The potential role of imaging techniques in avoiding neck dissection during salvage surgery after head and neck carcinoma treated with bioradiotherapy.

OBJECTIVE: This study aimed to evaluate the effectiveness of computed tomography and positron emission tomography-computed tomography prior to salvage surgery after head and neck carcinoma treated with bioradiotherapy and to look at the role of neck dissection in this setting. METHOD: This study was a retrospective chart review of a series of consecutive patients with locally advanced head and neck squamous cell carcinoma treated with bioradiotherapy. Radiological and pathological stages were compared to evaluate the accuracy of computed tomography and positron emission tomography-computed tomography in detecting occult neck metastasis in the context of recurrence of primary tumour. In order to assess the impact of neck dissection on survival, Kaplan-Meier survival curves after salvage surgery with and without neck dissection were derived. RESULTS: A total of 268 patients were identified, of which 22 underwent salvage surgery. The negative predictive value of computed tomography and positron emission tomography-computed tomography was excellent. Neck dissection did not represent an improvement on overall, disease specific and regional recurrence free survival (p = 0.67, p = 0.91 and p = 0.62, respectively) amongst clinically and radiologically negative necks. CONCLUSION: Conservative treatment of the neck should be considered when dealing with patients with primary site recurrence or persistent disease after bioradiotherapy without evidence of neck disease.

[Vascular reconstruction for limb preservation during sarcoma surgery: a case series and a management algorithm]. / Reconstrucción vascular durante la cirugía de sarcomas para la preservación de extremidades: serie de casos y algoritmo de manejo.

OBJECTIVE: To evaluate the results of vascular reconstruction in soft tissue sarcoma surgery and establish an algorithm based on current evidence. MATERIAL AND METHODS: We studied patients undergoing soft-tissue sarcoma in a tertiary hospital. A retrospective review of 8 cases was carried out, analysing the demographics, surgical planning, complications, disease-free survival and bypass patency. RESULTS: Successful limb preservation was observed in all patients, and the bypass remained patent in all cases. The mean follow-up was 38.4 months average, with 87.5% survival and no recurrences. CONCLUSIONS: The involvement of major vascular structures in soft tissue sarcomas of the limbs does not necessarily exclude resectability. In selected cases, resection is possible with vascular reconstruction and limb preservation. However, multidisciplinary planning is needed.

Indications of microsurgery in soft tissue sarcomas.

UNLABELLED: Sarcomas are uncommon tumors and free-margin surgical resection remains the single most important treatment in the curative therapy of soft tissue sarcomas. Refinements in surgical techniques have led to increased function preservation and limb salvage. PATIENTS AND METHODS: The records of patients (n = 41) who underwent microsurgical soft tissue reconstruction subsequent to resection of soft tissue sarcoma during the period 1998 to 2010 were reviewed and compared with a general nonmicrosurgery group (n = 188) in relation to clinicopathological characteristics, surgical procedures, postoperative complications, time until start of adjuvant radiation, functional outcome (Toronto Extremity Salvage Score, TESS), local recurrence, free survival, and disease-specific survival. RESULTS: Forty-one patients (age range: 23 to 95 years) received a total of 42 free flaps. When compared with the general nonmicrosurgery group, these patients presented significant differences with regard to location, histological grade, and neoadjuvant treatments. Complications were encountered in 10 cases, including 3 patients with complete flap loss and 1 patient with partial flap loss; other complications were cervical fistulae, knee arthritis, nonconsolidation, and wound infection. Extremity salvage was achieved in 90% (19/21) of limb sarcomas, with these patients showing adequate postoperative ambulation (TESS 77 ± 16) and adequate use of the upper extremity (TESS 66 ± 26). Two patients underwent amputation after recurrence. Disease-specific survival rates at 5 and 10 years were 79.49% and 76.93%, respectively. CONCLUSION: The microsurgical repair of sarcoma defects is a reliable option that, though not free of complications, is necessary in selected cases such as patients receiving neoadjuvant treatments and those with head and neck location and high-grade tumors. The procedure enables both adequate oncosurgical resection and function preservation. Our microsurgical sarcoma reconstruction data, based on an observation period of 12 years and presenting the results of 42 free tissue transfers in 41 patients, adds further evidence to the previously published smaller series.

Pyoderma gangrenosum in breast reconstruction.

We present two cases of immediate breast reconstruction that were diagnosed postoperatively with pyoderma gangrenosum. Given that the disease is uncommon and difficult to diagnose, the required treatment was delayed. Control was obtained after correct treatment and both cases healed.

Use of angioscanning in the surgical planning of perforator flaps in the lower extremities.

BACKGROUND: This is one of the few studies in the literature to describe angio-computed tomography (CT) as a planning tool in perforator flap surgery in the lower extremities. METHODS: Eighteen consecutive patients undergoing a perforator flap for lower-extremity reconstruction underwent preoperative CT angiography between September 2007 and November 2009. Eleven received propeller-type flaps, four medial sural artery perforator (MSAP) flaps, two lateral sural artery perforator (LSAP) flaps and one anterolateral thigh (ALT) flap. RESULTS: Preoperative CT angiography was highly specific (100%) and sensitive in mapping and visualising perforators in the lower limb. There were hardly any flap failures after angio-CT, and operative findings always correlated perfectly with preoperative imaging. Postoperative recoveries were uneventful except in three cases of peroneal artery perforator flaps that presented partial necrosis due to venous congestion. CONCLUSIONS: CT angiography is a valuable imaging tool for the preoperative assessment of the donor-site vascular supply for lower-extremity flaps. We recommend use of preoperative angio-CT for imaging vascular anatomy of the lower limb before defect reconstruction, especially in traumatic patients and patients with peripheral vascular disease. Its use can also reduce intra-operative dissection time and minimises surgical error in the identification of the vascular anatomy.

Surgical management of the acromegalic face.

We describe the planning and one-stage surgical correction of acromegalic facies. Patients with this condition may benefit from a relatively short treatment to solve both their aspect and their buccal functional problems. The aggressiveness of the surgical treatment, along with the characteristics of the disease, may make the permeability of the airway during the postoperative period problematic; therefore, we believe that temporary tracheostomy is indicated.

[Hematogenous pubic osteoarthritis]. / Osteoartritis pubiana hematógena.

Pubic osteoarthritis is a little known pathological entity with a very controversial etiology. We present four cases of public osteoarthritis in which the infectious etiology was hematogeneous. The causal germs were: Staphilococcus aureus, Pseudomona aeruginosa, Mycobacterium tuberculosis and Brucella melitensis. In the first three cases, a surgical approach was used, allowing us to establish the etiological diagnosis of the process and to perform the local debridement. In the case of brucellar etiology, an isolated medical treatment was applied, according to the therapeutical guidelines recommended for brucellar bone infections. We have not observed recurrence of the septic process in any of the four cases, with a follow-up period ranging from one to three years.

[Fistula of the pyriform sinus. Report of 2 cases]. / Fístula del sinus piriforme. A propósito de dos casos.

The authors present two patients of 8 and 11 years of age that presented a left sided piriform sinus fistula diagnosed by esophagram and surgically treated in our centre. One had been operated previously with a diagnosis of relapsing thyroglossal quist on five occasions. The piriform sinus fistula is a recently recognised entity as cause of thyroiditis and suppurative cervical infections in the pediatric age. Communicated for the first time in the literature in 1957 by Japanese authors, it was not until 1973 that Tucker published for the first time in English a case of recurrent cervical abscess caused by a fistula initiated in the piriform sinus. Until now very few cases have been published. The majority of authors consider it to be an embryological residue of the third or fourth pharyngeal pouch. The key to diagnosis is to bear it in mind whenever a patient presents suppurative thyroiditis or repetitive cervical infections, principally of the left side. An esophagram is necessary to demonstrate the course of the fistula. In cases of thyroiditis a thyroidal gammagraphy will allow vision of a cold zone in the upper third of the affected lobe. Treatment consists of total extirpation of the fistula and affected portion of the thyroidal lobe, once the infection has been solutioned. Before intervention it is important to collocate a tube in the fistula's course by means of a direct microlaryngoscopy which will serve as guide and allow the injection of methylene blue.