Endoluminal Vacuum Therapy (EVAC) in Managing Esophagogastric Anastomosis Fistula / Terapia de vacío endoluminal (Endo-Vac) en el manejo de la fístula de anastomosis esofagogástrica

Abstract Endoluminal vacuum therapy (EVAC) is a promising alternative for the endoscopic management of gastrointestinal fistulas or perforations that do not respond to endoscopic procedures using clips and stents or are even refractory to surgical procedures. In this case report, we describe the successful endoscopic closure of an esophagogastric anastomotic fistula using EVAC, connected to a vacuum system through a probe in the cavity, which did not close with clip management given the friability and edema of the peri-wound tissue. In conclusion, it is a successful alternative to treat these complications, which are sometimes difficult to resolve.

Resumen La terapia de vacío endoluminal (Endo-Vac) es una alternativa promisoria en el manejo endoscópico de las fístulas o perforaciones gastrointestinales, que no responden a procedimientos endoscópicos cuando se utilizan técnicas como clips, stents o incluso refractarias a procedimientos quirúrgicos. En este reporte de caso describimos el cierre endoscópico exitoso de una fístula anastomótica esofagogástrica, utilizando la terapia Endo-Vac, conectada a un sistema de vacío mediante una sonda en la cavidad, que no presentó cierre inicial a manejo con clips, dada la friabilidad y el edema del tejido perilesional. Se concluye que esta es una alternativa exitosa en el cierre de estas complicaciones, que en ocasiones son de difícil resolución.

Clinical Trial on the Incidence of Wound Infection and Patient Satisfaction After Stoma Closure: Comparison of Two Skin Closure Techniques

PURPOSE: Surgical site infection (SSI) is one of the most common complications that can occur after stoma closure. Reports have described differences in the incidence of wound infection depending on the skin closure technique, but there is no consensus on the ideal closure technique for a stoma wound. The aim of this study was to compare the incidence of SSI and the patient satisfaction between a circumferential purse-string approximation (CPA) and a primary linear closure (PC) of a stoma wound. METHODS: This prospective nonrandomized trial enrolled 48 patients who underwent a stoma closure from February 2010 to October 2013. Patients were divided into two groups according to the stoma closing technique: the CPA group (n = 34) and the PC group (n = 14). The incidences of SSI for the two groups were compared, and the patients' satisfaction with the stoma closure was determined by using a questionnaire. RESULTS: SSI occurred in 3 of 48 patients (6.3%) and was more frequent in the PC group than in the CPA group (3/14 [21.4%] vs. 0/34 [0%], P = 0.021). Time to complete healing after stoma closure in the CPA group was 32 days (range, 14-61 days). Patients in the CPA group were more satisfied with the resulting wound scar (P = 0.043). CONCLUSION: After stoma closure, CPA was associated with a significantly lower incidence of wound infection and greater patient satisfaction compared to PC. However, with the CPA technique, the time to heal is longer than it is with PC.

Multidirectional Vector Excision Leads to Better Outcomes than Traditional Elliptical Excision of Facial Congenital Melanocytic Nevus

BACKGROUND: The elliptical excision is the standard method of removing benign skin lesions, such as congenital melanocytic nevi. This technique allows for primary closure, with little to no dog-ear deformity, but may sacrifice normal tissue adjacent to the lesion, resulting in scars which are unnecessarily long. This study was designed to compare the predicted results of elliptical excision with those resulting from our excision technique. METHODS: Eighty-two patients with congenital melanocytic nevus on the face were prospectively studied. Each lesion was examined and an optimal ellipse was designed and marked on the skin. After an incision on one side of the nevus margin, subcutaneous undermining was performed in the appropriate direction. The skin flap was pulled up and approximated along several vectors to minimize the occurrence of dog-ear deformity. RESULTS: Overall, the final wound length was 21.1% shorter than that achieved by elliptical excision. Only 8.5% of the patients required dog-ear repair. There was no significant distortion of critical facial structures. All of the scars were deemed aesthetically acceptable based on their Patient and Observer Scar Assessment Scale scores. CONCLUSIONS: When compared to elliptical excision, our technique appears to minimize dogear deformity and decrease the final wound length. This technique should be considered an alternative method for excision of facial nevi.

Application of Lumbar Artery Perforator Flap for Reconstruction of Back Ulcer: Clinical Study with Computed Tomographic Angiography

PURPOSE: Un-healing and centrally located defect on back area, it is sometimes a challenge for the reconstructive surgeon. Although skin grafts are considered as the first choice for reconstruction of large skin defect on the back region, it is not always helpful but vascularized flaps provide a superior functional and aesthetic outcome. The present study was designed to investigate the clinical anatomy of the lumbar artery perforator flap to reconstruct back ulcer. MATERIALS AND METHODS: Clinical anatomy study was undertaken using computed tomographic angiographic analysis. We identified the courses of lumbar arteries and its perforators, measured pedicle length by layers. The location of the perforator vessel was charted against anatomical landmarks. RESULTS: The pedicle lengths of the third and fourth lumbar artery perforator reached a mean of 27.8 mm and 37.1 mm respectively from superficial fascia to deep fascia. The fourth perforator was more laterally located than the third perforator and less than 1 cm above the iliac crest. A case in which the fourth lumbar artery perforator was used as flap pedicle is described. CONCLUSION: For the reconstruction of central defect on the back area, the lumbar artery perforator flap coverage may be a good alternative option. Computed tomographic angiography can easily identify the course and location of lumbar artery perforators and can be helpful to elevate the flap successfully.