Arterialized venous free flap for reconstruction of burned face.

In this study, a forearm arterialized venous free flap (23 cm x 14 cm) was used in a 25-year-old male with facial burns sequels to reconstruct both cheeks, chin, lips, nose, columnella, nasal tip, and nostrils. It was arterialized by the facial artery to an afferent vein anastomosis. The venous flow was drained by four efferent vein to vein anastomoses. Although it developed small inferior marginal necrosis in the lower lip, the rest of the flap survived with good quality of the skin in both texture and color, with self-delimitation of the different esthetics units of the center of the face such as the nasogenian folds, nostrils, and upper lip filtrum, without the need of additional thinning surgical procedures. From all of the above, the arterialized venous free flap is an alternative reconstructive option for the treatment of burn sequels especially those that include the centrofacial region.

[Retrospective study between open vs. laparoscopic funduplication in gastroesophageal reflux disease]. / Estudio retrospectivo entre funduplicatura abierta vs. laparoscópica en enfermedad por reflujo gastroesofágico.

INTRODUCTION: Nissen funduplication is each time more frequently used for gastroesophageal reflux disease (GERD) treatment. Surgical technique has changed from open to laparoscopic. OBJECTIVE: To analyze in comparative form the results of open and laparoscopic Nissen procedure. MATERIAL AND METHODS: In a period of five years, Nissen funduplication was practiced to 144 patients with confirmed GERD (50 open and 94 laparoscopic). All the patients were follow-up in Outpatient Consultation of the hospital for a minimum period of a year, evaluating in comparative form results and complications of the intervention. Retrospective revision of the files was made. RESULTS: Surgical time average in open surgeries was of 2.6 hours, and laparoscopic 2.57 hours (p = ns). Splenectomy in a patient operated in open form was an only complication. Postoperating complications in four patients (5%) laparoscopic and in 10 (20%) open (p 0.002). Hospital stay in these last ones was of 7.6 days and in laparoscopic 4.7 days (p < 0.0001). A year after the intervention, 19 patients (38%) open surgeries presented suggestive symptoms of reflux or had proton pump inhibitors (PPIs). Of these, in 5 (10%) recurrence of the GERD by some method was confirmed requiring reoperation two of them. In five peptic acid gastro/duodenal disease was confirmed and the rest had drugs without specific indication, demonstrating suitable morphology of the SEGD intervention. In the laparoscopic group, there were 26 symptomatic patients or who had PPIs a year after the intervention (27%). In seven (7%) reflux recurrence was confirmed, becoming necessary the reintervention in two. Another gastric/duodenal pathology in 13 was documented and six had drugs without specific indication. CONCLUSIONS: Nissen operation allows reflux control in 90% of the patients. Laparoscopic intervention requires a smaller hospital stay and is associated to less frequency of complications. The accomplishment of all technical steps of Nissen surgery, open or laparoscopic, is indispensable for good results.

Endoscopic abdominoplasty: an alternative approach.

We describe a technique for endoscopic abdominoplasty in which we used 3 incisions, following the triangulation principles. To maintain the subcutaneous cavity, CO2 was insufflated at 8 mm Hg, and Esmarch bandages were placed at the submammary fold in a circumferential way to prevent subcutaneous emphysema. The aponeurosis plication was done with interrupted "8" figure sutures, with extracorporeal knots tied up in a double fisherman knot. The rest of the technique is similar to those previously described. Seven patients were treated, with an average age of 35.7 years (range, 25-60), and the mean length of surgery was of 197.11 minutes (range, 129-240). After surgery, 2 patients had mild pulmonary hypoventilation treated only with oxygen through a nasal mask for 24 hours. There were other complications such as seromas, inadequate implantation of the navel, and superficial periumbilical necrosis. According to the patients' opinion, the esthetic results have been satisfactory so far.

Maintenance of subcutaneous cavities with CO2.

UNLABELLED: Since mechanical retractors in endoscopic plastic surgery cause certain drawbacks, we developed a model in dogs, which, by insufflating CO2 into a subcutaneous cavity, we were able to maintain. We evaluated the magnitude of subcutaneous emphysema and absorption of CO2 by insufflating different pressures and the efficacy of external pressure on the skin with the purpose of limiting the subcutaneous emphysema. Sixteen dogs were divided in 3 groups, A, B, and C. We controlled the pulmonary function by using a volume-cycle ventilator. In all groups, we maintained a subcutaneous cavity by insufflating CO2. Groups A and C were insufflated at 15 mm Hg; group B, at 8 mm Hg. We placed circumferential Esmarch bandages on the thorax of groups B and C to delimit superiorly and inferiorly the surgical area. Arterial blood gas analyses (ABGA) were taken from the femoral artery 60 minutes after intubation, 60 minutes after Esmarch bandage was placed and at the end of the CO2 insufflation. Statistically, results were analyzed by Wilcoxon test. P < 0.05 was considered statistically significant. Group A showed extensive subcutaneous emphysema. Two dogs died. The systemic increase of the CO2 showed a median of 9.6 mm Hg (P < 0.05). In Group B, Esmarch bandages caused increase in CO2, with a median of 1.65 mm Hg (P < 0.028). None of these dogs showed subcutaneous emphysema during the insufflation after CO2 insufflation pressure augmented with a median of 3.7 mm Hg (P < 0.028). In Group C, chest restriction increased CO2 median of 6.1 mm Hg (P < 0.043), and subcutaneous emphysema shown was less extensive than group A. The CO2 increased after insufflation a median of 16 mm Hg (P < 0.043). CONCLUSIONS: Subcutaneous cavities can be maintained open with CO2 insufflation at 8 mm Hg, limiting perfectly the surgical area; as done with Esmarch bandages, it reduces CO2 absorption and makes this procedure safe.

Bile duct growing factor: an alternate technique for reconstruction of thin bile ducts after iatrogenic injury.

A variant of bilioenteric anastomosis, laterolateral hepatojejunostomy, is described in which the opened anterior aspect of the common hepatic duct and left hepatic duct is anastomosed to a Roux jejunal limb. This technique is specially designed for thin, injured bile ducts in which a conventional anastomosis is difficult due to the small diameter of the ducts. A wide anastomosis is obtained, leaving the posterior wall as a conduit for bile, ensuring an adequate anastomotic diameter.

An unusual cause of bilioenteric anastomotic dysfunction after iatrogenic bile duct injury.

Roux en Y hepatojejunostomy is the surgery of choice for bile duct repair. Anastomotical dysfunction after reconstruction has several etiopathologies. Besides technical factors, ischemia of the duct is responsible for late obstruction. Bile colonization with secondary stones and sludge can also be identified as a cause. An unusual cause of anastomotical dysfunction secondary to ascaris biliary infestation after biliary reconstruction is reported herein. The patient had intermittent cholangitis and eosinophilia. At operation, the worm was found obstructing the anastomosis.

Bile duct injuries related to misplacement of "T tubes".

INTRODUCTION: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. METHODS: In a 15-year period (1990-2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1-6 months), hospital in stay, long term outcomes as well as associated comorbidities. RESULTS: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum-ileum and 3 to the colon. A hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. CONCLUSION: Inadequate placement of the T tubes and long-term stay can produce complex biliary injuries with associated comorbidities such as fistulas to the adjacent viscera. Placement of T tubes need a careful surgical technique and their indication must be carefully assessed.

Long-term evaluation of biliary reconstruction after partial resection of segments IV and V in iatrogenic injuries.

Roux-en-Y hepatojejunostomy is the procedure of choice for biliary reconstruction after complex iatrogenic injury that is usually associated with vascular injuries and concomitant ischemia of the ducts. To avoid the ischemic component, our group routinely performs a high repair to assure an anastomosis in noninflamed, nonscarred, and nonischemic ducts. If the duct bifurcation is preserved, the Hepp-Couinaud approach for reconstruction is an excellent choice. Partial liver resection of segments IV and V allows adequate exposure of the bile duct at its bifurcation with an anterior approach of the ducts (therefore not jeopardizing the circulation), allowing a high quality anastomosis. Long-term results of bile duct reconstruction using this approach are described. Two hundred eighty-five bile duct reconstructions were done between 1989 and 2004 in a tertiary care university hospital. The first partial-segment IV resection was done in 1994; 94 cases have been reconstructed since then using this approach. All of them had a complex injury (Strasberg E1-E5), and although in many cases the bifurcation was preserved (E1-E3), a high bilioenteric anastomosis was done to facilitate the reconstruction. In 70 cases, the bifurcation was identified, and in the 24 in which the confluence was not preserved, the right and left ducts were found except in one case. In three patients, the right duct was found unsuitable for anastomosis, and a liver resection was done. In the remaining 21, an anastomosis was done using a stent (transhepatic, transanastomotic) through the right duct. According to Lillemoe's criteria, 86 cases had good results (91%). In four of the eight remaining patients, there was the need to operate again due to the presence of an obstruction and/or cholangitis. In the rest, radiological instrumentation was done. Four of these cases have developed secondary biliary cirrhosis, two of which have died while waiting for a liver transplant, four and six years after reconstruction. Partial segments IV and V resection allows adequate exposure of the confluence and the isolated left or right hepatic ducts. Anterior exposure of the ducts allows an anastomosis in well-preserved, nonischemic, nonscarred, or noninflamed ducts. Parenchyma removal also allows the free placement of the jejunal limb, without external compression and tension, obtaining a high quality anastomosis with excellent long-term results.