Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema

OBJECTIVE

The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF).

MATERIALS AND METHODS

We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect.

RESULTS

In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased.

CONCLUSIONS

Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

Merkel cell carcinoma: Clinical and anatomopathological features, management and survival in our centre

Objective

To summarize the features of the Merkel cell carcinoma (MCC) and to sistematyze its diagnosis and therapeutic management.

Method

We performed a literature review in PubMed, obtaining a total of 3,308 articles, selecting 10 for its complete reading and 22 for the reading of the summary according to the content.

Results

In none of our patients, the MCC was the first suspected diagnosis. The treatment consisted in surgical excision with tumor free margins and lymphadenectomy. We offered ad-juvant RT which they rejected. They remain disease-free at the present time.

Conclusions

MCC is a rare and aggressive disease which presents as a fast-growing solitary asymptomatic erythematous nodule in those areas of skin which are exposed to sunlight in elderly patients. The main risk factors include radiative ultraviolet, immunosuppression and merkel cell polyomavirus. Surgery is the main loco-regional treatment. Lymph node metastases in the course of the disease is one of the main prognostic factors. If there are no adenopaties, sentinel lymph node biopsy must be done; if there are adenopaties or a positive biopsy, lymphadenectomy is indicated. Radiotherapy is indicated in all stages of disease since it has shown to improve loco-regional control. In distant metastatic disease, immunotherapy and participating in clinical trials are the first choice.

Oncological outcomes of lipofilling in breast reconstruction: a matched cohort study with 250 patients

Background

Fat grafting is a procedure commonly used in breast reconstruction nowadays. Nevertheless, its oncological safety remains controversial. The potential risk that progenitor cells included in fat graft tissue may contribute to disease progression in patients with breast cancer is still debatable. We have designed a matching-cohort study with 250 patients with history of breast cancer trying to elucidate an answer for this question.

Methods

We selected 250 patients with a history of breast cancer in our hospital, between 2011 and 2019. A total of 125 patients (cases) had a history of breast cancer reconstructed with fat grafting. The additional 125 patients are matched controls. We analyzed the distribution of eight different variables within the cases and their matched controls: date of first oncological surgery, age, type of oncological surgery, histological subtype, Her-2 status, pN, smoking habit and diabetes mellitus. The objective of this study was to analyze the influence of fat grafting over breast cancer recurrence.

Results

There are not statistically significant differences in breast cancer locoregional recurrences (P=0.183), distant metastases (P=0.200) or total recurrences (P=0.065) amongst the two groups (cancer cases and matched controls).

Conclusions

Our study adds more information over the oncological safety of fat grafting. These findings should encourage long-term prospective trials to provide surgeons with accurate information regarding the role of lipofilling on breast neoplasms.

Penile and scrotal lymphedema associated with hidradenitis suppurativa: Case report and review of surgical options

Lymphedema is the result of an alteration of the lymphatic drainage, and its most common worldwide cause is filariasis. In our practice usually is associated to neoplasic, inflammatory and granulomatous processes, radiotherapy, hydroelectrolytic disbalances, and idiopathic. It can affect any part of the body, including the penis and scrotum. The genital lymphedema is a rare presentation, it corresponds to 0.6% of lymphedema. However, causes serious functional, social and emotional limitations for the patient. Too often have pain, recurrent infections, sexual dysfunction, cosmetic deformity, sometimes it limits mobility and ambulation. Although there are several treatment options, both medical and surgical, it has not been found ideal for this disease. We present a 43 years old patient with penoscrotal lymphedema due to hidradenitis suppurativa, it limits his normal activity. The patient was referred to our center after unsuccessful medical treatment (doxycycline and clindamycin cycles). Surgical treatment consisted of total excision of the skin and subcutaneous tissue to Buck's fascia. Split thickness skin grafts were used to cover the defect. The result was satisfactory both functionally and aesthetically.

Penile and scrotal lymphedema associated with hidradenitis suppurativa: Case report and review of surgical options

Lymphedema is the result of an alteration of the lymphatic drainage, and its most common worldwide cause is filariasis. In our practice usually is associated to neoplasic, inflammatory and granulomatous processes, radiotherapy, hydroelectrolytic disbalances, and idiopathic. It can affect any part of the body, including the penis and scrotum. The genital lymphedema is a rare presentation, it corresponds to 0.6% of lymphedema. However, causes serious functional, social and emotional limitations for the patient. Too often have pain, recurrent infections, sexual dysfunction, cosmetic deformity, sometimes it limits mobility and ambulation. Although there are several treatment options, both medical and surgical, it has not been found ideal for this disease. We present a 43 years old patient with penoscrotal lymphedema due to hidradenitis suppurativa, it limits his normal activity. The patient was referred to our center after unsuccessful medical treatment (doxycycline and clindamycin cycles). Surgical treatment consisted of total excision of the skin and subcutaneous tissue to Buck's fascia. Split thickness skin grafts were used to cover the defect. The result was satisfactory both functionally and aesthetically.

Postoperative mediastinitis in open heart surgery patients. Treatment with unilateral or bilateral pectoralis major muscle flap?

AIM

the treatment of mediastinitis, after median sternotomy, in open heart surgery operated patients, remains an important and challenging problem in cardiac surgery. The management of this severe complication by means of surgical debridement of the sternum followed by mediastinal closure with pectoralis major muscle flaps, represents one of the best effective and most common modalities of treatment. The aim of the present publication is to demonstrate the good and comparable result in the mediastinal closure by using a single pectoralis muscle flap instead of two pectoralis muscle flaps.

METHODS

in our hospital, between July 1998 and December 2004, 32 patients with mediastinitis were treated after adult open heart surgery with sternal debridement and pectoralis major muscle flaps. In 19 cases the sternal closure was performed with a single pectoralis muscle (group U) and in 13 cases with both pectoralis muscles (Group B).

RESULTS

comparing the group U and group B, we did not found statistical differences in the variables of age, sex, associated diseases, previous myocardial infarction, kind of cardiac surgery undertaken, quality of the sternum, type of germen, number of previous sternal debridement performed and time of hospitalization. Patients in group U showed a statistically significant (P=0.001) shorted plastic reconstructive surgery time, an earlier extubation time (non statistically significant) and less need of blood transfusion (non statistically significant). The morbidity and hospital mortality in group U and B did not show any statistical differences. There were three cases of flap related complications in group B and two in group U. One death was recorded in group U (7.69%) and another in group B (5.26%).

CONCLUSION

mediastinal infection after cardiac surgery can be effectively managed by surgical debridement followed by plastic coverage with a single pectoralis muscle flap. In our experience, this unilateral pectoralis muscle flap technique showed similar results to the classic closure with both pectoralis muscle flaps. The unilateral technique represents a relative low aggressive operation and preserves intact the contralateral pectoralis muscle. Comparing the single pectoralis muscle flap technique with the bilateral pectoralis musle technique, the former is faster, the extubation is earlier and there is less need of postoperative blood transfusions.

Usefulness of clinical findings, nerve conduction studies and ultrasonography to predict response to surgical release in idiopathic carpal tunnel syndrome

OBJECTIVES

To assess the usefulness of clinical findings, nerve conduction studies and ultrasonography performed by a rheumatologist to predict success in patients with idiopathic carpal tunnel syndrome (CTS) undergoing median nerve release.

METHODS

Ninety consecutive patients with CTS (112 wrists) completed a specific CTS questionnaire and underwent physical examination and nerve conduction studies. Ultrasound examination was performed by a rheumatologist who was blind to any patient's data. Outcome variables were improvement >25% in symptoms of the CTS questionnaire and patient's overall satisfaction (5-point Likert scale) at 3 months postoperatively. Success was defined as improvement in both outcome variables. Receiver operating characteristics (ROC) curves and logistic regression analyses were used to assess the best predictive combination of preoperative findings.

RESULTS

Success was achieved in 63% of the operated wrists. Utility parameters and area under the ROC curve (AUC) for individual findings was poor, ranging from 0.481 of the nerve conduction study to 0.634 of the cross-sectional area at tunnel outlet. Logistic regression identified the preoperative US parameters as the best predictive variables for success after 3 months. The best predictive combination (AUC=0.708) included a negative Phalen maneuver, plus absence of thenar atrophy, plus less than moderately abnormalities on nerve conduction studies plus a large maximal cross-sectional area along the tunnel by ultrasonography.

CONCLUSION

Although cross-sectional area of the median nerve was the only predictor of success after three months of surgical release, isolated preoperative findings are not reliable predictors of success in patients with idiopathic CTS. A combination of findings that include ultrasound improves prediction.