RESUMO
Subungual keratoacanthoma is a rare, benign tumor of the digits. Patients present with progressive fusiform swelling, erythema, and tenderness, usually affecting a single digit on the radial side of the hand. A cup-shaped lytic lesion of the distal phalanx is a uniform finding on radiography. Delay in diagnosis and misdiagnosis are common because of the rarity of the lesion and difficulties with histological differentiation from subungual squamous cell carcinoma. Accurate diagnosis requires a high index of suspicion, a careful history, and histological evaluation. The natural progression of the disease appears to be continued growth with ongoing destruction of the distal phalanx. Proper treatment involves surgical removal of the mass by curettage and close follow-up for at least 2 years to monitor for local recurrence.
Assuntos
Dedos , Ceratoacantoma/diagnóstico , Paroniquia/diagnóstico , Curetagem , Diagnóstico Diferencial , Feminino , Humanos , Ceratoacantoma/patologia , Ceratoacantoma/cirurgia , Pessoa de Meia-IdadeRESUMO
Accurate assessment of lower extremity blood flow is critical in selecting appropriate therapy for patients with peripheral vascular disease and nonhealing wounds. Although physical examination provides an idea about the extent and significance of the disease, further evaluation, including both noninvasive and invasive studies, is routinely obtained. Appropriate studies will provide valuable information about the location and severity of disease, the need for revascularization before definitive wound coverage, and the likelihood of wound healing. A brief overview of vascular laboratory tests, highlighting the values and limitations of each, is presented here.
Assuntos
Isquemia/diagnóstico , Perna (Membro)/irrigação sanguínea , Diagnóstico por Imagem , Hemodinâmica/fisiologia , Humanos , Isquemia/cirurgiaRESUMO
The detection and evaluation of breast parenchymal abnormalities in the presence of a radiodense implant are often difficult with standard techniques of physical examination and mammography. Breast lesions can be obscured on one or both views by the radiodense implant or concealed within the dense tissue at the prosthesis-breast tissue interface. We investigated the role of ultrasound as an adjunct to mammographic special views, including posterior displacement (Eklund et al.), in previously augmented patients who presented with a clinically palpable mass. The records of 125 consecutive breast augmentation patients seen by us over a 4-year period were retrospectively reviewed. Twenty-six patients presented with a palpable breast abnormality. All 26 patients underwent diagnostic mammograms and sonograms. Findings included 8 parenchymal lesions (4 cysts, 2 fibroadenomas, 1 seroma, 1 breast carcinoma), 8 implant-related irregularities (4 ruptures, 3 bulges, and 1 valve), and normal fibroglandular tissue in 10 patients. Mammography yielded a convincing diagnosis in 7 of 26 patients, whereas ultrasound characterized the abnormality in every case. Ultrasound is a useful adjunct to mammography in evaluating palpable breast abnormalities in the breast augmentation patient. It offers improved visualization of the breast tissue-prosthesis interface, and it is helpful in distinguishing breast parenchymal lesions from palpable irregularities of the implant.
Assuntos
Doenças Mamárias/diagnóstico por imagem , Mamoplastia , Próteses e Implantes , Ultrassonografia Mamária , Doenças Mamárias/etiologia , Feminino , Géis , Humanos , Mamoplastia/efeitos adversos , Mamografia , Próteses e Implantes/efeitos adversos , Silicones , Cloreto de SódioRESUMO
Free tissue transfer of a jejunal segment was undertaken for laryngopharyngoesophageal reconstruction in 20 patients who received postoperative irradiation therapy. Treatment consisted of 1.8- to 2-Gy-fractions, the average total dose was 55.57 Gy (range, 40 to 66 Gy). Anastomotic strictures (six) were encountered early in the series and associated with stapled anastomoses. Hand-sewing the jejunoesophagostomy eliminated the problem. Enteric cutaneous fistula, bowel necrosis, and hemorrhagic enteritis were not observed. We conclude that the application of postoperative irradiation therapy to patients requiring jejunal interposition grafts is feasible.
Assuntos
Esofagoplastia , Sobrevivência de Enxerto/efeitos da radiação , Neoplasias Hipofaríngeas/radioterapia , Jejuno/transplante , Faringe/cirurgia , Adolescente , Adulto , Idoso , Terapia Combinada , Feminino , Humanos , Neoplasias Hipofaríngeas/cirurgia , Jejuno/patologia , Jejuno/efeitos da radiação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Transplante AutólogoRESUMO
During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as "elderly." There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).
Assuntos
Envelhecimento , Microcirurgia , Complicações Pós-Operatórias/epidemiologia , Retalhos Cirúrgicos/efeitos adversos , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Microcirurgia/efeitos adversos , Pessoa de Meia-Idade , Estudos Retrospectivos , Retalhos Cirúrgicos/métodosRESUMO
A rabbit model of hind limb ischemia was designed to demonstrate that new, hemodynamically significant arterial connections will develop between ischemic skeletal muscle and an independently perfused muscle pedicle flap. The right common iliac artery was divided in 15 rabbits. In eight rabbits a muscle flap based on the left deep inferior epigastric artery was transposed to the right thigh (flap group). In seven rabbits a sham operation was performed where the flap was sutured to the abdominal wall (sham group). After 7 days angiography demonstrated arterial connections between the flap and the native limb circulation in all of the flap group animals. The flap increased muscle perfusion in the ischemic limb (2.99 ml/100 gm muscle/minute in the flap group, vs 2.06 ml/100 gm muscle/minute in the sham group, p less than 0.005). Hemodynamically significant vascular connections will develop between a well-perfused muscle flap and an ischemic limb. The augmentation in perfusion provided by these connections can be quantified.
Assuntos
Isquemia/cirurgia , Neovascularização Patológica , Retalhos Cirúrgicos , Animais , Membro Posterior/irrigação sanguínea , Artéria Ilíaca/cirurgia , Músculos/irrigação sanguínea , Coelhos , Fluxo Sanguíneo RegionalRESUMO
The use of microvascular tissue transfer as an adjunct to arterial reconstruction has begun to have a positive impact on limb salvage in patients with advanced arteriosclerosis and nonhealing ischemic wounds. However, many patients with severe peripheral vascular insufficiency not amenable to conventional arterial reconstructive procedures eventually require limb amputation. We have treated 12 patients with advanced peripheral vascular disease and nonhealing ischemic wounds by three different methods. These included distal bypass alone, distal bypass done in conjunction with free-tissue transfer, and free-tissue transfer alone. All bypass grafts were done to vessels at or below the ankle using a reversed saphenous vein. In each case, the distal anastomosis was performed, using the operating microscope and standard microvascular technique. Mean follow-up for these patients is 18 months. Distal bypass alone resulted in limb salvage in three of five patients. In the combined bypass and free-flap group, three of five patients had salvage of their threatened extremity at a 1-year follow-up. Two patients with ischemic ulcers, rest pain, and unsuitable distal vessels for bypass were treated with free-tissue transfer alone. This resulted in healed wounds, limb salvage, and complete resolution of the rest pain symptoms in both patients. When advanced ischemia is complicated by large areas of tissue loss, combined bypass and microvascular free-issue transfer, performed in stages or simultaneously, is safe and can often result in limb salvage. In the rare instance of a completely obliterated distal runoff bed, free-tissue transfer alone may provide not only a healed wound, but also a means of "indirect" revascularization of the extremity and limb salvage.
Assuntos
Arteriopatias Oclusivas/cirurgia , Perna (Membro)/irrigação sanguínea , Microcirurgia , Idoso , Pé/diagnóstico por imagem , Pé/patologia , Humanos , Isquemia/cirurgia , Perna (Membro)/patologia , Perna (Membro)/cirurgia , Pessoa de Meia-Idade , RadiografiaRESUMO
Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esophageal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.
Assuntos
Esofagoplastia/métodos , Jejuno/transplante , Estômago/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-OperatóriasRESUMO
Gastric pull-up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull-up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull-up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull-up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull-up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull-up group. Long-term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull-up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.