Management of the impaired adult cleft patient: the last chance.

OBJECTIVE: Unfortunately, not all patients receive the benefits of a well-trained, experienced, multidisciplinary cleft team, and a significant number of patients reach adulthood with severe neglected cleft related problems. The vast majority of this group have made their way through several surgical procedures, usually performed by different surgeons in different centers, and still carry the original cleft stigmata aggravated by variable degrees of maxillary hypoplasia, fistulae, scarring, muscle pull, soft tissue tension, lost teeth, dental adaptation, and instability of bony fragments. Adult patients who reach this stage with their original deformities have, in most instances, lost their best opportunity to be properly treated. With this assumption in mind, an aggressive surgical plan focused mainly on the deformities that can objectively achieve functional and aesthetical improvement should be individualized for each patient. In this article, experience with 38 consecutive adult patients with cleft managed following a two-stage protocol used at our cleft clinic for the last 4 years is presented. CONCLUSION: An algorithm to help definitively solve these deformities is suggested.

Determining the optimal time for consolidation after distraction osteogenesis.

The consolidation period, one of the biological factors participating in the distraction osteogenesis phenomenon, has not been elucidated. Parameters to assess new bone formation and consolidation in craniofacial distraction have been borrowed from the orthopedic experience. Up until now, the decision to discontinue distraction has been based more on personal experience than on objective data. By using Scintigraphy with Tc99 DP a method has been developed to accurately assess the termination of the consolidation phase. Scintigraphic evidence of consolidation was seen between the fourth and the fifth week after terminating distraction in infants (younger than 12 months). Not before the 10th week in children and between the 10th and the 14th week in adolescents and adults. The data roughly correlates with previous reports. It is believed that the consolidation period should be addressed in biologic terms and not in radiologic terms as done up until now. A method is proposed that offers objective qualitative and quantitative data for the noninvasive evaluation of bone consolidation which could have further applications in distraction of the craniofacial skeleton.

The Mexican experience with laparoscopic cholecystectomy and common bile duct exploration. A multicentric trial.

We present here the initial data collected since the first laparoscopic cholecystectomy (LC) was performed in our country (June 1990). Twenty-one centers were surveyed (2,399 patients). The most frequent indication for LC was chronic gallstone disease (76.2%). The female population predominated (69.4%). Seven centers always perform the laparoscopic approach. Antibiotic prophylaxis is the rule, and most centers use nasogastric tube and urinary catheterization. Perioperative cholangiography is done selectively. The instrument of choice to dissect the gallbladder is the electrosurgical hook-knife. General anesthesia is preferred (97%). The complication rate was 8.87%. Injury to the bile duct and bowel perforation occurred in 0.25% and common duct stone retention occurred in 0.29% of patients. Mortality rate reached 0.12%. It is our hope that this study will help in defining the situation of LC in developing countries and that it also can serve as a first step in the organization of minimally invasive surgery groups in Mexico.