Delayed Abdominal Flap for Upper Extremity Soft Tissue Coverage.

Unlike other body parts, the upper extremity has critical structures close to the skin, making soft tissue injuries more complex. These injuries can result from various causes, including trauma and necrotizing soft tissue infections, necessitating reconstruction. Historically, pedicled flaps from the groin and abdomen were commonly used for upper extremity reconstruction, but they had limitations, such as the need for flap division and debulking, patient discomfort, and stiffness. Free flap reconstruction has become the preferred method, but it still faces challenges like patient and facility issues, the absence of recipient vessels after injury, and multi-surface wounds. This case report describes a 67-year-old patient with a severe necrotizing soft tissue infection in the right upper extremity. After multiple debridement procedures, the patient underwent hand amputation and soft tissue coverage using an abdominal wall-based flap. The objectives of achieving stable soft tissue coverage while preserving maximal length of the upper extremity were successfully achieved, and the patient expressed satisfaction with the outcomes. Inadequate management of upper extremity wounds can lead to amputation and psychological distress. The reconstructive ladder is used to approach upper extremity soft tissue defects, with free tissue transfer being the standard for larger defects. However, abdominal flaps still have indications when free tissue transfer is not feasible or contraindicated. It is imperative that plastic surgeons have these techniques in their armamentarium to provide a service to the ever more complex patient with an upper extremity wound.

Synergistic impact of N-antigenemia profiled by a rapid antigen test and low anti-S1 antibodies on the risk of hospitalization in COVID-19.

OBJECTIVES: Identifying patients with COVID-19 who are at risk of poor evolution is key to early decide on their hospitalization. We evaluated the combined impact of nucleocapsid (N)-antigenemia profiled by a rapid test and antibodies against the S1 subunit of the SARS-CoV S protein (S1) on the hospitalization risk of patients with COVID-19. METHODS: N-antigenemia and anti-S1 antibodies were profiled at admission to the emergency department in 146 patients with COVID-19 using the Panbio® antigen Rapid Test and the SARS-CoV-2 immunoglobulin G II Quant/SARS-CoV-2 immunoglobulin G assay from Abbott. A multivariable analysis was used to evaluate the impact of these factors on hospitalization. RESULTS: Patients with a positive N-antigen test in plasma and anti-S1 levels <2821 arbitrary units/mL needed hospitalization more frequently (20 of 23, 87%). A total of 20 of 71 (28.2%) of those showing a negative N-antigen test and anti-S1 ≥2821 arbitrary units/mL were hospitalized for 18 of 52 (34.6%) of the patients with only one of these conditions. Patients with a positive N-antigen test and low antibody levels showed an odds ratio, 95% confidence interval, and P-value for hospitalization of 18.21, 2.74-121.18, and 0.003, respectively, and exhibited the highest mortality (30.4%). CONCLUSIONS: Simultaneous profiling of a rapid N-antigen test in plasma and anti-S1 levels could help to early identify patients with COVID-19 needing hospitalization.

Functional Rhinoplasty.

The nose is composed of intricate intranasal anatomy to serve its sophisticated functions. Although it only occupies a small area, it is the central focal point of the face and demands the highest level of understanding of the delicate interplay of form and function. Functional rhinoplasty, as opposed to aesthetic rhinoplasty, primarily aims to enhance nasal breathing and olfaction without altering the nose's appearance. The goal of this study is to describe the anatomy and physiology of the nose as well as the pathophysiology of nasal obstruction and the surgical approaches available for functional rhinoplasty. Whether when performed alone or combined with cosmetic rhinoplasty, functional rhinoplasty is a procedure that can bring significant benefits and improve the quality of life of our patients. Understanding nasal anatomy and physiology is key for successful management and outcomes. To provide optimal treatment for the patients, plastic surgeons must be familiarized with various techniques that have been documented.

Detection of Sentinel Lymph Nodes Using Indocyanine Green After Failing Scintigraphy in Merkel Cell Carcinoma.

Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer that carries a high rate of lymph node involvement and death. The National Comprehensive Cancer Network recommends sentinel lymph node (SLN) biopsy for the staging of the disease. Scintigraphy using radioactive isotopes (RI) such as technetium 99m (Tc99) remains the gold standard for the detection of SLNs, however, recently indocyanine green (ICG) fluorescence imaging has been used to aid in the detection of SLNs.We present the case of a patient who presented with MCC of the face and two SLNs successfully identified with ICG fluorescence despite the fact that they were not detected by intraoperative scintigraphy using Tc99. The use of ICG fluorescence imaging in MCC is safe and improves the ability to detect SLNs when combined with RI.

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method. METHODS: PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes. RESULTS: A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1). CONCLUSIONS: While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.

A National Inpatient Sample Analysis of Racial Disparities After Segmental Colectomy for Inflammatory Colorectal Diseases.

BACKGROUND: Racial disparities and poor access to care are common among African Americans (AA), potentially adversely affecting surgical outcomes in inflammatory bowel conditions. We aimed to analyze the effect of race on outcomes in patients undergoing segmental colectomy for inflammatory bowel conditions. METHODS: Retrospective review of data from the National Inpatient Sample between 2010 and 2015 identified patients who underwent segmental colectomy without ostomy for Crohn's or diverticular disease. AA patients were compared with Caucasians using a multivariable analysis model. Primary outcomes of interest were overall complications, mortality, and extended hospital stay. RESULTS: 38,143 admissions were analyzed; AA patients constituted 8% of the overall cohort. Diagnoses included Crohn's (11%) and diverticular disease (89%). After multivariable analysis, AA patients had significantly higher overall risk of complications (OR = 1.27; 95% CI, 1.15-1.40) and extended hospital stay (OR = 1.59; 95% CI, 1.45-1.75) than Caucasians. On bivariate analysis, there was no significant difference in mortality between AA and Caucasian patients. AA patients had significantly higher rates of Medicaid insurance (14% vs 6%, P < .001), lower rates of private insurance (35% vs 47%, P < .001), and were less likely to undergo surgery at a private hospital (31% vs 41%, P < .001). CONCLUSIONS: AA patients requiring segmental colectomy for inflammatory colorectal conditions experience significantly higher rates of postoperative complications, longer hospital stays, and lower rates of private insurance. Direct correlation between insurance status and postoperative outcomes could not be established, but we speculate such great disparity in outcomes may stem from these socioeconomic differences.

Near-Infrared Fluorescence Imaging for Sentinel Lymph Node Identification in Melanoma Surgery.

Although less common than other types of skin cancers, melanoma is accountable for the majority of skin cancer-related deaths. The standard management for patients with clinically negative nodes includes a sentinel lymph node (SLN) biopsy, which is commonly performed using a combination of radioactive tracer (Tc-99) and a blue dye (isosulfan or patent blue). There are numerous drawbacks associated with Tc-99 and blue dyes such as elevated costs, logistical challenges, and anaphylactic reactions among others. In recent years, near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has emerged as a safe, effective, less costly, and more convenient alternative for the identification of SLNs in melanoma. We discuss the case of a 51-year-old man with melanoma in his left upper back. Two SLNs in the left axilla were successfully identified using NIR fluorescence. NIR fluorescence with ICG for SLN identification has proven to increase the sensitivity and accuracy when used in combination with lymphoscintigraphy.

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes.

BACKGROUND: Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years. OBJECTIVES: To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older. SETTING: Academic hospital, United States. METHODS: After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ2 analysis were performed for nominal and categorical variables, respectively. RESULTS: From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group. CONCLUSIONS: Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.

Complications of feeding jejunostomy placement: a single-institution experience.

BACKGROUND: Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable. METHODS: A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30 days) and in a long-term follow-up (> 30 days). The Chi-square test was used to compare rates of complications according to tube size. RESULTS: Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6 days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications. CONCLUSION: The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.

Short-term multiorgan metabolic benefits of rapid weight loss after sleeve gastrectomy in severely obese patients.

BACKGROUND: Sleeve gastrectomy (SG) has become the most prevalent bariatric-metabolic surgical approach in the United States. Its popularity among surgeons and patients is mainly due to a better safety profile and less overall morbidity, with broad benefits from a systemic and metabolic perspective. OBJECTIVE: Comprehensively describe the short-term multiorgan metabolic effects of rapid weight loss after SG. SETTING: Academic hospital, United States. METHODS: We retrospectively reviewed the charts of patients that underwent SG at our institution between 2012 and 2016. We analyzed the required variables to calculate multiple risk scores, such as cardiovascular, hypertension, and diabetes risk scores. Furthermore, the renal and hepatic functions and the metabolic and hematologic profiles were assessed at 12 months of follow-up. RESULTS: A total of 1002 patients were included in the analysis. The percentage of excess body mass index loss was, on average, 65% at 12 months of follow-up. We observed a positive cardio-renal-hepatic improvement, demonstrated by a substantial reduction of the 10-year cardiovascular risk. We noticed an improvement of renal function, which was more significant in chronic kidney disease (stage ≥2), and a significant improvement on liver function tests (measured by decreased aspartate aminotransferase and alanine transaminase) at 12 months of follow-up. Our data also show a positive impact on decreasing the risk of developing hypertension and type 2 diabetes. There was a positive impact on the lipid profile, with the exception of low-density lipoprotein. CONCLUSION: There are significant short-term benefits on multiorgan metabolic parameters after rapid weight loss in severely obese patients undergoing sleeve gastrectomy.

Peripheral Neurectomy for Management of Trigeminal Neuralgia Refractory to Multiple Surgical Procedures.

Trigeminal Neuralgia (TN) is defined as a recurrent, unilateral, brief, electric shock-like pain and is associated with a significant deterioration in quality of life due to the debilitating nature of the pain. The first line treatment is medical therapy, and surgical treatment is reserved for patients with inadequate pain control or undesirable side effects. Surgical options for treatment may include microvascular decompression (MVD), stereotactic radiosurgery, percutaneous radiofrequency rhizotomy, and percutaneous balloon compression of trigeminal ganglion. MVD is considered the procedure of choice due to its high efficacy and safety profile; however, it carries a recurrence rate of 1%-5% annually and 15%-35% long term. Although re-operative MVD has been reported for recurrent cases, it carries a high risk of complications due to arachnoid adhesions and distorted anatomy. Peripheral neurectomy is a simple, expeditious, low-risk procedure that is well tolerated by patients and can be done even under local anesthesia. We report a case of a 69-year-old man who presented with a debilitating TN in the V1 and V2 territory refractory to MVD, stereotactic radiosurgery, and percutaneous balloon compression of the trigeminal ganglion, who had been treated with neurectomy of the left supraorbital, supratrochlear, and infraorbital nerves, with an excellent outcome at 6 months follow-up. Peripheral neurectomy is an effective alternative for patients with refractory TN who failed multiple surgical interventions. Previous publications have reported an elevated long-term recurrence rate after this procedure, perhaps due to peripheral nerve regeneration or neuroma formation. It is not yet studied whether using nerve conduits may lead to a decrease in recurrence.

Colorectal surgery obesity-related morbidity during COVID-19.

Tocilizumab, a monoclonal antiinterluekin-6 receptor antibody, has been empirically used in the treatment of cytokine release syndrome associated with severe coronavirus disease 2019 infections. The efficacy and safety of these medications for these patients is unknown. The purpose of this report was to present a case of acute large bowel perforation in a morbidly obese patient with coronavirus disease 2019 pneumonia who received empiric Tocilizumab. This case report analyzes the risks of acute large bowel perforation after using this medication empirically and discusses the appropriate management of this adverse event.

Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.

BACKGROUND: Despite its popularity, sleeve gastrectomy (SG) is not devoid of postoperative complications and weight regain. Some of these cases warrant conversion to Roux-en-Y gastric bypass or proximal gastrectomy with Roux-en-Y esophagojejunostomy. Complications after conversion are scarcely reported in the literature. OBJECTIVES: Report and review the outcomes of reoperation on severely obese patients with weight regain or complications after SG. SETTING: Bariatric Surgery Center of Excellence; Community Hospital, United States. METHODS: We retrospectively reviewed the medical records of patients converted from SG to Roux-en-Y gastric bypass/proximal gastrectomy with Roux-en-Y esophagojejunostomy at our center, from 2004 to 2018. Patients were stratified by reason for conversion. Group A included those converted for complications (leaks, strictures, or gastroesophageal reflux disease) and group B for reported weight regain. Demographic characteristics, postoperative outcomes, and complications were described. RESULTS: From 77 conversions identified, 63.6% (n = 49) underwent primary SG at an outside hospital. We observed predominant female (68.8%; n = 53) and Caucasian (76.6%; n = 59) populations. Conversions for complications were performed in 67.5% (n = 52) and for weight regain in 32.4% (n = 25). The most common conversion indication in group A was chronic leak (29.9%; n = 23), followed by gastroesophageal reflux disease (20.8%; n = 16), and stricture (16.9%; n = 13). Overall, major complications occurred in 16.9% (n = 13) and minor complications in 19.4% (n = 15). In group A, most common major complications were anastomotic leak and organ space surgical site infection (3.9%; n = 2 each); the most common minor complication was nonperforated marginal ulcer (7.7%; n = 4). In group B, the most common major complication was perforated marginal ulcer (8%; n = 2); the most common minor complication was stricture (16%; n = 4). Group B mean preconversion body mass index was 38.4 ± 4.3 and percentage excess body mass index loss was 48 ± 33, 63 ± 45, 59 ± 63, and 73 ± 25 (12, 24, 36, ≥48 mo). CONCLUSIONS: Our experience shows that major complications can occur in up to 17% of patients after conversion. Conversion to Roux-en-Y gastric bypass in nonresponders appears to be a safe and effective option for body mass index reduction.

Reduction of invasive interventions in severely obese with osteoarthritis after bariatric surgery.

BACKGROUND: Osteoarthritis (OA) affects 56,000,000 Americans, 30% with obesity. Their risk of developing OA is 5 times higher. With each extra kilogram above ideal weight, the risk of OA increases to 13%. The study aim is to describe changes in OA treatment after undergoing bariatric surgery (BS). METHODS: After IRB approval, we conducted a retrospective analysis of all severely obese patients and OA that underwent laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass from 2004 to 2018. Changes of OA severity were assessed based on the requirement of invasive intervention (INI) at 12 and 24 months after BS. INI was defined as the need for surgical drainage; articular injection; and surgical interventions such as meniscectomy, total hip replacement, and total knee replacement. RESULTS: A total of 11.52% (N = 486) had OA diagnosed prior to BS, the most common location being unilateral hip 31.1% (N = 151). A total of 35.2% (N = 159) of patients required pain management (PM) for OA at 12 months. Of these, 90% (N = 144) required only INI and 5.6% (N = 9) required PM only. Baseline and postoperative BMI were associated to need for INI. At 12 months, the 66.7% (N = 301) who did not require INI had a baseline BMI of 44.70 ± 8.22 and total weight loss percent (TWL%) of 14.29 ± 13 (P = 0.05; 95% CI 0.96-1.00). LSG patients were the majority compared to other procedures (44.5%; N = 134). On the other hand, 64.3% (N = 175) did not require INI at 24 months and had a baseline BMI of 17.82±17.4 and TWL% of 2.43 ± 6 (P = 0.003; 95% CI 1.04-1.25). The risk to require INI was reduced by 69.9% at 12 months and 80% at 24 months. Need for pain medications at 12 months was reduced by 96.9%. CONCLUSION: According to this study data, bariatric surgery reduces the need for INI in patients with OA. The effect seems to be related to the amount of weight loss. Additional studies conducted on a larger scale are necessary to validate findings.

Using indigenous knowledge to link hyper-temporal land cover mapping with land use in the Venezuelan Amazon: "The Forest Pulse" / Utilización de conocimiento indígena para relacionar el mapeado hiper-temporal de coberturas de suelo con el uso del territorio en el Amazonas venezolano: "El Pulso del Bosque"

Abstract:Remote sensing and traditional ecological knowledge (TEK) can be combined to advance conservation of remote tropical regions, e.g. Amazonia, where intensive in situ surveys are often not possible. Integrating TEK into monitoring and management of these areas allows for community participation, as well as for offering novel insights into sustainable resource use. In this study, we developed a 250 m resolution land-cover map of the Western Guyana Shield (Venezuela) based on remote sensing, and used TEK to validate its relevance for indigenous livelihoods and land uses. We first employed a hyper-temporal remotely sensed vegetation index to derive a land classification system. During a 1 300 km, eight day fluvial expedition in roadless areas in the Amazonas State (Venezuela), we visited six indigenous communities who provided geo-referenced data on hunting, fishing and farming activities. We overlaid these TEK data onto the land classification map, to link land classes with indigenous use. We characterized land classes using patterns of greenness temporal change and topo-hydrological information, and proposed 12 land-cover types, grouped into five main landscapes: 1) water bodies; 2) open lands/forest edges; 3) evergreen forests; 4) submontane semideciduous forests, and 5) cloud forests. Each land cover class was identified with a pulsating profile describing temporal changes in greenness, hence we labelled our map as "The Forest Pulse". These greenness profiles showed a slightly increasing trend, for the period 2000 to 2009, in the land classes representing grassland and scrubland, and a slightly decreasing trend in the classes representing forests. This finding is consistent with a gain in carbon in grassland as a consequence of climate warming, and also with some loss of vegetation in the forests. Thus, our classification shows potential to assess future effects of climate change on landscape. Several classes were significantly connected with agriculture, fishing, overall hunting, and more specifically the hunting of primates, Mazama americana, Dasyprocta fuliginosa, and Tayassu pecari. Our results showed that TEK-based approaches can serve as a basis for validating the livelihood relevance of landscapes in high-value conservation areas, which can form the basis for furthering the management of natural resources in these regions. Rev. Biol. Trop. 64 (4): 1661-1682. Epub 2016 December 01.

Resumen:La teledetección y el conocimiento ecológico tradicional (CET) se pueden combinar para avanzar en la conservación de regiones tropicales remotas como la Amazonía, donde la toma de datos intensiva in situ a menudo es imposible. Integrar el CET en el seguimiento y el manejo de estas áreas permite la participación de la comunidad, y ofrece nuevos puntos de vista sobre el uso sostenible de los recursos naturales. En este estudio se desarrolla un mapa de cobertura del suelo del Escudo Guayanés (Venezuela), con una resolución espacial de 250 m, basado en datos de teledetección, y se utiliza el CET para validar su relevancia en relación con la subsistencia de los pueblos indígenas y el uso que éstos hacen del territorio. En primer lugar se ha empleado un índice de vegetación basado en teledetección hiper-temporal para realizar una clasificación del territorio. Durante una expedición fluvial de 8 días, a lo largo de 1 300 km por áreas sin carreteras en el Estado Amazonas (Venezuela), se han visitado seis comunidades que han proporcionado datos geo-referenciados sobre sus actividades cinegéticas, pesqueras y agrícolas. Estos datos de CET se han superpuesto al mapa de clasificación, con el fin de relacionar las clases de coberturas con los usos indígenas. Se han caracterizado las clases de cobertura en función de patrones de cambio temporal del verdor y la topo-hidrografía, y se han propuesto 12 tipos de cobertura del suelo, agrupadas en cinco tipos principales de paisaje: 1) masas de agua; 2) campo abierto/ márgenes del bosque; 3) bosques siempre-verdes; 4) bosques semi-caducifolios submontanos; y 5) bosques nublados. Cada clase de cobertura del suelo se ha identificado con un perfil pulsátil que describe cambios temporales en el verdor, de ahí que el mapa haya sido titulado "El Pulso del Bosque". Estos perfiles de verdor han mostrado una tendencia ligeramente ascendente, durante el periodo 2000 a 2009, en las clases que representan pastizales y zonas de matorral, así como una tendencia ligeramente decreciente en las clases que representan bosques. Este hallazgo es compatible con la ganancia de carbono en los pastizales como consecuencia del calentamiento del clima, y también con una cierta pérdida de vegetación en los bosques. De este modo, nuestra clasificación muestra potencial para la evaluación de efectos futuros del cambio climático sobre el paisaje. Algunas clases han resultado estar significativamente relacionadas con la agricultura, la pesca, la caza como práctica general, y más concretamente con la caza de primates, de Mazama Americana, Dasyprocta fuliginosa, y Tayassu pecari. Los resultados demuestran la utilidad de las aproximaciones basadas en CET como base para validar la importancia del paisaje, en áreas con alto valor de conservación, para la supervivencia de las personas, lo que proporciona una base para avanzar en el manejo de los recursos naturales en estas regiones.

Using indigenous knowledge to link hyper-temporal land cover mapping with land use in the Venezuelan Amazon: "The Forest Pulse".

Remote sensing and traditional ecological knowledge (TEK) can be combined to advance conservation of remote tropical regions, e.g. Amazonia, where intensive in situ surveys are often not possible. Integrating TEK into monitoring and management of these areas allows for community participation, as well as for offering novel insights into sustainable resource use. In this study, we developed a 250 m resolution land-cover map of the Western Guyana Shield (Venezuela) based on remote sensing, and used TEK to validate its relevance for indigenous livelihoods and land uses. We first employed a hyper-temporal remotely sensed vegetation index to derive a land classification system. During a 1 300 km, eight day fluvial expedition in roadless areas in the Amazonas State (Venezuela), we visited six indigenous communities who provided geo-referenced data on hunting, fishing and farming activities. We overlaid these TEK data onto the land classification map, to link land classes with indigenous use. We characterized land classes using patterns of greenness temporal change and topo-hydrological information, and proposed 12 land-cover types, grouped into five main landscapes: 1) water bodies; 2) open lands/forest edges; 3) evergreen forests; 4) submontane semideciduous forests, and 5) cloud forests. Each land cover class was identified with a pulsating profile describing temporal changes in greenness, hence we labelled our map as "The Forest Pulse". These greenness profiles showed a slightly increasing trend, for the period 2000 to 2009, in the land classes representing grassland and scrubland, and a slightly decreasing trend in the classes representing forests. This finding is consistent with a gain in carbon in grassland as a consequence of climate warming, and also with some loss of vegetation in the forests. Thus, our classification shows potential to assess future effects of climate change on landscape. Several classes were significantly connected with agriculture, fishing, overall hunting, and more specifically the hunting of primates, Mazama americana, Dasyprocta fuliginosa, and Tayassu pecari. Our results showed that TEK-based approaches can serve as a basis for validating the livelihood relevance of landscapes in high-value conservation areas, which can form the basis for furthering the management of natural resources in these regions.

Cirugía del carcinoma mamario revisión de 20 años / Surgery of breast cancer twenty years review

Exponer los diferentes tratamientos quirúrgicos del carcinoma de mama realizados en los últimos veinte años y las características clínico-patológicas tumorales. Estudio descriptivo, retrospectivo de pacientes vistos en el lapso comprendido entre junio de 1990 a diciembre de 2009. Se evaluó la procedencia, edad, mama afectada, cuadrante, forma de diagnóstico, tipo histológico, estadio clínico, tratamiento, intervalo libre de enfermedad, recidiva, tiempo de seguimiento. 446 casos, edad promedio 54,91 años (DS± 13,03, rango 22 - 91 años). La mama izquierda presentó lesión tumoral más frecuente. Predominó estadio II. Tipo histológico mayoritario fue carcinoma ductal infiltrante. Los casos avanzados recibieron quimioterapia neoadyuvante, la mayoría de los demás tratamiento adyuvante. El procedimiento quirúrgico fue variable entre mastectomía parcial oncológica, mastectomía radical modificada, cirugía oncoplástica, predominando la primera con 55,83%. El 4,41% de los pacientes presentó recidivas locales, intervalo libre de enfermedad fue 34,52 meses (DS ± 11,31 rango, 10 - 130) después del tratamiento quirúrgico. En relación al seguimiento, se mantienen 408 pacientes (91,47%), con una media de 54,34 meses (DS ± 48,21, rango 1-240 meses) fallecieron 78 pacientes, 22 por comorbilidad (5,39%) y 56 por el cáncer (13,72%), el tiempo de sobrevida fue 42,40 meses (DS ± 25,62, rango 10-132 m.). El carcinoma de mama presenta una historia natural variable, heterogénea, aún después del tratamiento quirúrgico y adyuvante, hay que evitar que la lesión neoplásica progrese a estadios avanzados, y podamos efectuar un diagnóstico temprano

Discuss the different surgical treatments of breast cancer conducted in the last twenty years and clinical and pathological tumor characteristics. We performed descriptive, retrospective study of patients by diagnosis of mammary carcinoma seen in June 1990 to December 2009. The variables were evaluated: origin, age, affected breast, quadrant, form of diagnosis, histological type, clinical stage, treatment, free interval of disease, recurrence, follow-up time. Review 446 cases, the average age was 54.91 years (STD +/- 13.03, range 22 to 91). The left breast made the tumor more frequently. More than half of patients were in stage II at diagnosis. The predominant histological type was infiltrating ductal carcinoma without other specification. More patients received neo-adjuvant and adjuvant chemotherapy. The surgicalprocedure varied between partial oncologic mastectomies, modified radical mastectomy, oncoplastic surgery, dominating the first one with 55.83 %. 4.41 % the patients had local relapses with a free interval disease of 34.52 months (STD +/- 11.31 r: 10-130) after surgical treatment. Follow-up has been achieving 408 patients (91.47 %), the average was 54.34 month (Std +/- 48.21, range 1-240 m). 78 patients died, 22 for comorbility (5.39 %) and 56 for the cancer (13.72%), the survival average time was 42.40 months (STD +/- 25.62, range 10-132 m). The breast cancer presents highly variable natural history even after surgical and the adjuvant treatment; we must prevent the neoplastic lesion to progress to advanced stages. Early diagnosis is very important

Cirugía laparo-endoscópica por puerto único (LESS): experiencia hospitalaria (21 casos) / Laparo-endoscopic single site surgery (LESS): public hospital experience (21 cases)

La tendencia global es la de evolucionar la cirugía minimamente invasiva (laparoscópica) a una menos invasiva aun, la razón: menos daño a la pared abdominal, menos complicaciones relacionadas con la colocación de portales, y mejor resultado cosmético. La cirugía laparoendoscópica por puerto único (LESS) permite utilizar la experiencia y los instrumentos de la laparoscopia convencional, manteniendo costos aceptables, y permitiendo que la técnica sea reproducible. Entre junio y noviembre del 2010 en el Servicio de Cirugía General del Hospital IVSS "Dr. Angel Larralde" se realizó un estudio prospectivo de corte longitudinal, descriptivo y quasi-experimental en 21 pacientes ejecutándose 13 colecistectomías, 6 apendicectomías, 1 cura de hernia inguinal bilateral (TEP), 1 cistectomía + rafia de ovario, usando unicamente dos dispositivos SILS®. Los tiempos quirúrgicos estuvieron acordes con los estipulados por la literatura internacional siendo de 73,5 minutos (± 32,7 min r: 37-137) para las colecistectomías y de 50,6 minutos (± 24,1 min r: 28-93) para las apendicectomías. En 4 pacientes debió realizarse conversión a puertos adicionales. No hubo complicaciones durante el intraoperatorio y todos los pacientes egresados antes de las 24 horas. Se pudo hacer seguimiento presencial en 15 (71,4%) pacientes, por un período de 39,06 días (± 32,87). La infección del sitio quirúrgico (1 caso) y los seromas (3 casos) fueron las únicas complicacines en el postoperatorio. En promedio según la escala análoga del dolor, el mismo fue de 3,9 para el día de mayor dolor, el número de tabletas de ketoprofeno ingeridas en el postoperatorio fue de 4 (± 1,5). el resultado cosmético ya es satisfactorio a las dos semanas. La cirugía LESS es un procedimiento seguro, poco invasivo, y de baja morbilidad. Nuestra experiencia demuestra que esta cirugía puede ser reproducida a nivel hospitalario.

The overall trend is to develop minimally invasive surgery (laparoscopic) to an even less invasive one, the reason: less damage to the abdominal wall, fewer complications related to portal placement, better comestic effect. laparo-endoscopic sigle site surgery (LESS) can use the experience and instruments of conventional laparoscopy, while maintaining acceptable costs, and allow the technique to be reproduced. Between July and November 2010 in the General Surgery Sevice of "Dr. Angel Larralde" Hospital, was performed a prospective, descriptive and quasi-experimental trial in 21 patients. Performing 13 cholecystectomies, 6 appendectomies, 1 bilateral inguinal hernia cure (TEP), 1 ovarian cystectomy, using only two SILS® device. Surgical times were consistent with the ranges set by the international literature being 73,5 minutes (± 32.7 min r: 37-137) for the cholecystectomies and 50,6 minutes (± 24,1 min r: 28-93) for the appendectomies group, 4 patients had to be converted to additional ports, there were no complications during surgery, all patients were discharged before 24 hours, 15 (71,4%) patients were followed up for an average period of 39,06 days (± 32,87). Surgical site infection (1 patients) and seroma (three patients) were the only complications in the postoperative period, in average the analog pain scale was 3,9 the day of most pain, patients ingested 4 tablets (±1,53) of ketoprofen in the postoperative period. Cosmetic results were satisfactory in two weeks. LESS Surgery is a safe, minimally invasive, and low morbidity procedure. The initial develoment of our experience shows that surgery can be reproduced in hospitals of the developing countries.

Ganglio centinela en el carcinoma mamario / Sentinel lymph node in patients with breast cancer

Evaluar la efectividad del ganglio centinela en predecir el estado ganglionar de la axila en pacientes con cáncer de mama. Se incluyeron 50 pacientes consecutivas de la Unidad de Mastología del Centro Medico "Dr. Rafael Guerra Méndez" de la Ciudad de Valencia entre mayo 2001 y noviembre 2007, con diagnóstico histopatológico previo, con tumores menores de 2 cm y axila clínicamente negativa. Se inyectaron 1-1,5 milicurie de tecnecio 99 usando como vehículo el sulfuro coloidal entre 4 y 12 horas antes del acto quirúrgico, y 2 ml de azul patente, en forma subareolar, veinte minutos antes de la exploración axilar, posterior a la intubación anestésica, procediendo luego a resecar el ganclio centinela axilar y a efectuarle una biopsia intraoperatoria. 49/50 pacientes (98 por ciento) de las pacientes fueron sometidas a cirugía preservadora, con un franco predominio del uso de dos incisiones (88 por ciento). El ganglio centinela fue identificado en 92 por ciento de los casos, el 24 por ciento de la muestra tuvo axila positiva. En 42 por ciento se encontró un solo ganglio centinela, en otro 42 por ciento dos ganglios centinelas, en 8 por ciento se encontraron 3 ganglios centinelas, y en 4 casos (8 por ciento) el ganglio centinela no fue identificado por ninguna de las dos técnicas. El centinela fue el único ganglio positivo en 72.7 por ciento de las pacientes sometidas a vaciamiento axilar. En un período de seguimiento promedio de 39.02 meses (DS ± 25.59) con un rango de 3 a 79 meses. No hemos tenido ningún falso negativo. La determinación del ganglio centinela es adecuada para predecir el estado axilar, siendo ideal el empleo de la doble técnica, es decir tecnecio 99 y azul patente, de esta forma podemos evitar en las pacientes estadio I, IIa hasta un 76 por ciento de vaciamientos axilares, una vez cumplida la curva de aprendizaje.