La greffe de visage,archétype de l’innovation microchirurgicale

Is innovation breaking of the way of thinking, breaker of taboos, concretisation of chimeras or simple benefit of an ineluctable evolution? The surgical act should be considered as innovation itself? From the first facial allotransplantation, innovation is declined in various ways, which could constitute the different answers regarding the planning and management to prepare such surgery, the realisation of the transplantation and also the multiple developments in terms of science and medicine. It is exactly in that meaning that could be really mentioned the term archetypal.     

Validación de un modelo de riesgo de evisceración

Introduction

The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscence's risk in patients who underwent midline laparotomy incisions.

Materials and methods

Observational longitudinal retrospective study. Sample: Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital–Parc Taulí’s Health and University Corporation–Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence. Independent variables: Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence.

Results

Sample: 176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P<.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P<.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64).

Conclusion

The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.     

Sistema GRADE: clasificación de la calidad de la evidencia y graduación de la fuerza de la recomendación

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.     

Implicaciones de los nuevos diseños protésicos de baja densidad en la mejora de la reparación de defectos herniarios

The use of a prosthetic material to treat abdominal and/or thoracic disease has, to a great extent, resolved the problem created by the tissue defect itself and complications of recurrence. The most commonly used of these materials has been polypropylene in the form of a reticular mesh. This biomaterial, which boasts optimal biocompatibility, has been the object of constant modification aimed at better adapting it to the functional needs of the host tissue. Hence, the classic prostheses, nowadays known as heavyweights, are being gradually replaced by lighter materials with a simple spatial configuration and, more importantly, with a larger pore size (lightweight prostheses). Lightweight meshes are able to preserve abdominal wall compliance by generating less post-implant fibrosis and rigidity. However, further studies are still needed to achieve the ideal balance between material density and pore size. These two factors will determine the behaviour of these new prosthetic designs.     

Myocardite révélant une maladie de Still de l’adulte

Adult onset Still's disease is an inflammatory disorder characterized by daily spiking high fevers, arthritis and an evanescent rash. It is a rare disease of unknown aetiology and can be life-threatening. We present a case of adult onset Still's disease associated with myocarditis requiring the use of invasive ventilation, in which the patient responded well to systemic steroids.     

Colgajo de cresta ilíaca de doble pedículo vascular

Introduction

The iliac crest flap is commonly used in reconstructions of the head and neck. The vascularisation of this region depends on the deep circumflex iliac artery and vein (ACIP/VCIP). The present study describes for the first time, the simultaneous use of the deep and superficial circumflex iliac systems to obtain an iliac crest flap for head and neck reconstructions.

Material and method

Ten inguinal regions were dissected in five cadavers in the Human Anatomy and Embryology Unit of the Faculty of Medicine of the Rovira i Virgili University. In the period 2005-2007, three patients required mandibular reconstruction with a microvascularised iliac crest osteocutaneous flap at the Maxillofacial Surgery Unit of the Joan XXIII University Hospital.

Results

The 3 cases showed a favourable outcome. This “supercharging” variation guarantees the perfusion to the skin flap, provides a better three-dimensional arrangement of the soft tissue and lowers the morbidity at the donor site, as much less internal oblique muscle cuff is harvested.

Conclusions

This technique may be of great interest in the reconstruction of complex maxillofacial defects instead of having to carry out a vascular dissection and its extra anastomosis.     

Evolución psicológica de los pacientes afectos de obesidad mórbida intervenidos mediante una gastrectomía tubular

Background

The aim of this study is to observe the psychological changes at one year postop in a group of patients undergoing laparoscopic vertical sleeve gastrectomy (GVL) and multidisciplinary follow- up.

Methods

A total of 46 patients with a BMI-35 or higher, who were selected for GVL, completed psychological testing. After GVL surgery, patients received psychological, nutritional, and medical attention during 12 months, and they retook the same tests.

Results

Psychological tests showed an improvement on almost all scales tested, except perfectionism. The most significant change was in the benchmark for Eating Disorders with an improvement of 89% for bulimia (P<.01), and 55% for body dissatisfaction (P<.01) and ineffectiveness (P<.01). In quality of life there was an improvement of 57% in the change in health status (P<.01).

Conclusion

During our study, a protocol involving GVL and multidisciplinary follow-ups seems proved to be an effective intervention for improving bulimic symptoms and quality of living. The results of these psychological changes are similar to Roux-en-Y Gastric bypass but different to vertical banded gastroplasty or adjustable gastric band, according to previous studies. However, long-term studies are necessary to confirm this trend.     

Complicaciones y nivel de satisfacción tras la realización de una dermolipectomía y abdominoplastia después de efectuar una cirugía bariátrica

Background

Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction.

Material and methods

Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003-2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated.

Results

a) Complications: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%).b) Satisfaction rating: 1) very satisfied: 51.4%, 2) satisfied: 31.9%, 3) dissatisfied: 8.3%, 4) very dissatisfied: 8.3%.c) The presence of complications was significantly associated with patients’ satisfaction, reoperation rate and longer hospital stays (P<.001).

Conclusions

Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients’ satisfaction was negatively influenced by complication occurrence and not by the aesthetic results.     

Influence du mode de ventilation sur la variation respiratoire de la pression pulsée artérielle : étude randomisée

Objective

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.

Study design

Double-blind randomized study, cross-over design.

Patients

Patients in intensive care unit after a cardiac surgery.

Method

Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.

Results

Among the 26 patients analyzed, mean ΔPP value was de 14.0 ± 7.3% in VVC and 11.8 ± 6.2% in VPC (P < 0,0001). On Bland-Altman representation, mean bias was +2.2 ± 2.3% and inferior and superior limits of agreement were respectively −2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.

Conclusion

ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.