Use of “House” Advancement Flap in Anorectal Diseases

BACKGROUND: A retrospective review of 28 patients who had "house flap" anoplasty was carried out to evaluate the therapeutic effectiveness of the procedure. METHODS: House flap anoplasty was performed at Istanbul University Cerrahpasa Medical School, General Surgery Department, in 28 patients over 4 years. Indications were chronic anal fissure, anal stenosis, high transsphincteric fistula, low rectovaginal fistula, anal neoplasia, and obstetric third-degree perineal tear and incontinence. After rectangular excision of the anal or perianal lesion, the "walls" and "roof" of the house flap were incised to the depth of ischiorectal fat. The "base" of this house-shaped flap was then fixed to the top of the excised area. RESULTS: Median postoperative hospital stay was 4.86 (range = 2-12) days. Postoperative complications included three patients with minimal wound dehiscence and one with rectovaginal fistula recurrence. At a median follow-up of 26.4 (range = 1-46) months, excluding the patient with recurrence, all patients were satisfied with house flap anoplasty. CONCLUSION: House advancement flap anoplasty is a relatively simple procedure, combining the beneficial features of rectangular flaps and V-Y plasties. It can be used in nearly all types of anoderm deficiencies with a high rate of success and patient satisfaction.     

Contractile response of different segments of the latissimus dorsi muscle to chronic stimulation

Objective: This study was planned to investigate if there is any difference in terms of the muscle force between the distal and proximal segments of the latissimus dorsi muscle.Subjects and Methods: An implantable mock circulation system was placed around the latissimus dorsi muscle. The wrapping procedure around the implantable mock circulation was performed by using two different latissimus dorsi muscle segments. In group 1, the very proximal and in group 2, very distal part of the latissimus dorsi were wrapped. The main differences is the blood supply to the distal part of the latissimus dorsi that was interrupted during dissection. During the stimulation period which lasted 120 minutes, the pressure developed in this system and adenosine triphosphate (ATP) levels were measured.Results: The stimulation at 20 Hz did not result in any change in pressure and metabolic data. When it was switched to 43 and 85 Hz, ATP levels decreased with a resultant drop in pressure in group 2. However ATP levels were 15.9±2.2 μmol/gr and 14.8±2.5 μmol/gr in group 1, 12.0±1.4 μmol/gr and 6.1±1.2 μmol/gr in group 2 at 43 and 85 Hz respectively (p<0.05) at the end of the 90 minutes. The pressures at the same time interval were 89±11 and 102±7 mmHg in group 1, 61±7 and 65±8 mmHg in group 2 (p<0.05).Conclusion: In this study, we demonstrated that changes in the distal segment of the latissimus dorsi muscle affects its performance in terms of metabolic and pressure changes during high frequency electrical stimulation at 43 and 85 Hz.     

Surgical treatment of acute arch dissection.

OBJECTIVES: Acute type A arch dissections are rare and no consensus has been reached on their surgical treatment. We studied perioperative risk factors for mortality in arch dissection patients. METHODS: Between October 1995 and October 2001, 108 patients with acute type A dissection were operated on, of whom 16 had acute arch dissections. Their mean age was 58 +/- 9 (44-77). Surgery involved total arch replacement in 4, hemiarch replacement in 10, and intimal tear repair with pledgeted sutures and ascending aortic replacement in 2. RESULTS: One patient who underwent total arch replacement died intraoperatively due to bleeding. Both patients who underwent ascending aortic replacement and primary repair of arch tears died 2 days postoperatively, 1 due to bleeding, and the other due to multiorgan failure. In-hospital mortality was thus 18.75%, or 3 of 16. All 3 had cardiac tamponade preoperatively. The 13 survivors were discharged after a mean hospital stay of 11 +/- 6 days. Mean follow-up was 38 +/- 25 months, from 3 months to 6 years. One patient died due to graft infection 3 months postoperatively, but the remaining 12 remain in good condition. Univariate predictors of in-hospital mortality were the type of surgery (primary intimal tear repair) (p = 0.027) and preoperative cardiac tamponade (p = 0.007). CONCLUSION: Surgical treatment of acute type A-arch dissections can be done with reasonable mortality and mid-term survival comparable with those of other subgroups with acute type A dissection. As with series of arch dissections, our patient population is too small to draw specific conclusions, but our experience leads us to conclude that the sites of intimal tears should be resected in acute type A arch dissection.     

Surgical anatomy of the external branch of the superior laryngeal nerve

Palsy of the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery is an important complication reported with varying frequency. This study was carried out to investigate the relationship between the EBSLN, the upper part of the thyroid gland and the inferior constrictor muscle of the pharynx (IC), and also to define consistent landmarks for identifying and preserving the EBSLN. Forty neck halves of 20 cadavers were dissected. Measurements were obtained between the crossing point of the EBSLN with the superior thyroid artery (STA) and the upper pole of the thyroid gland, the point where EBSLN penetrates the IC and the inferior thyroid tubercle, and the middle point of the oblique line of the thyroid cartilage, and the EBSLN. In 22.5%, the EBSLN crossed the STA more than 1 cm above the upper pole of the thyroid gland (Type I of Cernea et al. [1992a] Head Neck 14:380-383). In 60%, the EBSLN crossed the STA less than 1 cm above the upper pole of the thyroid gland (Type IIa of Cernea et al. [1992a] Head Neck 14:380-383). In 17.5%, the EBSLN crossed the STA under the upper pole of the thyroid gland (Type IIb of Cernea et al. [1992a], Head Neck 14:380-383). In 22.5%, the full course of the nerve was superficial to the IC (Type 1 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In 67.5%, the nerve penetrated the IC (Type 2 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In 10%, the nerve could not be identified at the lateral side of the IC (Type 3 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In conclusion, it is possible to identify the nerve superficial to the IC in 90% of specimens on average. Knowledge of the relationship between the EBSLN, IC, inferior thyroid tubercle, oblique line of the thyroid cartilage and the sternothyroid muscle will be useful for the surgeon in avoiding unexpected complications.     

Does fixation method affects temporomandibular joints after mandibular advancement?

Purpose

Sagittal split ramus osteotomy (SSRO) is a standard procedure in which miniplates and screws are used to achieve stabilization. Although the titanium plate and screw fixation system is stable, resorbable fixation systems are also used. There is currently no consensus on the ideal fixation technique for SSRO procedures and its effect on the condyle. We aimed to evaluate the stress distribution on temporomandibular joints (TMJ).

Supravalvular aortic stenosis: repair with the Yacoub procedure

Preservation and restoration of the aortic valve and root, as well as relief of the stenosis, is of paramount importance during surgical treatment of supravalvular aortic stenosis. A 23-year-old woman with a history of medically treated endocarditis presented with progressive fatigue and dyspnea on exertion. A diagnostic work-up revealed multiple stenoses and a small saccular aneurysm involving the diffusely hypoplastic ascending aorta, in addition to severe mitral regurgitation. The aortic root and ascending aorta were replaced using the Yacoub remodeling technique. Hemiarch replacement was performed under hypothermic circulatory arrest, and the mitral valve replaced. By using a remodeling technique, it was possible to augment the left sinus of Valsalva, to obtain the largest diameter at the sinotubular junction, and to adjust the spatial relationship of commissures that renders good leaflet coaptation. Although extended aortoplasty has been used widely for supravalvular aortic stenosis, the Yacoub procedure is a good option in diffuse type hypoplasia with multiple stenosis of the ascending aorta.