Reconstrucción en amputaciones distales de dedos en niños con injerto compuesto y vendaje semioclusivo / Reconstruction of distal finger amputations in children with composite autograft and semi-oclusive dressing

La reconstrucción de una amputación distal de dedo en un niño es un desafío. Los procedimientos propuestos son muchos, y los resultados no han sido buenos. La reconstrucción con reposición del segmento a modo de injerto compuesto, o con técnicas microquirúrgicas, parece ofrecer la mejor de las posibilidades, pues se conservan estructuras irremplazables, como el lecho ungueal y el hiponiquio, lo que permite que los niños mantengan un pulpejo anatómico y con función normal. Presentamos una serie de tres pacientes pediátricos tratados con una nueva técnica, que combina la reposición del segmento, como un injerto compuesto, y el uso de curación semioclusiva (composite autograft and semi-oclussive dressing, CASOD, en inglés). Hemos observado buenos resultados.

The reconstruction of finger tip amputation in children is challenging. There are many procedures described to treat this injury, none of which present optimal results. Repositioning of the amputated segment as an autograft or with microsurgical techniques seems to offer the best outcome. It enables the preservation of otherwise irreplaceable structures, such as the nail bed and the hyponychium, thus enabling children to mantain an anatomically and functionally normal finger pad. We present a series of three pediatric patients treated with tha new technique, which combines composite autograft and semi-oclusive dressing (CASOD). The results observed so far have been promising.

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience

ABSTRACT Introduction and Objective: Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR). Materials and Methods: Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed. Results: 71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days. Conclusions: The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Does aortic valve repair in valve-sparing aortic root reconstruction compromise the longevity of the procedure?

OBJECTIVES: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.

Long term outcomes of laparoscopic and open modified lich-gregoir reimplantation in adults: a multicentric comparative study

Background and Objective: Obstructive ureteral pathologies in adult patients are most commonly due to ureteral strictures and secondary to surgical interventions. In this study, we aimed to compare open and iaparoscopic modified Lich-Gregoir ureteral reimplantation with regards to outcomes in benign ureteral pathologies in adult patients

Methods: Between December 2008 and December 2014, 32 open cases and 29 laparoscopic cases were performed as per the data retrieved from surgical databases. All laparoscopic procedures were performed in Bakirkoy Dr. Sadi Konuk Training and Research Hospital [BEAH] and all open ureteral reimplantation procedures in Kartal Dr Lutfi Kirdar Training and Research Hospital [KEAH] and Okmeydani Training and Research Hospital [OEAH]

Results: The mean operation time was significantly lower in the group of patients operated with open group [142.5 minutes versus 188.9 minutes; P< 0.0001]. The mean duration of follow-up was longer in the laparoscopy group [31 versus 28 months; p< 0.0001]. The mean amount of operation associated blood loss was significantly lower in patients operated laparoscopically [93.7 ml versus 214 ml; P< 0.0001]. The mean VAS score obtained six hours after surgery was 6.6 +/- 0.8 in open group, and 5.8 +/- 0.7 in laparoscopic group [p=0.0004]. The mean VAS scores measured at post-operative day 1 was 4.5 +/- 0.7 in open group and 3.7 +/-0.9 in laparoscopy group. Time required to achieve the pre-operative capability of daily activities was significantly longer in open group [15 +/- 1.4 days vs 11 +/- 1.4 days; p< 0.0001]

Conclusion: Despite open techniques provide shorter operation time and laparoscopic techniques require long learning curve, we think that laparoscopic techniques are superior to open ones since that they provide a better post-operative comfort and are better tolerated in terms of complications

Reconstrucción en un tiempo del pabellón auricular en amputación parcial traumática con preservación del pedículo inferior: revisión de la literatura y presentación de dos casos / One-stage auricular replantation in traumatic partial ear amputation with inferior pedicle preservation: review of the literature and presentation of two cases

La amputación parcial traumática del pabellón auricular con preservación del pedículo inferior corresponde a una patología infrecuente. Su reconstrucción incluye el uso de diversas técnicas quirúrgicas. Presentamos dos casos de reimplante inmediato, sin uso de microcirugía, con resultados favorables y sin necesidad de reintervenciones, junto a una revisión de la literatura. La revisión bibliográfica realizada apoya el uso de esta técnica, basándose en la preservación del puente cutáneo bajo el tragus que incluye una rama de la arteria temporal superficial y que sería responsable de la irrigación del reimplante.

Partial auricle amputation with preservation of the inferior pedicle is an unusual pathology. The reconstruction in these cases includes many surgical techniques. We present two cases of immediate replantation, without the use of microsurgery, with favorable outcomes and without need of new interventions. The revision of the literature supports this technique based in the preservation of the cutaneus bridge under the tragus that includes a branch of the superficial temporal artery that is responsible of the perfusion of the reimplant.

Contemporary Series of Robotic-Assisted Distal Ureteral Reconstruction Utilizing Side Docking Position

Purpose: The robot-assisted approach to distal ureteral reconstruction is increasingly utilized. Traditionally, the robot is docked between the legs in lithotomy position resulting in limited bladder access for stent placement. We examined the use of side docking of the daVinci robot® to perform distal ureteral reconstruction. Materials and Methods: A retrospective review of distal ureteral reconstruction (ureteral reimplantation and uretero-ureterostomy) executed robotically was performed at a single institution by a single surgeon. The daVinci robotic® Si surgical platform was positioned at the right side of the patient facing towards the head of the patient, i.e. side docking. Results: A total of 14 cases were identified from 2011–2013. Nine patients underwent ureteral reimplantation for ureteral injury, two for vesicoureteral reflux, one for ureteral stricture, and one for megaureter. One patient had an uretero-ureterostomy for a distal stricture. Three patients required a Boari flap due to extensive ureteral injury. Mean operative time was 286 minutes (189–364), mean estimated blood loss was 40cc (10–200), and mean length of stay was 2.3 days (1–4). Follow-up renal ultrasound was available for review in 10/14 patients and revealed no long-term complications in any patient. Mean follow-up was 20.7 months (0.1–59.3). Conclusion: Robot-assisted laparoscopic distal ureteral reconstruction is safe and effective. Side docking of the robot allows ready access to the perineum and acceptable placement of the robot to successfully complete ureteral repair.

Reintegração de amputação digital distal com enxerto composto e difusão plasmática ampliada distal no plano dérmico palmar - relato de um caso em criança de 2 anos de idade e revisão da literatura / Reintegration of distal digital amputation with composite graft and plasmatic diffusion expanded distally on the palmar dermal plane - a case report of a 2-year-old child and a literature review

Nas amputações mais distais da ponta dos dedos, o reimplante microcirúrgico pode não ser praticável. Nestes casos, o enxerto composto oferece os melhores resultados funcionais e estéticos, sendo, porém, incerta a sua reintegração. Várias técnicas foram aventadas para melhorar a sobrevida do enxerto volumoso, basicamente diminuindo o seu volume, associando ou não um retalho cutâneo. Outras técnicas criam uma superfície adicional de contato para difusão plasmática, o "bolso subcutâneo", sem diminuir o volume do enxerto composto, com altas taxas de sucesso. O presente artigo apresenta um caso de amputação da ponta distal do dedo mínimo (zona I de Ishikawa) numa criança de 2 anos de idade. Impossível de reimplante microcirúrgico, a reintegração foi feita com enxerto composto do coto amputado, sem desbridamento, e com a criação de uma nova superfície de contato para difusão plasmática, na extremidade distal do coto enxertado, no plano dérmico da região hipotênar, aumentando assim a área de contato e diminuindo a distância radial da difusão plasmática no enxerto composto. Doze dias após, esse contato adicional foi separado e ambas as superfícies apresentaram sangramento. A reintegração foi total, com mínimas cicatrizes no dedo e na região hipotênar. Uma breve revisão bibliográfica foi feita e discutidos os conceitos cirúrgicos, assim como os fatores que influenciam na sobrevida do enxerto composto. Na área receptora, o plano anatômico mais adequado e melhor vascularizado, para o contato adicional com o enxerto, necessita ser determinado.

In more-distal amputations of the fingertips, microsurgical replantation is not feasible. For these cases, composite graft provides the best functional and aesthetic results. However, its reintegration is uncertain. Several techniques have been proposed to improve bulky graft survival by basically reducing its volume, regardless of whether a skin flap is connected. Other techniques create an additional contact surface for plasmatic diffusion, the so-called subcutaneous pocket, without reducing the composite graft volume and yielding high success rates. This article presents a case of amputation of the distal tip of the fifth digit (Ishikawa zone I) of a 2-year-old child. Because of the impossibility of microsurgical replantation, a composite graft was used to reintegrate the amputated stump, without debridement, by creating a new contact surface for plasmatic diffusion at the distal end of the grafted stump, on the dermal plane in the hypothenar region, thereby increasing the contact area and decreasing the radial distance for the plasmatic diffusion of the composite graft. Twelve days later, the additional contact was separated and both surfaces presented bleeding. Full reintegration occurred with minimal scarring of the finger and hypothenar region. A brief literature review was conducted, discussing surgical concepts and factors that influence composite graft survival. The most appropriate and best vascularized anatomic plane for additional contact with the graft in the recipient area needs to be determined.

Re-implantation of a degloving amputation of distal index finger caused by fireworks: a case report and literature review / Re-implantación de una amputación por desguantamiento de un dedo índice distal causada por fuegos artificiales: Reporte de caso y revisión de la literatura

Amputations associated with fireworks are customarily treated by stump revision resulting in permanent disability. In this case report, we present an eight-year old boy who suffered an amputation of his right distal index finger at the level of the epiphyseal disk with degloving injury of the amputated finger caused by fireworks. Successful re-implantation was achieved. Two-year follow-up revealed fair cosmesis and acceptable functional and aesthetic recovery though the free distal phalanx had been absorbed completely. Re-implantation of a degloving amputation finger caused by fireworks is possible and can provide good distal soft tissue coverage and recovery ofsensory and motor functions.

Las amputaciones relacionadas con fuegos artificiales son tratadas habitualmente por revisión de muñón, lo que trae como resultado una discapacidad permanente. En este reporte de caso, presentamos a un niño de 8 años que sufrió una amputación de su dedo índice derecho distal a nivel del disco epifisario con lesión por desguantamiento del dedo amputado causada por fuegos artificiales. Se logró una re-implantación exitosa. Los dos años de seguimiento revelaron una corrección quirúrgica cosmética satisfactoria, así como una recuperación funcional y estética aceptable, aunque la falange distal libre había sido absorbida completamente. La re-implantación de un dedo amputado por desguantamiento causado por fuegos artificiales es posible y puede proporcionar buena cobertura de tejido suave distal y recuperación de las funciones sensoriales y motoras.

Traumatic avulsion of extraocular muscles: case reports / Avulsão traumática de músculos extraoculares: relatos de casos

We described the clinical, surgical details and results (motor and sensory) of the retrieving procedure of traumatically avulsed muscles in three patients with no previous history of strabismus or diplopia seen in the Department of Ophthalmology, State University of Campinas, Brazil. The slipped muscle portion was reinserted at the original insertion and under the remaining stump, which was sutured over the reinserted muscle. For all three cases there was recovery of single binocular vision and stereopsis.

Foram descritos os quadros clínicos, detalhes cirúrgicos e resultados (motores e sensoriais) da reinserção de músculos traumaticamente avulsionados, em três pacientes sem estória prévia de estrabismo ou diplopia, atendidos no Departamento de Oftalmologia da Universidade Estadual de Campinas. A porção muscular deslizada foi reinserida na linha da inserção original e sob o coto remanescente, o qual foi acomodado e suturado sobre o músculo reinserido. Para os três casos houve recuperação da visão binocular única e da estereopsia.

Autotrasplante cardiaco en el tratamiento quirúrgico de tumores cardiacos primarios: Caso clínico / Heart autotrasplantation for the treatment of a rhabdomyosarcoma of the left ventricle: Report of one case

Background: Heart autotrasplantation is an exceptional surgical technique used in the treatment of uncontrolled cardiac arrhythmias and primary unresectable cardiac tumors. We report a 28-year-old male with a rhabdomyosarcoma of the left ventricle, localized in the lateral and posterior wall, which involved the mitral valve and circumflex artery. After a complete study ruling out dissemination of the tumor, the patient was operated. Surgical exploration determined the unresectabilility of the tumor with the heart in situ. Therefore, the heart was explanted, preserving the right atrium and coronary sinus for re-implantation. Fifty percent of the mitral valve and the circumflex artery from its origin, were resected due to tumor infiltration. The heart was reconstructed with bovine pericardium and a mechanical valve was implanted in the mitral position. Afterward, the heart was implanted again following the same sequence as in bicaval transplantation, followed by a double bypass grafting to the distal circumflex territory. The patient had no significant complications and after nine months of follow up, there was no evidence of local recurrence. In the fourth postoperative month, a subcutaneous mass in the left thigh that was considered a metastasis without histological confirmation appeared. The lesion disappeared with radio and chemotherapy.

Reimplante e revascularização da ponta do dedo: revisão de literatura e relato de caso de amputação da ponta do dedo mínimo na criança de um ano de idade / Fingertip replantation and revascularization: literature review and a case report of fingertip amputation of the fifth finger of a one-year-old child

A falange distal é funcionalmente importante e deve ser reimplantada em casos de acidente. A técnica de eleição é microcirúrgica, porém a anastomose da veia pode ser extremamente difícil ou impossível, principalmente em crianças pequenas. Este artigo reporta um caso de reimplante microcirúrgico da falange distal do dedo mínimo em uma criança de sexo masculino, de um ano de idade, que sofreu amputação da falange distal do dedo mínimo tipo "guilhotina", na porta residencial. A falange foi reimplantada 8 horas após a amputação, com anastomose de uma artéria e uma veia extremamente finas. A região apresentou congestão, que durou mais de uma semana, porém sem necrose, não necessitando condutas coadjuvantes. Neste artigo, que também faz revisão bibliográfica da conduta no retorno venoso difícil em crianças dessa faixa etária, várias técnicas foram revistas e apresentadas na solução de retorno venoso difícil, assim como os fatores que influenciam a sobrevivência da parte amputada, porém não há um estudo específico de conduta para essa faixa etária. A criança, provavelmente, tem melhor recuperação ou readaptação funcional, porém a parte amputada tem as mesmas chances de sobrevivência no reimplante, e algumas técnicas possivelmente não sejam aplicáveis. A literatura é escassa, sendo necessária a realização de um estudo para determinar uma conduta prática e eficiente especificamente para essa faixa etária.

The distal phalanx has important functions and must be replanted in case of accidental amputation. Microsurgery is the preferred technique; however, the necessary vein anastomosis can be very difficult or even impossible, especially in small children. This paper reports a case of microsurgical replantation of the distal phalanx of the fifth finger of a one-year-old male child who suffered a crush-type amputation of the fifth fingertip in a house door. The fingertip was replanted eight hours after the amputation, with anastomosis of a very thin artery and vein. The region exhibited congestion, which persisted for more than one week without necrosis; no other procedure was required after the replantation. This paper presents a literature review of the difficulty of restoring venous return in children. Several techniques for restoring venous return in difficult cases, as well as determinants of survival of the amputated part, are reviewed and presented; however, there are no specific studies on procedures for the age group in question. Children probably have better functional recovery or adaptation than do adults, but the amputated part has the same chance of survival, and some of the techniques used in adults are not applicable in children. The literature on this topic is scant, and a study on the most practical and efficient method for fingertip replantation in small children is warranted.

Conhecimento dos professores de 1ª a 4ª série de escolas públicas municipais de Manaus/AM frente à avulsão dentária / knowledge of 1st-4th-grade teachers from municipal public schools of the city of Manaus/AM about tooth avulsion

Objetivo: Avaliar o conhecimento dos professores de 1ª a 4ª série de escolas públicas do município de Manaus-AM, sobre avulsão dentária. Método: Foram entrevistados 311 profissionais, de todas as zonas de Manaus, por meio de formulário padronizado, contendo perguntas fechadas, abertas e de múltipla escolha sobre avulsão dentária, reimplante e procedimentos necessários para favorecer o prognóstico em casos de dentes avulsionados. Após a entrevista, foi entregue um folder sobre os corretos procedimentos de urgência a serem adotados frente aos casos de avulsão dentária, possibilitando transformar os professores da rede pública de ensino em agentes multiplicadores de conhecimento. Resultados: 57,1% dos professores possuíam apenas formação de ensino médio e 49,8% tinham experiência profissional entre 1 e 5 anos. Dos professores que realizaram treinamento de primeiros socorros (29,9%), apenas 12,9% obtiveram informações sobre traumatismo alvéolo-dentário. 66,9% não souberam distinguir os dentes decíduos dos permanentes e 61,7% apenas dariam uma toalha para o aluno morder em caso de traumatismo, não dispensando a atenção necessária ao elemento avulsionado. Apenas 5,5% realizariam o reimplante do elemento dentário no local do acidente. A maioria (55,9%) considerou que a procura do atendimento deve ser imediata, 51,1% escolheria o dentista como profissional mais qualificado para estes casos e 58,8% escolheria a água da torneira como meio de conservação ideal para o dente avulsionado. Conclusão: Não se observou conhecimento adequado dos professores entrevistados em relação aos procedimentos de urgência a serem adotados frente à avulsão dentária, demonstrando a necessidade da inclusão deste tema na matriz curricular destes profissionais e também da realização de campanhas de educação em saúde, melhorando assim o prognóstico do reimplante dentário.

Objective: To evaluate the knowledge of 1st-4th grade teachers form municipal public schools of the city of Manaus/AM about tooth avulsion.Method: Three hundred and eleven professionals from all regions of the city of Manaus/AM were interviewed using a standardized form containing closed, open and multi plechoice questions about tooth avulsion, tooth replantation and the procedures necessary to improve the prognosis in cases of avulsed teeth. After the interview, a folder containing information about the correct urgency procedures to be adopted in case of tooth avulsion was handed to the participants, in an attempt to make elementary public school teachers capable of spreading this knowledge. Results: 57.1% of the teachers had only high school education and 49.8% had 1 to 5 years of professional experience. From the teachers that attended first-aid training (29.9%), only 12.9% had previous information on dento-alveolar trauma. 66.9% could not distinguish primary from permanent teeth, and 61.7% would only give a towel for the student to bite in case of dental trauma, not dispensing the necessary attention to the avulsed tooth. Only 5.5% would replant the avulsed tooth at the site of the accident. Most teachers (55.9%) responded that immediate dental care is necessary, 51.1% considered the dentist as the most qualified professional for these cases, and 58.8% would choose tap water as the ideal storage medium for the avulsed tooth. Conclusion: The interviewed teachers did not have adequate knowledge of the urgency procedures to be adopted in case of tooth avulsion, demonstrating the need of incorporating this subject to the curriculum of these professionals and performing health educational campaigns to improve the frequency and prognosis of replanted teeth.

Laparoscopic ureteral reimplant for ureteral stricture

Purpose: Evaluate the initial experience of laparoscopic ureteral reimplant for ureteral stenosis. Materials and methods: From January 2004 to June 2008, 10 patients underwent 11 laparoscopic reconstruction surgeries for ureteral stenosis. Seven cases of stenosis of the distal ureter, two at the level of iliac vessels, a case of bilateral distal stenosis and one in the medium third. Eight ureteroneocystotomies were performed by extravesical technique with anti-reflux mechanism, two cases of vesical reimplant with Boari technique and one case using the psoas hitch technique. Results: The average surgical time was 166 minutes (115-245 min), mean blood loss was 162 mL (100-210 mL) and the average hospital stay was 2.9 days (2-4 days). There were two complications: a lesion of the sigmoid colon identified peroperatively and treated with laparoscopic sutures with good evolution, and a case of ureteral stone obstruction at the 30th day postoperative, treated by laser ureterolitotripsy. All patients had resolution of the stenosis at an average follow-up period of 18 months (3-54 months). Conclusions: Laparoscopic surgery represents a feasible, safe and low morbidity technique for ureteral reimplant in ureteral stenosis.

Modelo experimental de reimplante digital utilizando os vasos femorais do rato / The rat femoral vessels as a training model for digital replantation

Introdução: A oportunidade de aprendizado em microanastomoses vasculares confere ao indivíduo em treinamento a possibilidade de execução de operações de maior complexidade. O presente estudo traz um modelo laboratorial que possibilita o aprendizado das técnicas microvasculares. Objetivo: Demonstrar um protocolo de treinamento em microanastomoses vasculares que reproduz a situação clínica do reimplante digital. Metodologia: São utilizados roedores oriundos de uma população excedente do biotério de projetos de pesquisa em andamento. O treinamento é focalizado na dissecção e confecção dos diversos tipos de anastomoses nos vasos femorais do rato. O indivíduo realiza o treinamento de forma independente e executa em seqüência de complexidade anastomoses microvasculares arteriais e venosas terminoterminais, terminolaterais e enxertos venosos e arteriais. Resultados: A posição superficial e a bilateralidade dos vasos, neste modelo, possibilita o treinamento e a avaliação da permeabilidade na confecção das microanastomoses. O calibre dos vasos femorais reproduz com acurácia o calibre dos vasos digitais humanos. Conclusão: O protocolo de treinamento laboratorial de estudo independente nos vasos femorais do rato permite a confecção de diversos tipos de microanastomoses e apresenta semelhança no calibre dos vasos encontrados com os vasos digitais no reimplante digital.

Introduction: The opportunity of learning in vascular microanastomoses gives the trainee the chance to perform operations of greater complexity. This study presents a laboratory animal model that allows the learning of microvascular techniques. Aim: To demonstrate a training protocol in vascular microanastomoses that reproduces the clinical situation of digital replantation. Methods: Rodents of an excess population from the breeding colony of the ongoing research program are used. The training is focused on the dissection and performance of several types of anastomoses in rat femoral vessels. The trainee undergoes the training in independent fashion and performs a sequence of ascending complexity of terminoterminal and terminolateral arterial and venous microvascular anastomoses and venous and arterial grafts. Results: The superficial position and the bilaterality of vessels, in this model, allows training and evaluating the permeability of the performed microanastomoses. The caliber of femoral vessels accurately reproduces the caliber of human digital vessels. Conclusion: The protocol of laboratory training as independent study of rat femoral vessels allows the performance of several types of microanastomoses and bears resemblance in vessel caliber with the digital vessels in digital replantation.

Aneurisma de artéria renal em rim transplantado: reparo ex vivo e reimplante do enxerto / Renal artery aneurysm in a transplanted kidney: ex vivo graft repair and reimplantation

Aneurisma verdadeiro de artéria renal em rim transplantado é ocorrência rara. As possibilidades de tratamento dependem do tamanho, da localização do aneurisma e da clínica apresentada pelo paciente. Descreve-se um caso de aneurisma gigante de artéria renal em rim transplantado que recebeu tratamento ex vivo e reimplante na fossa ilíaca direita. Detalhes do procedimento cirúrgico são descritos.

True aneurysm of a renal artery in a transplanted kidney is a rare occurrence. Treatment options depend on size and location of the aneurysm and the patient's clinical condition. We report a case of a giant aneurysm of the renal artery in a transplanted kidney that was treated ex vivo and reimplanted in the right iliac fossa. Details of the surgical procedure are described.

Results of renewed glenn-anderson technique in reimplantation of refluxing or obstructed lower end ureter [25 patients]

The aim of this study is to analyze the efficacy and outcome of distal tunnel ureteral reimplantation in refluxing and obstructed lower end ureter. The present study included 25 patients[17 males and 8 females], selected from Al-Azhar University Hospital [New Damietta], at the period between April 2005 and April 2007, Glenn-Anderson advancement [distal tunnel] ureteral reimplantation was performed in 10 patients with refluxing ureter [8 patients with secondary reflux and 2 patients with primary reflux], and 15 patients with obstructed lower end ureters. The success rate At 3 months improvement was observed in 20 cases [80, 0%] while at 9 months success rate was 88% and at 18 months success rate was 92%, The results of the present work revealed that the Glenn-Anderson technique [intravesical ureteral reimplantation] is a suitable and excellent for treatment of both refluxing or obstructed lower end ureter [stricture] whatever the cause

Extravesical ureteral reimplantation in stricture lower end ureter

Ureteral stricture is a problem that always has confronted the surgeons. Traditionally, stricture occurs most often in the ureter injured at operation and repair of the stricture has been accomplished by open surgical management. The aim of the work was to evaluate the extravesical ureteral reimplantation in stricture lower end ureter. The study was carried out on 11 patients [8 males and 3 females] with stricture lower end ureter, selected from Al-Azhar University Hospital [New Damietta] between April 2005 to April 2007. All cases were submitted to full history taking, clinical examination and laboratory investigations [urine analysis, blood urea and serum creatinine]. Imaging studies in the form of abdominopelvic ultrasound and excretory urography both pre and postoperatively. In addition to ascending cystography postoperatively at 3, 9 and 18 months. Post operative follow up by Ultrasound revealed improvement in 8 patients out of 10 with pervious moderate hydronephrosis while 2 patients show stabilization. In one patient with severe hydronephrosis shows stabilization without further deterioration. Using excretory urography followup, 6 patients of grade II hydronephrosis and 4 patients of grade III hydronephrosis showed improvement while in one patient with grade IV hydronephrosis remained stabilized. Hospital stay ranged from 5 to 6 days. The results of the present study demonstrated that extravesical ureteral reimplantation is a reliable procedure with a low complication rate, and we have found that this approach is applicable to many different situations but is especially advantageous for ureteral tailoring and the vesical psoas hitch since retrovesical exposure is excellent

Initial experience with hand replantation after traumatic amputation in a nonspecialized center

Traumatic amputation of the hand is an incapacitating injury, requiring skilled surgical care. Achieving functional recovery in addition to salvage of the amputated extremity should be the goal of the patient care team, after the life of the patient is secured. This is a report of the first five cases of hand replantation after complete traumatic amputation in Manaus (Amazonas, Brazil), carried out at Hospital Pronto-Socorro Dr. João Lúcio Pereira Machado. The patients were all young males, mean age of 22.8 years, presenting at the emergency room with complete sharp amputation of the hand. After initial procedures according to the ATLS® protocol, the following surgical actions were taken: heparinization of the blood vessels of the amputated extremity, fixation of the bones, wide opening of the carpal tunnel, primary vascular anastomoses and repair of nerves and tendons. In four cases, viability and partial functional recovery of the replanted hands were achieved. The unsuccessful case was due to extensive venous thrombosis.Through this preliminary experience, we can state that hand replantation can be performed successfully in a nonspecialized hospital and that optimal results depend on adequate prehospital care, multidisciplinary surgical treatment and careful postoperative assistance.

A amputação traumática de mão é uma lesão incapacitante, requerendo tratamento cirúrgico hábil. Alcançar recuperação funcional além de salvar a extremidade amputada deve ser o objetivo da equipe médica, depois de resguardada a vida do paciente. Este é o relato dos cinco primeiros casos de reimplante de mão após amputações traumáticas completas na cidade de Manaus (AM), realizados no Hospital Pronto-Socorro Dr. João Lúcio Pereira Machado. Todos os pacientes eram homens jovens, média das idades de 22,8 anos, sendo admitidos na sala de emergência com amputação completa da mão por trauma inciso. Após medidas iniciais de acordo com o protocolo do ATLS®, foram realizados os seguintes tempos cirúrgicos: heparinização dos vasos sangüíneos da extremidade amputada, fixação óssea, abertura ampla do túnel do carpo, anastomoses vasculares primárias e sutura de nervos e tendões. Em quatro casos, ocorreu recuperação parcial dos movimentos das mãos reimplantadas. O caso de insucesso foi devido à extensa trombose venosa.A partir desta experiência inicial, podemos afirmar que o reimplante de mão pode ser realizado com sucesso em um hospital não-especializado e que os resultados ideais dependem de cuidados pré-operatórios adequados, tratamento cirúrgico multidisciplinar e assistência pós-operatória cuidadosa.