Safe Gluteal Fat Graft Avoiding a Vascular or Nervous Injury: An Anatomical Study in Cadavers.

Background: Fat grafting for gluteal augmentation is one of the most popular aesthetic surgery procedures. It has an associated mortality to fat embolism of 0.2%. Objectives: The authors of this study sought to describe which technique for synthetic graft application was least likely to cause a fat embolism. Methods: Ten fresh bodies were obtained and 4 groups arranged with 5 buttocks each randomly assigned. Group 1 was infiltrated through the upper medial intergluteal sulcus (upper medial intergluteal sulcus) with an angulation of -30°, -10°, and 0°. Group 2 was infiltrated through the middle lower gluteal sulcus with an angulation of -30°, 0°, and +15°. Group 3 was infiltrated through a peritrochanteric (PT) access at the level of the femur head at 0° and +10° and in the middle of the buttock at the level of the posterior superior iliac crest at -30° toward the trochanter (lateral direction). Group 4 was infiltrated in the same manner as group 1 without -30°. A complication occurred when the graft was in contact with the vascular or nervous bundle, within the gluteus medius muscle, or both. Results: Group 1 had 3 buttocks with a complication (UMIGS -30°). Group 2 had complications in all the injection techniques. Group 3 had 5 buttocks with a complication (PT at 0°). Group 4 had no complications. Conclusions: The injection of the fat graft through the UMIGS at 0° and 10° angles, and through the middle of the buttock at the level of posterior superior iliac crest a -30° angle, reaches the surface needed for gluteal augmentation. The group 2 techniques should be avoided because they have a high risk of complication.

Acute appendicitis in an overweight and obese Mexican population: A retrospective cohort study.

INTRODUCTION: México is the second place in overweight and obese adults. Acute appendicitis (AA), is the most common indication for an emergency surgery around the world, with an estimated lifetime incidence of 7-14%. Laparoscopic appendectomy (LA) has been described as a safe and good surgery approach for this group of patients. Nevertheless, in México, there is not any evidence supporting these outcomes in our population. METHODS: All the patients that came to the ER from July to December 2014 with age >16-year, body mass index (BMI) > 25 kg/m(2) (overweight) and, BMI >30 kg/m(2) (obese) were included in the study. We recorded the age, gender, BMI, grade of appendicitis, complications classified by the Clavien-Dindo Classification, and a follow-up period of 7-day, 30-day, 6-month, and 1-year. RESULTS: 27 patients met the inclusion criteria, five had overweight (18.5%), and twenty-two were obese (81.5%). No surgical conversion was needed. The overall complications rate was 29.6%%, with 22.2% mild complications and 7.4% of moderate complication. The average in-hospital cost for the procedure was $15,860 MXN (range $12,860-$22,860 MXN). The surgical time was ≈53.7 ± 19.93 h and the LOS ≈1.6 ± 0.6 days. CONCLUSION: The outcomes in the Mexican adult obese population with acute appendicitis when a laparoscopic appendectomy is performed are as good as reported in other countries.

Treatment of choledochal cyst in a pediatric population. A single institution experience of 15-years. Case series.

BACKGROUND: Choledochal cyst (CC) is a rare congenital anomaly of the bile duct that approximately 75% of the patients are diagnosed in childhood. Without a standardized surgical procedure for the biliary reconstruction, we present our experience over the last 15 years and show the differences between the biliary reconstructions techniques in our population. METHODS: We did a retrospective hospital archive search for patients admitted to the pediatric surgery department with the diagnosis of a choledochal cyst from January 2000 to June 2015. RESULTS: We found 15 patients, of which, 1 was excluded because of missing data from the hospital record. Of the remaining 14, eight had hepaticojejunal (HY) anastomosis in Roux-en-Y, with a 25% rate of complications; six had hepatoduodenal (HD) anastomosis with a rate of complications of 16.6%. The average hospital length of stay in the group of HD vs. HY was 14 ± 1.6-days vs. 19 ± 8.2-days respectively. DISCUSSION: There are no standardized surgical reconstruction techniques of the biliary tract after the CC excision, there is literature that supports the biliary reconstruction with an HY and an HD without a distinct advantage over one or the other. CONCLUSION: In our series HD anastomosis represents a safe procedure with fewer complications than HY.

Karewsky syndrome: A case report and review of the literature.

INTRODUCTION: Gallstone ileus can be a lethal disease, rarely suspected in the clinical scenario. It represents about 25% of all bowel obstruction cases in patients older than 65. There is a classification of gallstone ileus based on the onset time: acute, subacute and chronic (Karewsky syndrome). We describe the first reported case of chronic gallstone ileus. CASE PRESENTATION: A 78-year-old female was admitted to the ER with a 15-day case of consistent bowel obstruction. The subject reported a five-year history of recurrent hospital admissions that resolved spontaneously after non-surgical management. Karewsky syndrome was diagnosed and managed with enterolithotomy. After five days of postoperative evolution the patient was discharged, and at six months follow up, no other hospital admission or relapse has been registered. DISCUSSION: The gallstone ileus diagnosis demands a higher clinical suspicion, there is no biochemical marker, and an abdominal CT is ideal for imaging-based diagnosis. There is no consensus on the optimal surgical approach. CONCLUSION: We describe the first case of Karewsky syndrome and a gastro-jejune and gastric-choledochus double fistula. We emphasize the importance of higher clinical suspicion for patients with bowel obstruction older than 65 years old and make evident that although there are not evidence-based guidelines for this treatment, enterolithotomy is a recommended approach.

Amyand hernia: Case report and review of the literature.

INTRODUCTION: Amyand Hernia is a rare disease seen in approximately 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the pre-operative period; it is usually an incidental finding. PRESENTATION OF CASE: This paper describes the case of a forty-year-old male patient, which was presented to the outpatient clinic of surgery with an incarcerated right side inguinal hernia without any signs of ischemic complications. He was admitted, and an hernioplasty was performed, as an incidental finding we encountered an Amyand hernia treated without appendectomy and placement of a prosthetic mesh without any complications. DISCUSSION: This disease represents a very challenging diagnosis, seven years ago the standardization of management had already been established; in this case we encountered a type 1 Amyand's Hernia so we performed a standard tension free hernioplasty without complications. CONCLUSION: Amyand hernia is a rare condition, which represents two of the most common diseases a general surgeon has to face. Standardization of treatment is still ongoing and more prospective studies need to be done. This case demonstrates that this pathology must remain in the mind of the surgeons especially in the event of a strangulated hernia and offer a comprehensive review.