopical Techniques for the treatment of pediatric hydrocephalus Study in 360 patients

Objective: To analize our experience in the endoscopical treatment of pediatrichydrocephalus. Methods: In a retrospective study we analyzed 360 hidrocephalic patients treated endoscopically in 5 Pediatric Neurosurgical Services in Buenos Aires. 374 procedures were performed: 207 third-ventriculostomies, 70 septal fenestrations, 48 catheter implantations, 26 cyst-ventriculostomies, 11 septomies, 7 catheter removals, 4 aqueductoplasties and 1 monoplasty. Results: Third ventriculostomy was the most frequent procedure with a very low failure rate (19,8 por ciento). The overall complication rate was 4,5 por ciento. IN pineal tumor related hydrocephalus, a simultaneous biopsy procedure was always sucessful. Conclusions: Endoscopic treatment of hydrocephalus must always be consideraded as an effective method and as the first choice treatment in an important number of patients