Microcirugía y estrategias adyuvantes en el tratamiento de los aneurismas intracraneales

Introducción: El riesgo del ser humano de padecer un aneurisma intracraneal se calcula entre 1-2 %, en el 80 % de los casos su forma de presentación es una hemorragia subaracnoidea. Objetivo: Evaluar la utilidad de diferentes maniobras adyuvantes para facilitar la micro disección y el presillamiento del cuello de los aneurismas intracraneales. Metodología: Se realizó un estudio descriptivo con todos los pacientes admitidos en el servicio de neurocirugía del Hospital "Roberto Rodríguez", en Morón, Ciego de Ávila, Cuba, que presentaron un diagnóstico de aneurisma intracraneal y que fueran intervenidos con técnica de microcirugía para su exclusión de la circulación, en el periodo comprendido entre enero de 1997 y diciembre del 2020. Resultados: 201 pacientes fueron intervenidos, 198 (98,51 %) con aneurismas de la circulación anterior y solo 3 (1,49 %), de la circulación posterior. En total fueron abordados 252 sacos, se utilizaron estrategias adyuvantes al procedimiento convencional para facilitar el acto del presillamiento aneurismático como lo fueron el drenaje espinal continuo, la ventriculostomìa al exterior para drenaje de LCR y monitorización continua de la PIC y de la presión de retracción cerebral, cierre temporal de la arteria madre, succión retrograda descompresión en los aneurismas gigantes. El 74,62 % de los casos se recuperaron sin ningún tipo de síntomas o secuelas y la mortalidad fue del 1,49 %. Discusión: La microcirugía resulta un procedimiento eficaz, con elevado nivel de eficiencia, para el tratamiento de los aneurismas intracraneales en nuestro medio. Las estrategias adyuvantes facilitan la relajación del parénquima, la disección y el presillamiento del cuello aneurismático.

Introduction: The human risk of suffering from an intracranial aneurysm is estimated between 1-2%, in 80% of cases its presentation is a subarachnoid hemorrhage. Objectives: To evaluate the usefulness of different adjunctive maneuvers to facilitate micro dissection and clamping of the neck of intracranial aneurysms. Method: We have carried out a descriptive study including all the patients admitted in the neurosurgery department of "Roberto Rodríguez" Hospital in Moron, Ciego de Avila, Cuba with the diagnosis of intracranial aneurysms who were operated on through microsurgical cliping techniques in the period between january 1997 and december 2020. Results: 201 patients were operated on, 198 (98.51%) with aneurysms of the anterior circulation and only 3 (1.49%), of the posterior circulation. A total of 252 sacs were approached, adjuvant strategies to the conventional procedure were used to facilitate the act of aneurysmal clamping, such as continuous spinal drainage, ventriculostomy to the outside for CSF drainage and continuous monitoring of ICP and brain retraction pressure, temporary closure of the mother artery, retrograde suction decompression in giant aneurysms. 74.62% of the cases recovered without any type of symptoms or sequelae, and mortality was 1.49%. Discussion: Microsurgery is an effective procedure, with a high efficiency index, for the treatment of intracranial aneurysms in our environment. Adjunctive strategies facilitate parenchymal relaxation, dissection, and clamping of the aneurysmal neck.

Modelo alternativo para o treinamento de técnicas de microssuturas em "patch" de pericárdio bovino / Alternative model for training microsuture techniques in bovine pericardium patches

Introdução: As técnicas microcirúrgicas caracterizam-se pela aplicação de manobras e suturas em estruturas milimétricas com o auxílio de lentes de aumento. São técnicas complexas, utilizadas em diversas especialidades médicas, que demandam grande habilidade e treinamento antes da aplicação em humanos. O objetivo é desenvolver um modelo de baixo custo e alta fidelidade, para o treinamento de técnicas de microcirurgia, utilizando um fragmento de patch de pericárdio bovino. Método: São utilizados para a confecção deste modelo segmentos remanescentes de uma placa de pericárdio bovino, previamente utilizado em reparos vasculares. O material é recortado em duas partes simétricas e suas extremidades fixadas aos campos cirúrgicos, com auxílio de clamps. A borda superior de cada uma das partes é, então, suturada à borda inferior com fio de Prolene 8-0, de maneira que cada uma forme uma estrutura tubular. Posteriormente, as extremidades tubulares livres passam pela dissecção da camada adventícia e são suturadas entre si, mimetizando uma anastomose vascular término-terminal. Resultados: Com o modelo, simulam-se os mesmos inconvenientes/ dificuldades presentes nas suturas vasculares humanas, como a delaminação de camadas, excesso da camada adventícia e risco de sutura inadvertida da parede posterior, provando sua utilidade na aquisição de habilidades microcirúrgicas básicas, sem necessidade de manipulação de tecidos humanos ou animais. A prática neste modelo pode ocorrer dentro do próprio centro cirúrgico e emprega materiais que seriam descartados. Conclusão: A utilização do pericárdio bovino para confecção de suturas milimétricas mimetiza o tecido vascular humano e é um procedimento de baixo custo, que possibilita o treinamento de habilidades microcirúrgicas.

Introduction: Microsurgical techniques are characterized by the application of maneuvers and sutures to millimetric structures with the aid of magnifying lenses. These are complex techniques, used in various medical specialties, which require great skill and training before applying them to humans. The objective is to develop a lowcost and high-fidelity model for training microsurgery techniques using a fragment of bovine pericardium patch. Method: Remaining segments of a bovine pericardium plate, previously used in vascular repairs, are used to create this model. The material is cut into two symmetrical parts, and its ends are fixed to the surgical drapes with the aid of clamps. The upper edge of each part is then sutured to the lower edge with 8-0 Prolene thread so that each one forms a tubular structure. Subsequently, the free tubular ends undergo dissection of the adventitial layer and are sutured together, mimicking an end-to-end vascular anastomosis. Results: With the model, the same inconveniences/ difficulties present in human vascular sutures are simulated, such as delamination of layers, excess of the adventitial layer, and risk of inadvertent suturing of the posterior wall, proving its usefulness in the acquisition of basic microsurgical skills, without need to manipulate human or animal tissues. Practice in this model can take place within the surgical center itself and uses materials that would otherwise be discarded. Conclusion: The use of bovine pericardium to create millimetric sutures mimics human vascular tissue and is a low-cost procedure that allows the training of microsurgical skills.

Eight years experience of transanal endoscopic microsurgery

Introduction: Transanal Endoscopic Microsurgery (TEM) is a minimally invasive method for management of different proctologic conditions. Despite widespread use of this method, it is not used widely in Iran. This report is about to describe the application of TEM in managing different proctologic conditions in a tertiary colorectal referral center in Iran regarding methods and complications. Methods: All of the patients' documents such as procedure, method, early postop complications and further operations were actively reviewed and the data were entered in to the database. Results: Since 2012 till the end of 2020 chart review was done and 150 cases of TEM operation were found. The most frequent procedure that was done was resection procedure. Using different energy devices during surgery or suturing versus not suturing the defect were not associated with complication. There was a case of in hospital mortality and one case delayed perianal fistula following TEM. Measurement of lesion distance from anal verge was not significantly different using TEM or colonoscopy. Villous adenomas detected in colonoscopy were mostly associated with malignancy. In evaluated resected lesions most of cases had free base and distance from anal verge or using different energy devices were not associated with obtaining free base. Conclusion: TEM is a safe minimal invasive procedure with acceptable complications that could be helped in managing different proctologic conditions and the results of reviewing our patients revealed the same results that is reported from other colorectal centers. (AU)

Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review

Abstract Introduction Tympanoplasty is a reparative surgery that has multiple indications. The aid of a microscope or an endoscope is necessary to carry out the procedure. The classic method utilizes the microscope; however, in the recent decades, the endoscope has been popular. Although many articles try to compare these two techniques, there is still no robust evidence that confirms the superiority of either technique. In the present work, we seek to perform a systematic review contribute with this discussion. Objectives The present systematic review attempted to compare endoscopic and microscopic surgery techniques and to discover whether there would be superiority in the results of any of them, based on data currently available in the literature. Data Synthesis The objectives of the present review were organized according to the PICO planning and strategy adapted for systematic reviews. The inclusion and exclusion criteria were established aiming to select only select primary data. The main medical databases were searched usingan optimized search string with appropriate descriptors. The searched databases were MEDLINE, LILACS, SciELO, and EMBASE. A total of 99 studies were selected and 38 were fully assessed after the inclusion criteria were applied. All included articles were reviewed by all authors and their results were discussed and summarized. Conclusion The endoscopic technique was shown to be a safer technique comparable in effectiveness to the use of microscopy. In addition, it provides possible advantages such as shortening the surgical time and better postoperative pain outcomes.

Microcirugía transanal endoscópica en el tratamiento para el cáncer del recto / Transanal Endoscopic Microsurgery for Treating Rectal Cancer

Introducción: La microcirugía transanal endoscópica es un procedimiento mínimamente invasivo que se aplica para el tratamiento local del cáncer del recto en estadios iniciales. Su utilización en estadios más avanzados del cáncer del recto resulta controversial. Sin embargo, con el uso rutinario del tratamiento neoadyuvante constituye una opción atractiva que se ha comenzado a considerar. Objetivo: Evaluar los resultados de la microcirugía transanal endoscópica para el tratamiento del cáncer del recto en el Centro Nacional de Cirugía de Mínimo Acceso. Métodos: Se realizó un estudio retrospectivo de una base de datos prospectiva de 18 años. La muestra fue de 150 pacientes que cumplieron con los criterios de selección y las variables estudiadas fueron: edad, sexo, indicación, tiempo quirúrgico, entre otras. Resultados: La principal indicación fue el adenocarcinoma del recto T1. La edad media fue 63 años (32-93); el tiempo quirúrgico, 76 minutos (25-240) y el tamaño tumoral, 2,8 cm (1-4). La estancia hospitalaria fue de 1 día (12 horas-7 días), la morbilidad fue 6,7 porciento y las principales complicaciones posoperatorias fueron el sangramiento, la dehiscencia de sutura, el absceso, la fístula rectovaginal y la estenosis. La recurrencia local fue 8,2 porciento, 7,1 porciento y 2,5 porciento para los adenocarcinomas T1, T2 y T3 respectivamente. La supervivencia global a los 5 años fue 97,5 porciento y la supervivencia libre de enfermedad fue 95,5 porciento. Conclusión: La microcirugía transanal endoscópica es una técnica factible y segura en el tratamiento de los adenocarcinomas T1, mientras que en los T2 y T3 se requiere de la radioquimioterapia preoperatoria(AU)

Introduction: Transanal endoscopic microsurgery is a minimally invasive procedure applied for the local treatment of rectal cancer at early stages. Its use in more advanced stages of rectal cancer is controversial. However, with the routine use of neoadjuvant treatment, it is an attractive option that has begun to be considered. Objective: To assess the outcomes of transanal endoscopic microsurgery for the treatment of rectal cancer at Centro Nacional de Cirugía de Mínimo Acceso. Methods: A retrospective study of an 18-year prospective database was performed. The sample consisted of 150 patients who met the selection criteria and the variables studied were age, sex, indication, surgical time, among others. Results: The main indication was T1 rectal adenocarcinoma. The mean age was 63 years (32-93); surgical time, 76 minutes (25-240); and tumor size, 2.8 cm (1-4). Hospital stay was 1 day (12 hours-7 days), morbidity was 6.7 percent, and the main postoperative complications were bleeding, suture dehiscence, abscess, rectovaginal fistula and stenosis. Local recurrence was 8.2 percent, 7.1 percent and 2.5 percent for T1, T2 and T3 adenocarcinomas, respectively. Overall survival at 5 years was 97.5 percent and disease-free survival was 95.5 percent . Conclusion: Transanal endoscopic microsurgery is a feasible and safe technique for treating T1 adenocarcinomas, while T2 and T3 adenocarcinomas require preoperative radiochemotherapy(AU)

La escisión total del mesorrecto transanal en el tratamiento del cáncer del recto como nueva técnica en Cuba / Total Excision of the Transanal Mesorectum as a New Technique for Treating Rectal Cancer in Cuba

Introducción: Las indicaciones de la Microcirugía Transanal Endoscópica han evolucionado desde la cirugía de tumoraciones rectales hasta otras enfermedades pélvicas. La asociación de esta y la escisión total del mesorrecto transanal ofrece una serie de ventajas. Objetivo: Determinar las indicaciones, describir la técnica quirúrgica y mostrar los resultados a largo plazo obtenidos en la realización de la escisión total del mesorrecto transanal en el tratamiento del cáncer del recto medio y bajo. Métodos: Se realizó un estudio observacional descriptivo y prospectivo de los pacientes con cáncer del recto medio y bajo sometidos a esta técnica quirúrgica en el período comprendido entre febrero de 2017 y febrero de 2022 en el Centro Nacional de Cirugía de Mínimo Acceso. Resultados: Se operaron 13 pacientes, 9 con cáncer del recto bajo y 4 con cáncer del recto medio y un promedio de edad de 56,2 años (rango 28-76). El promedio de tiempo quirúrgico fue de 183 minutos (rango 120-270) y las pérdidas hemáticas estimadas de 68 mililitros. La incidencia de morbilidad mayor fue de 15,4 por ciento y la media de estadía hospitalaria de 5,4 días. La media del período de seguimiento fue de 35 (rango 9-69) meses con una recidiva local de 7,7 por ciento y una supervivencia global a los 5 años de 100 por ciento. Conclusiones: La escisión total del mesorrecto transanal combinado con cirugía laparoscópica es una técnica factible y segura. La introducción de la variante técnica utilizando el instrumental de la Microcirugía Transanal Endoscópica es más ergonómica y disminuye los costos(AU)

Introduction: The indications for transanal endoscopic microsurgery have evolved from surgery of rectal tumors to other pelvic diseases. The association between this and total excision of the transanal mesorectum offers a series of advantages. Objective: To determine the indications, to describe the surgical technique and to show the long-term outcomes obtained in the performance of total excision of the transanal mesorectum for treating cancer of the middle and lower rectum. Methods: A descriptive and prospective observational study was carried out of patients with cancer of the middle and lower rectum who underwent this surgical technique in the period from February 2017 to February 2022 at Centro Nacional de Cirugía de Mínimo Acceso. Results: Thirteen patients were operated on, 9 with cancer of the lower rectum and 4 with cancer of the middle rectum, as well as an average age of 56.2 years (range 28-76). The average surgical time was 183 minutes (range 120-270) and estimated blood loss was 68 milliliters. The incidence of highest morbidity was 15.4 percent and mean hospital stay was 5.4 days. The median follow-up period was 35 (range 9-69) months, with a local recurrence of 7.7 percent and an overall 5-year survival of 100 percent . Conclusions: Total excision of the transanal mesorectum combined with laparoscopic surgery is a feasible and safe technique. The introduction of the variant technique using the instruments of endoscopic transanal microsurgery is more ergonomic and reduces costs(AU)

Transcutaneous injection of triamcinolone acetonide for persistent glottic granulation after laser microsurgery

Abstract Objective The aim of study was to demonstrate that transcutaneous intralesional injection of Triamcinolone Acetonide (TA) under fibrolaryngoscopy could be an option for persistent granulation after Transoral Laser Microsurgery (TLM) in glottic cancer patients. Methods We recruited 32 patients, who had conservative treatment but failed. 20 patients accepted TA injection monthly until the granulation disappeared or did not shrink further. 12 patients chose to closely monitor. Results For the 20 patients, 17 (85.0%) patients' granulations completely disappeared. 3 (15.0%) patients' granulations had reduced 80%. For the 12 patients, 3 (25.0%) patients' granulations disappeared but 9 (75%) patients' granulations did not have an obvious change. Recurrence was not observed. Conclusion Our experience showed that transcutaneous intralesional TA injection for persistent granulation after TLM through cricothyroid membrane is an efficient, security, harmless and low recurrence method. Especially suitable for huge granulation which blocks the glottis and recur after a second operation.

Bevacizumab effect on viability of free groin flaps in rats / Efeito do bevacizumabe na viabilidade de retalho inguinal livre em ratos

Introduction: Bevacizumab is among the most frequently used drugs in cancer treatment. There is evidence that some anti-angiogenic drugs reduce flap survival, but it is unclear whether this applies to Bevacizumab. We investigated the effect of Bevacizumab on the viability of free flaps in rats. Methods: The animals were randomly assigned to one of three groups. The Graft group received intravascular saline and was submitted to a full-thickness skin graft. The Flap-Saline and the Flap- BVZ groups underwent a free groin flap after receiving, respectively, intravascular saline solution or intravascular administration of Bevacizumab. Results: The Graft group showed a lower percentage of the viable area (22.81%) relative to the Flap- Saline (83.98%; p<0.0001) and the Flap-BVZ groups (60.50%; p=0.0048). The lowest vascular pedicle patency was observed in the Flap-BVZ group, but the difference relative to the Flap-Saline was not significant (arteries, p=0.0867; veins, p=0.9999). A significant difference was observed in the occurrence of necrosis (p=0.0010), which was higher in the histological samples of the Graft (87.50%) and the Flap- BVZ (60.00%) relative to the Flap-Saline Group (0%). Inflammation occurred less frequently in the Flap-Saline (33.33%) compared to the Graft (87.5%) and Flap- BVZ group (70.00%), but the difference did not reach significance (p=0.0588). No significant differences emerged in the occurrence of hemorrhage or intraluminal thrombosis. Conclusion: The increase in inflammation, decrease in patency and reduction of viable area, though not significant, are in line with the histological analysis and call for further research on the potential adverse effects of the drug.

Introdução: Bevacizumabe é um dos fármacos mais utilizados no tratamento do câncer. Existem evidências de que drogas antiangiogênicas reduzem a taxa de sobrevivência dos retalhos, porém não está claro se isso se aplica ao bevacizumabe. Investigamos o efeito de bevacizumabe na viabilidade de retalhos livres em ratos. Método: Os animais foram randomizados em três grupos. O grupo Enxerto recebeu injeção intravenosa de soro fisiológico 0,9% (SF 0,9%) e foi submetido a uma enxertia de pele total. Os grupos Retalho-SF e Retalho-BVZ foram submetidos a retalhos inguinais livres e receberam injeções intravenosas, respectivamente, de SF 0,9% e Bevacizumabe. Resultados: O grupo Enxerto apresentou menor percentual de área de retalho viável (22,81%) em relação ao grupo Retalho-SF (83,98%; p<0,0001) e Retalho-BVZ (60,50%; p=0,0048). Os pedículos do grupo Retalho-BVZ apresentaram menor patência, mas a diferença em relação ao grupo Retalho-SF não foi significante (artérias, p=0,0867; veias, p=0,9999). A ocorrência de necrose foi significativamente maior nos grupos Enxerto (87,50%) e Retalho-BVZ (60,00%) em relação ao grupo Retalho-SF (0%) (p=0,0010). A ocorrência de inflamação foi menor no grupo Retalho-SF (33,33%) em relação aos grupos Enxerto (87,5%) e Retalho-BVZ (70,00%), porém essa análise não atingiu significância (p=0,0588). Não houve diferenças significantes na ocorrência de hemorragia ou trombose intraluminal entre os grupos. Conclusão: O aumento da inflamação, redução da patência e das áreas viáveis dos retalhos, apesar de não significantes, corroboram com efeitos deletérios do bevacizumabe evidenciados na análise histológica e demandam futuros estudos dos potenciais efeitos adversos da droga.

Pediatric canalicular laceration repair using the Mini Monoka versus Masterka monocanalicular stent / Correção de laceração canalicular pediátrica usando os stents monocanaliculares Mini-Monoka versus Masterka

ABSTRACT Purpose: One of the most important disadvantages of using Mini Monoka stents in pediatric canalicular laceration repair is premature stent loss. In this study, we aimed to compare clinical outcomes between the use of Mini Monoka and Masterka monocanalicular stents in children and discuss the potential causes of premature stent loss. Methods: The medical records of 36 patients who underwent surgical repair of canalicular lacerations were retrospectively reviewed. Children aged <18 years who underwent canalicular laceration repair with either Mini Monoka or Masterka and had at least 6 months of follow-up after stent removal were included in the study. The patients' demographics, mechanism of injury, type of stent used, premature stent loss, and success rate were analyzed. Success was defined as stent removal without subsequent epiphora and premature stent loss. Results: Twenty-seven children fulfilled our study criteria, and their data were included in the analyses. Mini Monoka was used in 14 patients (51.9%), whereas Masterka was used in 13 patients (48.1%). The preoperative clinical features, including age, sex, and mechanism of injury, were similar between the two groups. The mean age was 8.3 ± 5.5 years in the Mini Monoka group and 7.8 ± 5.9 years in the Masterka group (p=0.61). Three patients in the Mini Monoka group (21.4%) underwent reoperation due to premature stent loss. No premature stent loss was observed in the Masterka group. As a result, the rate of success was 78.6% in the Mini Monoka group, whereas it was 100% in the Masterka group (p=0.22). Conclusions: Even though the two groups did not show any statistically significant difference in success rate, we did not observe any premature stent loss in the Masterka group. Further studies with larger and randomized series are warranted to elaborate on these findings.

RESUMO Objetivo: Uma das desvantagens mais importantes do uso de stents Mini Monoka no reparo de lacerações canaliculares pediátricas é a perda prematura do stent. Neste estudo, objetivamos comparar os resultados clínicos dos stents monocanaliculares Mini Monoka e Masterka em crianças e discutir as possíveis causas da perda prematura do stent. Métodos: Foram incluídos nesta revisão retrospectiva 36 pacientes <18 anos de idade que se submeteram ao reparo cirúrgico de uma laceração canalicular com um stent Mini Monoka ou Masterka e tiveram pelo menos 6 meses de acompanhamento após a remoção do stent. Foram analisados os dados demográficos, o mecanismo da lesão, o tipo de stent utilizado, a ocorrência de perda prematura de stent e o sucesso da intervenção. O sucesso foi definido como a ausência de epífora após a remoção do stent, sem a perda prematura deste. Resultados: Vinte e sete pacientes preencheram os critérios do presente estudo e foram incluídos nas análises. O stent Mini Monoka foi usado em 14 pacientes (51,9%), enquanto o Masterka foi usado em 13 pacientes (48,1%). As características clínicas pré-operatórias, incluindo idade, sexo e mecanismo de lesão, foram semelhantes entre os dois grupos. A média de idade foi de 8,3 ± 5,5 anos no grupo Mini Monoka e de 7,8 ± 5,9 anos no grupo Masterka (p=0,61). Três pacientes do grupo Mini-Monoka (21,4%) tiveram que ser operados novamente por perda prematura do stent. Nenhuma perda prematura do stent foi observada no grupo Masterka. Como resultado, a taxa de sucesso foi de 78,6% no grupo Mini Monoka e de 100% no grupo Masterka (p=0,22). Conclusões: Embora nenhuma diferença estatisticamente significativa tenha sido detectada entre os dois grupos em termos de taxas de sucesso, não observamos nenhuma perda prematura de stent no grupo Masterka. São necessários mais estudos, com séries maiores e randomizadas, para chegar a maiores conclusões sobre esses achados.

Papilomatosis laringea recurrente con compromiso pulmonar: reporte de caso / Recurrent laryngeal papillomatosis with pulmonary involvement: case report

La papilomatosis respiratoria recurrente es una enfermedad neoplásica causada por el virus del papiloma humano y caracterizada por el crecimiento de lesiones proliferativas exofíticas que afectan la mucosa de las vías respiratorias. En su epidemiología se presenta una distribución bimodal, con una forma juvenil en menores de 20 años, más agresiva, con múltiples lesiones papilomatosas y alta frecuencia de recurrencia, en comparación con la forma adulta. El compromiso pulmonar es poco frecuente y su manejo es un desafío. Se presenta el caso de un varón de 13 años con antecedente de papilomatosis laríngea desde los dos años. El paciente mostró dificultad respiratoria y múltiples nódulos estenosantes en laringe y tráquea, y varios quistes pulmonares visualizados en la tomografía de tórax. Se le realizó exéresis de las lesiones papilomatosas y traqueostomía. Recibió dosis única de bevacizumab 400 mg intravenoso y terapias respiratorias con evolución favorable, sin recurrencias en el seguimiento.

Recurrent respiratory papillomatosis is a neoplastic disease caused by the human papillomavirus and characterized by the growth of exophytic proliferative lesions affecting the mucosa of the respiratory tract. This condition has a bimodal age distribution; the juvenile form affects those under 20 years of age, is more aggressive and presents multiple papillomatous lesions and high frequency of recurrence, compared to the adult form. Pulmonary involvement is rare and challenging to treat. We present the case of a 13-year-old male with a history of laryngeal papillomatosis since the age of two years. The patient showed respiratory distress and multiple stenosing nodules in the larynx and trachea, as well as several pulmonary cysts identified on chest CT. The patient underwent excision of the papillomatous lesions and tracheostomy. Then, the patient received a single dose of intravenous bevacizumab 400 mg and respiratory therapies with favorable evolution, without recurrences during follow-up.

Evaluation of konjac noodle as a microsurgery training model: learning curve analysis / Avaliação do uso de macarrão japonês para treinamento microcirúrgico: análise objetiva da melhora na performance

ABSTRACT Background: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. Methods: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. Results: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. Conclusions: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

ABSTRACT Introdução: modelos tradicionais de treinamento de anastomose microcirúrgica costumam ter custos elevados e implicações éticas de aquisição e manutenção, buscando-se alternativas que reúnam baixo custo e facilidade de armazenamento. Existem diferentes propostas, porém há poucas evidências de que conhecimentos adquiridos com o treinamento nessas plataformas se traduza em melhora na performance, quando estes são comparados a modelos consagrados. Este projeto objetiva avaliar a viabilidade do macarrão de konjac como modelo confiável de treinamento microcirúrgico. Métodos: 10 residentes de neurocirurgia realizaram uma anastomose término-terminal em artéria placentária humana de 2-3mm. As anastomoses foram avaliadas quantitativamente, registrando-se o tempo de confecção e qualitativamente, aplicando-se um escore validado (Anastomosis Lapse Index - ALI) por neurocirurgiões experientes e verificando-se a presença de vazamento grosseiro através da visualização no modo fluorescente injetando-se fluoresceína. Subsequentemente, realizaram 10 sessões de treinamento não consecutivos de anastomose términoterminal no modelo de konjac. Por fim, uma anastomose final foi realizada no modelo placentário e os mesmo parâmetros reavaliados. Resultados: observamos uma redução de 17 min no tempo médio de confecção da anastomose no modelo de placenta após os treinos no modelo do macarrão (p<0.05). Houve uma redução não significativa de 20% no vazamento grosseiro. As sessões de treino no macarrão não foram capazes de melhorar consistentemente o score ALI. Conclusão: o treinamento em modelo de macarrão konjac é capaz de reduzir o tempo para realização das anastomoses no modelo em placenta humana, mostrando-se alternativa viável de baixo custo e manutenção, útil em serviços que disponham de microscópio apenas no ambiente cirúrgico.

Distal neurotization of the anterior interosseous nerve to recover hand grasping / Neurotização distal do nervo interósseo anterior para recuperação da preensão da mão

ABSTRACT Lower trunk lesions are uncommon, representing about 3 to 5% of brachial plexus lesions in adults. One of the functions lost by patients who suffer this type of injury is the flexion of the fingers, with important harming of palmar grip. This series of cases proposes the transfer of a branch of the radial nerve to the anterior interosseous nerve (AIN), presenting a new alternative for the treatment of these lesions with highly satisfactory results. Objective: To demonstrate our strategy, technique, and results in the reinnervation of the AIN in lesions isolated from the lower trunk of the brachial plexus in four cases of high lesion of the median nerve. Method: Prospective cohort study in which four patients underwent neurotizations. The treatment was directed to the recovery of the fingers' flexors of the hand and the grip. Results: All patients presented reinnervation of the flexor pollicis longus (FPL) and deep flexors of the 2nd, 3rd, and 4th fingers. The deep flexor of the 5th finger also showed reinnervation but with reduced strength (M3/4) comparing to the others (M4+). Conclusion: Despite the limited number of cases in this and other studies, the results are uniformly good, allowing to consider this treatment predictable. Level of Evidence IV, Case Series.

RESUMO As lesões do tronco inferior são incomuns, representando cerca de 3 a 5% das lesões do plexo braquial em adultos. Uma das funções perdidas pelos pacientes que sofrem esse tipo de lesão é a flexão dos dedos, com comprometimento importante da preensão palmar. Esta série de casos propõe a transferência de um ramo do nervo radial para o nervo interósseo anterior (NIA), apresentando uma nova alternativa para o tratamento dessas lesões com resultados altamente satisfatórios. Objetivo: Demonstrar nossa estratégia, técnica e resultados na reinervação do NIA em lesões isoladas do tronco inferior do plexo braquial em quatro casos de lesão alta do nervo mediano. Método: Estudo de coorte prospectivo no qual quatro pacientes foram submetidos a neurotizações. O tratamento foi direcionado para a recuperação dos flexores dos dedos da mão e da preensão. Resultados: Todos os pacientes apresentaram reinervação do flexor pollicis longus (FPL) e dos flexores profundos do 2º, 3º e 4º dedo. O flexor profundo do 5º dedo também apresentou reinervação, porém com força reduzida (M3/4) em relação aos demais (M4+). Conclusão: Apesar do número de casos limitados neste e em outros estudos, os resultados se mostram uniformemente bons, o que permite considerar esse tratamento previsível. Nível de Evidência IV, Série de Casos.

Development and validation of a 3D laryngeal model in surgical skills training

Abstract Objective: To present and validate a new simulation model for endoscopic phonomicrosurgery training as an improved teaching method. Methods: A low-cost artificial model was assembled using 3D printing, silicone, and gelatin. The study was designed to test the model's ability to carry out training and teaching of endoscopic phonomicrosurgery. The synthetic model was built to simulate normal and pathological vocal folds such as polyps, intracordal cysts and keratoses, made of silicone and gelatin and embedded in a larynx framework made by 3D printing. Simulations of endoscopic surgical procedures were performed and documented through photographs and videos and the images were submitted to the evaluation of a group of 17 otorhinolaryngologists who used a Likert scale questionnaire. The responses were submitted to an agreement analysis using the sum of the scores obtained for the responses as an appropriate level of validation. Cronbach's alpha index was calculated to measure the degree of the questionnaire internal consistency. Result: The evaluations indicated maximum approval for the model adequacy for use in practical classes and for the teaching of the procedures, as well as in the overall satisfaction with the model in the use of surgical training. Conclusion: The present proposal for training laryngeal endoscopic surgery in a 3D synthetic model is a viable option according to the validation methodology used in the present study.

O que os olhos não veem a microcirurgia ensina: modelo de treinamento oftalmológico com olho de boi / What the eye cannot see, microsurgery teaches: a model of ophthalmological training with a bull's eye

RESUMO Objetivo Descrever e validar um modelo oftalmológico para treinamento de transplante e microssutura de córnea utilizando globo ocular bovino. Métodos Para a montagem do modelo de treinamento, o globo ocular foi disposto sob o campo cirúrgico, apoiado sobre um recipiente plástico cilíndrico comum de 3,5cm de diâmetro, para a retirada da córnea. Foi realizada uma incisão circular superficial, e, posteriormente, uma tesoura Castroviejo curva de 9 cm foi utilizada para remoção completa da córnea, que foi recolocada em sua posição original, para que, em seguida, fossem confeccionados nove pontos equidistantes, usando fio de nylon 10-0. Por fim, foram avaliados os seguintes critérios: tempo de realização das suturas; evolução do tempo e da qualidade a cada teste; e destreza e aperfeiçoamento da realização das suturas. Resultados O modelo descrito demonstrou-se viável e adequado para o treinamento de microssuturas na córnea, possibilitando aperfeiçoamento e ganho de habilidades cirúrgicas. Conclusão O modelo de treinamento microcirúrgico apresentado possui alta viabilidade para a simulação de cirurgias oftalmológicas e textura semelhante à do olho humano real, o que o torna próximo à realidade.

ABSTRACT Objective To describe and validate an ophthalmic model for corneal transplantation and micro suture training using a bovine eyeball as a model. Methods For the training model, the eyeball was placed under the sanitary field placed on the ends of a common 3.5cm diameter cylindrical plastic container for corneal removal. A superficial circular incision was made, then 9cm curved Castroviejo scissors were used for complete corneal removal. The cornea was replaced in its original position, and 10-0 nylon thread was used to perform the sutures, with 9 equidistant stitches. Finally, the following criteria were evaluated: suturing time, time and quality progression in each attempt, dexterity and suturing improvement. Results The described model proved to be feasible and suitable for corneal micro suture training, allowing improvement and gain of dexterity in the sport. Conclusion The presented microsurgical training model has a high feasibility for the simulation of ophthalmic surgeries, in addition to a texture similar to the real human eye, which makes it close to reality.

Role of temporary arterial occlusion in subarachnoid hemorrhage outcomes: a prospective cohort study

Purpose: Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO's role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. Methods: This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. Results: TAO was associated with intraoperative rupture (IOR) (odds ratio ­ OR = 10.54; 95% confidence interval ­ 95%CI 4.72­23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11­4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). Conclusions: TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.

Low-fidelity simulation models in urology resident's microsurgery training

Purpose: To evaluate the gain of microsurgical skills and competencies by urology residents, using low-fidelity experimental models. Methods: The study involved the use of training boards, together with a low-fidelity microsurgery simulator, developed using a 3D printer. The model consists in two silicone tubes, coated with a resin, measuring 10 cm in length and with internal and external diameters of 0.5 and 1.5 mm. The support for the ducts is composed by a small box, developed with polylactic acid. The evaluation of the gain of skills and competencies in microsurgery occurred throughout a training course consisting of five training sessions. The first sessions (S1-S4) took place at weekly intervals and the last session (S5) was performed three months after S4. During sessions, were analyzed: the speed of performing microsurgical sutures in the pre and post-training and the performance of each resident through the Objective Structure Assessment of Technical Skill (OSATS) and Student Satisfaction Self-Confidence tools in Learning (SSSCL). Results: There was a decrease in the time needed to perform the anastomosis (p=0.0019), as well as a progressive increase in the score in the OSATS over during sessions S1 to S4. At S5, there was a slightly decrease in performance (p<0.0001), however, remaining within the expected plateau for the gain of skills and competences. The SSSCL satisfaction scale showed an overall approval rating of 96.9%, with a Cronback alpha coefficient of 83%. Conclusions: The low-fidelity simulation was able to guarantee urology residents a solid gain in skills and competencies in microsurgery.

Can temporary artery catheterization extend limits of ischemia time for macroreplantation? / Cateterização temporária arterial amplia o limite de tempo de isquemia no macrorreimplante?

ABSTRACT We observe delayed referrals to appropriate Microsurgery Unit and definitive treatment of traumatic limb amputations. Cases with wrist proximal amputations have a deadline for surgical replantation as these configure life-threatening injuries. Objective: To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results. Methods: A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021. Results: In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours). Conclusion: Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

RESUMO Observa-se um atraso no referenciamento dos casos para o tratamento definitivo das amputações traumáticas de membros no Brasil. Casos com amputações proximais ao punho apresentam um prazo limite para reimplante, sendo lesões que promovem risco de vida ao paciente. Objetivo: Analisar os macrorreimplantes com tempo de isquemia prolongado submetidos à cateterização temporária da artéria, para determinar a viabilidade do coto de amputação, e seus resultados. Métodos: Série de casos de todos os pacientes com amputações traumáticas proximais ao punho, cujo tempo de isquemia fria foi igual ou superior a seis horas, entre 2017 e 2021. Resultados: A amostra foi composta por oito pacientes com amputações traumáticas de antebraço operados por dois cirurgiões. O tempo médio de isquemia foi de oito horas. Todos os pacientes necessitaram de cirurgias adicionais, sendo as mais comuns o enxerto de pele ou a revisão da fixação óssea. Sucesso do macrorreimplante foi observado em cinco pacientes. O tempo médio de isquemia fria foi maior no grupo com sucesso no macrorreimplante (7,4 horas) quando comparado com o grupo sem sucesso (9 horas). Conclusão: Os macrorreimplantes necessitam de transferência imediata para serviços especializados, e, apesar de a cateterização temporária arterial auxiliar no manejo cirúrgico, a técnica parece não interferir nos resultados. Nível de Evidência IV, Série de Casos.

Microcirugía endodóntica: regeneración ósea guiada en defecto óseo tunelizado: caso clínico / Endodontic microsurgery: guided bone regeneration in a through-and-through bone defect: a clinical case

Se presentó a la Cátedra de Endodoncia de la Facultad de Odontología de la Universidad de Buenos Aires un paciente masculino de 62 años de edad que al examen clínico presentaba una fístula vestibular en la zona de la pieza 1.2 y dolor a la percusión. Al examen radiográ-fico se identificó una lesión apical extensa abarcando las piezas dentarias 1.2 y 1.1 endodónticamente trata-das con alteración severa de la anatomía del espacio endodóntico, así como la presencia de postes metáli-cos que no respetaban el eje del canal radicular. Ante el análisis tomográfico se observó una perforación de la pieza 1.2 y una lesión periapical extensa afectando ambas corticales (vestibular y palatina). Se decidió un abordaje microquirúrgico con técnicas de regenera-ción ósea guiada (ROG) y se realizaron los controles clínico-tomográficos a los 6, 12 y 24 meses. Por otro lado, se evaluó con micromografía de rayos X la ana-tomía de los ápices radiculares resecados. La lesión extirpada fue analizada histológicamente (AU)

A 62-year-old male patient attended the Endodontics department of the Buenos Aires University. He was examined clinically and a vestibular fistula in 1.2 area and pain under percussion were found. Radiographic examination identified an extended periapical lesion compromising teeth 1.2 and 1.1 with endodontic treatment severely altering the root canal anatomy, as well as metallic cast posts that did not preserve root canal axis. Regarding the tomographic analysis, a vestibular root perforation was observed (1.2), and both, vestibular and palatal corticals, were affected. We decided to perform a surgical approach with guided bone regeneration techniques (GBR). Clinical-CBCT controls were done at 6, 12 and 24 months. Furthermore, the anatomy of the resected root apex-es was evaluated with X ray microtomography. The removed lesion was histologically analyzed (AU)

Short term efficacy of 3D printed individualized prosthesis for precise reconstruction of bone and joint defects after upper limb microsurgical repair / 中华显微外科杂志

Objective:To evaluate the efficacy of 3D printed individualised prosthesis in treating bone and joint defects in upper limbs remained after earlier microsurgical repairs.Methods:From June 2019 to September 2021, 12 patients were treated in the Institute of Orthopaedic Trauma of PLA, the 80th Group Army Hospital for bone and joint defects in upper limb that had been remained after earlier repairs with soft tissue flaps. The defects were: 1 in completely severed wrist, 2 defects of digit metacarpal bone, 4 defects of interphalangeal joint, 4 defects of bones in radiocarpal joint and 1 defect of lunate bone. The area of soft tissue defect ranged from 1.5 cm×3.0 cm to 12.0 cm×18.0 cm, and the length of bone defects ranged from 2.5 to 8.5(average 3.64) cm. For incompletely severed and completely severed limbs, replantation of severed limbs (digits) were performed in the primary surgery and the repair of soft tissue defects were performed in the second stage surgery. The remaining defects of bone and joint were reconstructed by 3D printed individualised prostheses in the third stage surgery. Finger soft tissue defects were covered with a local flap in the primary surgery, and bone and joint defects were reconstructed with a 3D printed prosthesis in the second surgery. Finger soft tissue defects were covered with a local flap in the first phase, and bone and joint defects were reconstructed with a 3D printed prosthesis in the second phase. After the surgery, the bone integration between the broken end of the bone joint defect and the prosthesis was determined based on the X-ray results and the Paley fracture healing score standard. Simultaneously measured the Total Active Motion(TAM) of the forearm and hand joints. At 1, 2, 3, 6, 9 and 12 months after hospital discharge. Follow-up X-ray examinations were taken followed by examinations on the recovery of soft tissues and bones. The upper limb function was graded according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association.Results:Postoperative follow-up at outpatient clinic lasted for 6 to 26 months, with an average of 11.5 months. All flaps were free from necrosis and infection, also there was no infection in bones and joints. According to the Paley fracture healing scale, 10 patients were in excellent and 2 in good. In addition, according to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 5 patients achieved upper limb function in excellent, 5 in good and 2 in fair. The ranges of motion of the affected wrists were 30°-42°(average 37.3°) for the implanted prostheses of distal end of radius and the radial shaft. Wrist flexion 40° to 55°(average 43.5°). The range of motion of finger and wrist was 60° to 70°(average 65.7°) with a metacarpal and phalangeal bone prosthesis.Conclusion:3D printed individually customised prostheses are safe, accurate and effective in repair of the remained bone and joint defects in upper limbs after primary and early stages of microsurgical flap repairs. It can effectively restore anatomical structures of bone and joint in upper limbs.

Make a way in the wilderness, climb the highest mountain / 中华显微外科杂志

In March 1973, the Department of Hand Surgery and Oral Surgery of Huashan Hospital Affiliated to Shanghai First Medical College (now Huashan Hospital Affiliated to Fudan University) jointly carried out the first case of free flap transfer in China. In the past 50 years, Chinese colleagues have been constantly exploring and innovating in the field of microsurgery, and have made great progress, always leading the world. On the occasion of the 50th anniversary celebration, it would like to pay tribute to the predecessors who made contributions to Chinese microsurgery, and also encourage the colleagues in microsurgery to take Professor Yang Dongyue as an example, forge ahead, scale brave heights, and make new contributions to the healthcare of mankind.