Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap

IntroductionThe pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results.MethodsWe retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients.ResultsThere were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed.ConclusionsThe pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence.     

Maxillary-to-petrous internal carotid artery bypass: an anatomical feasibility study

The possibility for maxillary artery (MA) to petrous internal carotid artery (ICA) bypass was investigated. Five adult cadavers were dissected bilaterally. After zygomatic arch osteotomy, the coronoid process was sectioned at its base. An extensive infratemporal craniotomy was performed at the level of foramina ovale, rotundum and spinosum. The petrous portion of the ICA was exposed by drilling away the floor of the middle fossa, posterior to the foramen ovale and medial to the foramen spinosum. The MA was identified medial to the infratemporal crest and was followed in the pterygopalatine fossa, then transected at the origin of the infraorbital artery. The MA graft was brought posteromedially to reach the petrous ICA. The mean caliber of the MA before the origin of the infraorbital artery was 2.54±0.31 mm, 2.76±0.14 mm at the site of anastomosis, and 3.46±0.32 mm after giving off the middle meningeal artery. The average length of the MA between the middle meningeal artery and the infraorbital artery was 43.4±2.35 mm, and up to the site of anastomosis was 37.64±1.68 mm. We conclude that the length and diameter of the MA are sufficient for a tension-free anastomosis between MA and petrous ICA, and such a procedure could be used in the treatment of patients with tumors of the infratemporal fossa invading the high cervical ICA.

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Étude anatomique des possibilités de by-pass entre la partie pétreuse de l'artère carotide interne et l'artère maxillaire

Résumé La possibilité d'un by-pass entre l'artère maxillaire et la partie pétreuse de l'artère carotide interne a été étudiée. Cinq cadavres adultes ont été disséqués des deux côtés. Après ostéotomie de l'arcade zygomatique, le processus coronoïde était sectionné à sa base. Une large craniotomie infra-temporale était effectuée au niveau du foramen ovale, du foramen rond et du foramen épineux. La partie pétreuse de l'artère carotide interne était exposée par fraisage du plancher de la fosse cérébrale moyenne, en arrière du foramen ovale et en dedans du foramen épineux. L'artère maxillaire était identifiée en dedans de la crête infra-temporale et suivie dans la fosse ptérygo-palatine, puis sectionnée à l'origine de l'artère infra-orbitaire. Le greffon d'artère maxillaire était transposé en dedans et en arrière pour atteindre la partie pétreuse de l'artère carotide interne. Le calibre moyen de l'artère maxillaire était de 2,54±0,31 mm à l'origine de l'artère infra-orbitaire, 2,76±0,14 mm au niveau de l'anastomose, et 3,46±0,32 mm après la naissance à l'artère méningée moyenne. La longueur moyenne de l'artère maxillaire entre l'artère méningée moyenne et l'artère infra-orbitaire était de 43,4±2,35 mm et au-delà du site d'anastomose était de 37,64±1,68 mm. Nous en avons conclu que la longueur et le diamètre de l'artère maxillaire était suffisant pour une anastomose sans tension entre l'artère maxillaire et la partie pétreuse de l'artère carotide interne. Ainsi, une telle technique pourrait être utilisée pour le traitement de patients porteurs d'une tumeur de la fosse infra-temporale envahissant la partie cervicale haute de l'artère carotide interne.

     

Ideal Suggestions for Discharge Training and Telephone Counseling of Patients With Coronary Artery Bypass Graft Surgery: A Randomized Controlled and Experimental Study

BackgroundIn this context, discharge training and telephone counseling given to patients who underwent coronary artery bypass graft surgery increase the ability of patients to cope with and adapt to their self-care.MethodsThis study was a randomized controlled, experimental design. Both experimental and control groups consisted of 35 individuals with G*power analysis (n = 70). Patients in the experimental group were given discharge training and telephone counseling for two months. At the end of the process, data collection forms were administered to both groups for the last time. Necessary ethical approvals were taken and consent was taken from the patients.ResultsAfter the discharge training and telephone counseling given to the experimental group, the mean Exercise of Self-Care Agency Scale (ESCA) score of the patients increased by 13.94; the mean Coping and Adaptation Processing Scale (CAPS) increased by 13.6. The mean ESCA score of the control group increased by 7.86; the mean CAPS score increased by 9.14. The effect size that occurred for both groups was statistically significant (P < 0.05).ConclusionPositive results were achieved in the experimental group which received given discharge training and telephone counseling.Trial RegistrationClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT05104996","term_id":"NCT05104996"}}NCT05104996     

Application of Lidocaine Jelly on Chest Tubes to Reduce Pain Caused by Drainage Catheter after Coronary Artery Bypass Surgery

The objective of this study was to assess the effect of lidocaine jelly application to chest tubes on the intensity and duration of overall pain, chest tube site pain and the required analgesics for postoperative pain relief in coronary artery bypass graft (CABG) patients. For patients in group L, we applied sterile 2% lidocaine jelly on the chest tubes just before insertion, and for patients in group C, we applied normal saline. Overall visual analogue scale (VAS), maximal pain area with their VAS were documented postoperatively, and the frequency that button of patient-controlled analgesia was pressed (FPB) and total fentanyl consumption were assessed. The number of patients who complained that tube site was the most painful site was significantly higher in group C than in group L (85% vs. 30% at extubation, P<0.001). The overall VAS score was significantly higher in group C than in group L (39.14±12.49 vs. 27.74±13.76 at extubation, P=0.006). After all of the tubes were removed, the VAS score decreased more in group C (5.74±4.77, P<0.001) than in group L (3.05±2.48, P<0.001). FPB and total fentanyl consumption were significantly higher in group C than in group L (73.00, 59.00-78.00 vs. 34.00, 31.00-39.25, P<0.001; 2,214.65±37.01 vs. 1,720.19±361.63, P<0.001, respectively). Lidocaine jelly application is a very simple way to reduce postoperative pain by reducing chest tube site pain after CABG. (Clinical Trials Registry No. ACTRN 12611001215910)     

Sexual Activity After Bariatric Surgery: A Prospective Monocentric Study Using the PISQ-IR Questionnaire

IntroductionObesity can lead to pelvic floor disorders, interfering with women’s sexual life; Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association–Revised (PISQ-IR) is a new instrument to measure sexual life in women with pelvic floor disorders.AimsTo assess the utility of using PISQ-IR in morbidly obese women undergoing bariatric surgery and to show the improvement of bariatric surgery on sexuality.MethodsThis prospective monocentric study included all women who underwent bariatric surgery from June 2016–May 2017. Sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) was performed by 1 surgeon, and data were collected by 1 researcher. Demographics, medical history, number of deliveries, and type of bariatric surgery (SG or RYGB) were collected at baseline. At the 1-year follow-up consultation, postoperative complications, percentage of total body weight loss (TWL) and percentage excess weight loss were assessed. Questionnaires were given at baseline and at 1-year follow-up.Main Outcome MeasuresPostoperative complications and total weight loss were measured at the 1-year follow-up. Sexual activity, using the PISQ-IR, and pelvic organ prolapse, urinary incontinence, and anal incontinence, using the urinary symptom profile and PFDI (Pelvic Floor Distress Inventory) 20, were compared before surgery and at 1-year follow-up.Results72 patients were included at baseline, 54 (75%) were considered for final analysis (30 RYGB and 24 SG), and 51 patients were considered for PISQ-IR. The mean preoperative body mass index was 41 ± 5.4 kg/m², and mean age was 43 ± 11.8 years. Both procedures induced an important weight loss (mean TWL of 33%) and had a similar percentage of TWL for each procedure: 31 (15–46) for SG vs 34 (9–51) for RYGB. 9 patients (17 [6%]) became sexually active 1 year after surgery. For the sexually inactive population after 1 year, there was no differences in the PISQ-IR in the follow-up. When body mass index loss was >13 kg/m², a higher percentage of the sexually active population improved their different scores, and there were significant results for both global quality of life and desire (P = .026 and .046). The other questionnaires showed a significant decrease in urinary incontinence symptoms (P < .001) associated with weight loss, whereas there was no difference in terms of pelvic organ prolapse or anal incontinence.ConclusionPISQ-IR is a useful instrument to measure sexual function regarding pelvic floor disorders. Bariatric surgery improves sexual activity in obese women 1 year after surgery.Treacy PJ, Mazoyer C, Falagario U, et al. Sexual Activity After Bariatric Surgery: A Prospective Monocentric Study Using the PISQ-IR Questionnaire. J Sex Med 2019;16:1930–1937.     

一种可以避免血管再狭窄的双移植管搭桥方式的数值模拟

目的为改善冠状动脉旁路移植管的局部血流动力学,降低血管再狭窄的发生机率,研究一种可以避免血管再狭窄的双移植管搭桥方式。方法利用有限元分析方法,对传统模型和双移植管搭桥模型进行血流动力学模拟仿真,计算缝合区附近的流场、壁面切应力等血流动力学因素的分布情况。结果该双移植管搭桥具有较好的血流动力学分布,明显改善了主搭桥血管与冠状动脉缝合处的血流动力学参数,消除了该部位的涡流和流动停滞点,提高了底面的壁面切应力数值。在辅助搭桥血管与冠状动脉缝合处涡流区长度仅3 mm,与原主搭桥血管缝合处的涡流长度4.5 mm相比明显减小。辅助搭桥管分流了约36%的血液,只有约64%的血液流过了主搭桥管。结论该双移植管搭桥有助于减小内膜增生的发生机率。     

The evaluation of intracranial bypass patency in neurosurgical practice

BackgroundThe patency of cranial bypasses must be carefully evaluated during and after the microsurgical procedure. Although, several imaging techniques are used to evaluate the patency of bypasses, their findings are sometimes difficult to interpret.PurposeThe goal of this study was to assess the consistency of different diagnostic modalities for evaluating intracranial bypass patency.Patients and methodThis prospective study included 19 consecutive patients treated with EC-IC or IC-IC bypass for MoyaMoya disease (MMD) or complex/giant aneurysms between June 2016 and June 2018. In the early postoperative period (< 7 days), all patients had transcranial Doppler (TCD), CT angiography (CTA) and MRA to demonstrate patency of anastomoses and to confirm exclusion of the aneurysm. When findings of anastomosis patency differed between these techniques, conventional angiography was performed.ResultsAll anastomoses were patent on indocyanine green videoangiography at the end of microsurgical procedure. The results of noninvasive postoperative exams were consistent to demonstrate the patency of anastomoses in 13 patients. In 4 patients, a discrepancy in patency of anastomoses arose between TCD, CTA and MRI in the early postoperative period. In 2 other patients, the interpretation of bypass patency remained inconclusive before the decision to occlude the aneurysm. In these 6 patients, a significant edema was noted in 2 cases, a postoperative subdural hematoma in 1 case, a low flow in the anastomosis in 1 case and vasospasm in 2 cases. The anastomosis was patent on the conventional angiography in five patients.ConclusionNoninvasive imaging techniques provide useful data about the patency but their findings should be carefully interpreted due to local anatomical, physiological, and pathological factors. In case of discrepant findings, conventional angiography including supraselective catheterization of the donor vessel is suggested.     

Coronary artery bypass grafts: assessment of graft patency and native coronary artery lesions using 16-slice MDCT

The objective of this study was to evaluate the accuracy of electrocardiography (ECG)-gated 16-slice multidetector-row computed tomography (MDCT) in detection of stenosis of bypass grafts and native coronary arteries in patients who have undergone coronary artery bypass grafting (CABG). ECG-gated contrast-enhanced MDCT using 12×0.75-mm collimation was performed in 20 patients with recurrent angina 4.75 years after undergoing CABG. A total of 50 grafts, 16 arterial and 34 venous, were examined. All graft and coronary segments were evaluated for stenosis in comparison with conventional coronary angiography (CCA). Among the 80 arterial graft segments, 62 could be assessed (77.5%). Sensitivity, specificity, and positive and negative predictive values for stenosis were 96.2%, 97.2%, 96.2%, and 97.2%, respectively. In a total of 180 venous graft segments, 167 could be assessed. Sensitivity, specificity, and positive and negative predictive values for stenosis were 98.5%, 93.9%, 91.8%, and 98.9%, respectively. MDCT could assess 179 of 260 native coronary artery segments (68.8%).Sensitivity, specificity, and positive and negative predictive values for stenosis were 92.1%, 76.9%, 87.5%, and 84.7%, respectively. Sixteen-slice MDCT provides excellent image quality and diagnostic accuracy in detection of graft and coronary artery lesions in patients with suspected graft dysfunction.     

Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae.ObjectiveThis study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG.SettingSingle bariatric center, United States.MethodsAnalysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI).ResultsA total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB.ConclusionConversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.