Sensibility of the Ear After Otoplasty

Changes in skin sensibility occur in various postoperative plastic surgeries, especially when they involve major skin and subcutaneous dissection. There were no studies so far that objectively compared changes of ear sensibility. This prospective study was conducted to compare ear sensibility before and after otoplasty. Patients with prominent ears (n = 15) underwent bilateral otoplasty. Ear tactile sensibility was tested preoperatively and 6 and 12 months after surgery by Pressure Specified Sensory Device, an apparatus that quantifies cutaneous pressure sensation (g/mm(2)). Comparison between preoperative and 6-months postoperative results indicated an increment on mean skin pressure thresholds; however, mean thresholds between pre- and 12 months postoperative period were similar. Vibratory and hot/cold sensibility did not present any difference during this period. This is the first comparative assessment of ear tactile sensibility using quantitative methods. After otoplasty, initially there was reduction in an ear tactile sensibility, followed by a return to levels similar to preoperative sensibility.

Microsurgical Anatomy of the Optic Radiation and Related Fibers in 3-Dimensional Images

BACKGROUND: The fiber dissection technique provides unique 3-dimensional anatomic knowledge of the white matter. OBJECTIVE: To examine the optic radiation anatomy and its important relationship with the temporal stem and to discuss its findings in relation to the approaches to temporal lobe lesions. METHODS: We studied 40 cerebral hemispheres of 20 brains that had been fixed in formalin solution for 40 days. After removal of the arachnoid membrane, the hemispheres were frozen, and the Klingler technique was used for dissection under magnification. Stereoscopic 3-dimensional images of the dissection were obtained for illustration. RESULTS: The optic radiations are located deep within the superior and middle temporal gyri, always above the inferior temporal sulcus. The mean distance between the cortical surface and the lateral edge of the optic radiation was 21 mm. Its fibers are divided into 3 bundles after their origin. The mean distance between the anterior tip of the temporal horn and the Meyer loop was 4.5 mm, between the temporal pole and the anterior border of the Meyer loop was 28.4 mm, and between the limen insulae and the Meyer loop was 10.7 mm. The mean distance between the lateral geniculate body and the lateral margin of the central bundle of the optic radiation was 17.4 mm. CONCLUSION: The white matter fiber dissection reveals the tridimensional intrinsic architecture of the brain, and its knowledge regarding the temporal lobe is particularly important for the neurosurgeon, mostly because of the complexity of the optic radiation and related fibers.

Abdominal compression: A new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV

Background Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection. Patients and Methods From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel. Results In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak. Conclusion To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study. (C) 2012 Wiley Periodicals, Inc. Head Neck, 2012

Eosinophils may predict occult lymph node metastasis in early oral cancer

Objective The aim of this study was to investigate whether tumor-associated tissue eosinophilia (TATE) in early oral squamous cell carcinoma (OSCC) would aid in predicting occult lymph node metastasis. Patients and methods Seventy-one patients undergoing elective neck dissection for T1 and T2 OSCC were evaluated for clinical features, prognosis, and TATE. The degree of TATE in OSCC was statistically analyzed in relation to the clinicopathological features, tumor invasion, occult lymph node metastasis, and survival using chi (2) test and Kaplan-Meier method. Results Statistical analysis revealed that intense TATE was a significant feature (p = 0.004) to predict occult lymph node metastasis in patients with early OSCC. All regional recurrences of the OSCC occurred in patients showing intense TATE. Conclusions These results suggest that intense TATE can be clinically used as a predictive factor for occult lymph node metastasis. Clinical relevance The presence of intense TATE is an adjunctive histopathological marker to reinforce the indication of elective neck dissection of the patients with early OSCC.

Adjuvant chemoradiotherapy after d2-lymphadenectomy for gastric cancer: the role of n-ratio in patient selection. results of a single cancer center

Background: Adjuvant chemoradiotherapy is part of a multimodality treatment approach in order to improve survival outcomes after surgery for gastric cancer. The aims of this study are to describe the results of gastrectomy and adjuvant chemoradiotherapy in patients treated in a single institution, and to identify prognostic factors that could determine which individuals would benefit from this treatment. Methods: This retrospective study included patients with pathologically confirmed gastric adenocarcinoma who underwent surgical treatment with curative intent in a single cancer center in Brazil, between 1998 and 2008. Among 327 patients treated in this period, 142 were selected. Exclusion criteria were distant metastatic disease (M1), T1N0 tumors, different multimodality treatments and tumors of the gastric stump. Another 10 individuals were lost to follow-up and there were 3 postoperative deaths. The role of several clinical and pathological variables as prognostic factors was determined. Results: D2-lymphadenectomy was performed in 90.8% of the patients, who had 5-year overall and disease-free survival of 58.9% and 55.7%. The interaction of N-category and N-ratio, extended resection and perineural invasion were independent prognostic factors for overall and disease-free survival. Adjuvant chemoradiotherapy was not associated with a significant improvement in survival. Patients with node-positive disease had improved survival with adjuvant chemoradiotherapy, especially when we grouped patients with N1 and N2 tumors and a higher N-ratio. These individuals had worse disease-free (30.3% vs. 48.9%) and overall survival (30.9% vs. 71.4%). Conclusion: N-category and N-ratio interaction, perineural invasion and extended resections were prognostic factors for survival in gastric cancer patients treated with D2-lymphadenectomy, but adjuvant chemoradiotherapy was not. There may be some benefit with this treatment in patients with node-positive disease and higher N-ratio.

Cloning and characterisation of a novel chromosome end repeat enriched with homopolymeric (dA)/(dT) DNA in Rhynchosciara americana (Diptera: Sciaridae)

Short tandem DNA repeats and telomerase compose the telomere structure in the vast majority of eukaryotic organisms. However, such a conserved organisation has not been found in dipterans. While telomeric DNA in Drosophila is composed of specific retrotransposons, complex terminal tandem repeats are present in chromosomes of Anopheles and chironomid species. In the sciarid Rhynchosciara americana, short repeats (16 and 22 bp long) tandemly arrayed seem to reach chromosome ends. Moreover, in situ hybridisation data using homopolymeric RNA probes suggested in this species the existence of a third putative chromosome end repeat enriched with (dA).(dT) homopolymers. In this work, chromosome micro-dissection and PCR primed by homopolymeric primers were employed to clone these repeats. Named T-14 and 93 % AT-rich, the repetitive unit is 14 bp long and appears organised in tandem arrays. It is localised in five non-centromeric ends and in four interstitial bands of R. americana chromosomes. To date, T-14 is the shortest repeat that has been characterised in chromosome ends of dipterans. As observed for short tandem repeats identified previously in chromosome ends of R. americana, the T-14 probe hybridised to bridges connecting non-homologous polytene chromosome ends, indicative of close association of T-14 repeats with the very end of the chromosomes. The results of this work suggest that R. americana represents an additional example of organism provided with more than one DNA sequence that is able to reach chromosome termini.

Endoscopic anatomy of the palatovaginal canal (palatosphenoidal canal)

Objectives/Hypothesis: Demonstrate the endoscopic anatomy of the palatovaginal (PV) canal and artery for identification and dissection of the vidian nerve during endoscopic transpterygoid approaches. Evaluate the length of the PV canal and its relation with the vidian nerve. Show that the traditionally known PV canal is a misnomer and should be renamed. Study Design: Experimental study: anatomical and radiological. Methods: Dissection of eight cadaveric heads was performed to demonstrate the endoscopic anatomy of the PV canal. Computed tomography scan analysis of 20 patients was used to evaluate the length of the PV canal, the angle formed between this canal and the vidian nerve, and the distance between the vidian canal and the PV canal. Study of 10 dry skull bases was performed to verify the structures involved in the formation of the PV canal. Results: Anatomic steps and foundations for dissection of the vidian nerve using the PV canal as a landmark were described. The mean length of the PV canal was 7.15 mm. The mean proximal distance between the vidian and the PV canal was 1.95 mm, and the mean distal distance was 4.14 mm. The mean angle between those canals was 48 degrees. The osteology study showed the vaginal process of the sphenoid bone did not contribute to the formation of the PV canal. Conclusions: Our anatomic investigations, radiologic studies, and surgical experience demonstrate the important anatomic relationship of the PV canal with the vidian canal and the relevance of the PV canal as a surgical landmark in endoscopic endonasal transpterygoid approaches. Anatomically, PV canal is a misnomer and should be replaced with palatosphenoidal canal.

Gross morphology and topography of the digestive apparatus in rheas (Rhea americana americana)

Rodrigues M.N., Oliveira G.B., Silva R.S.S, Tivane C.T., Albuquerque J.F.G., Miglino M.A. & Oliveira M.F. 2012. [Gross morphology and topography of the digestive apparatus in rheas (Rhea americana americana).] Macroscopia e topografia do aparelho digestorio de emas (Rhea americana americana). Pesquisa Veterinaria Brasileira 32(7):681-686. Departamento de Cirurgia, Faculdade de Medicina Veterinaria e Zootecnia, Universidade de Sao Paulo, Cidade Universitaria, Av. Prof. Dr. Orlando Marques de Paiva 87, Sao Paulo, SP 05508270, Brazil. E-mail: marcio_medvet@hotmail.com Rheas are birds belonging to the ratites group and, among ostriches and emus, are the largest birds currently alive. In this work we studied the macroscopic aspects of rheas' digestive tract in order to provide important information to a better understanding of these birds' eating habits as well their anatomy. Twenty young animals aging between two and six months from the Centre for Wild Animals Multiplication (Cemas, scientific breeding license form Ibama no.1478912) were used. After dissection it was observed that their tongue was small and presented a rhomboid form, being disposed on the oral cavity floor, and inserted in its base by a frenulum. The esophagus was a rectilinear tube with elastic aspect and longitudinal elastic fibers, without dilation, which gives it an absence of crop. The proventriculus presented a fusiform form and the gastric ventricle showed and slightly oval form when filled, and was internally coated with a thick gastric cuticle. The small intestine was composed of three distinct regions: duodenum, jejunum and ileum. The duodenum had a light gray color and showed a "U" curved shaped. The jejunum was dark green, long and composed of several short loops arranged above each other. The ileum had a gray color and was connected with the jejunum. In ventral line to the rectum and cloaca, the ileum extended cranially, dorsally to the ascending duodenum. The large intestine was composed of two caeca, one right and one left, and colon-rectum and ileum were continuous with the cloaca. The structures of the rhea digestive tract resemble those described in the literature regarding to its shape and topography, even though rhea's caeca are well developed and relatively long.

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50 min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face. (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Pachymetry-Guided Intrastromal Air Injection ("Pachy-Bubble") for Deep Anterior Lamellar Keratoplasty

To evaluate an innovative technique for intrastromal air injection to achieve deep anterior lamellar keratoplasty (DALK) with bare Descemet membrane (DM). Thirty-four eyes with anterior corneal pathology, including 27 with keratoconus, underwent DALK. After 400 mm trephination with a suction trephine, ultrasound pachymetry was performed 0.8 mm internally from the trephination groove in the 11 to 1 o'clock position. In this area, a 2-mm incision was created, parallel to the groove, with a micrometer diamond knife calibrated to 90% depth of the thinnest measurement. A cannula was inserted through the incision and 0.5 mL of air was injected to dissect the DM from the stroma. After peripheral paracentesis, anterior keratectomy was carried out to bare the DM. A 0.25-mm oversized graft was sutured in place. Overall, 94.1% of eyes achieved DALK. Bare DM was achieved in 30 eyes, and a pre-DM dissection was performed in 2 eyes. Air injection was successful in detaching the DM (achieving the big bubble) in 88.2% of the eyes. In keratoconus eyes, the rate was 88.9%. All cases but one required a single air injection to achieve DM detachment. Microperforations occurred in 5 cases: 3 during manual layer-by-layer dissection after air injection failed to detach the DM, 1 during removal of the residual stroma after big-bubble formation, and 1 during the diamond knife incision. Two cases (5.9%) were converted to penetrating keratoplasty because of macroperforations. The technique was reproducible, safe, and highly effective in promoting DALK with bare DM.

Pharyngocutaneous fistula following total laryngectomy

Pharyngocutaneous fistula (PCF) is the most common complication after total laryngectomy. Objectives: To establish the incidence of this complication and to analyze the predisposing factors. Method: This is a cross-sectional study of a historical cohort including 94 patients who underwent total laryngectomy. The following aspects were correlated to the occurrence of PCF: gender, age, tumor site, TNM staging, type of neck dissection, previous radiation therapy, previous tracheotomy, and use of stapler for pharyngeal closure. The following were considered in PCF cases: the day into postoperative care when the fistula was diagnosed, duration of occurrence, and proposed treatment. Results: Twenty (21.3%) patients had PCF. The incidence of PCF was statistically higher in T4 tumors when compared to T2 and T3 neoplasms (p = 0.03). The other analyzed correlations were not statistically significant. However, 40.9% of the patients submitted to tracheostomy previously had fistulae, against 21.1% of the patients not submitted to this procedure. Conclusion: Advanced primary tumor staging is correlated with higher incidences of PCF.

Intratumoral Lymphatic Vessel Density in Vulvar Squamous Cell Carcinomas: A Possible Association With Favorable Prognosis

Lymphatic vessels serve as major routes for regional dissemination, and therefore, lymph node status is a key indicator of prognosis. To predict lymph node metastasis, tumor lymphatic density and lymphangiogenesis-related molecules have been studied in various tumor types. To our knowledge, no previous studies have evaluated the role of intratumoral lymphatic vessel density (LVD) in the behavior of vulvar carcinomas. The aim of this study was to analyze intratumoral LVD in relation to patient survival and well-characterized prognostic factors for cancer. Thirty-five patients with vulvar squamous cell carcinoma underwent vulvectomy and dissection of regional lymph nodes. Clinical records were reviewed, in addition to histological grade, peritumoral lymphatic invasion, and depth of infiltration for each case. Tissue microarray paraffin blocks were created, and lymphatic vessels were detected using immunohistochemical staining of podoplanin (D2-40 antibody). Intratumoral LVD was quantified by counting the number of stained vessels. Higher values for intratumoral LVD were associated with low-grade and low-stage tumors, and with tumors without lymphatic invasion and reduced stromal infiltration. In a univariate analysis, high intratumoral LVD was associated with a higher rate of overall survival and a lower rate of lymph node metastasis. Our results suggest that increased intratumoral LVD is associated with favorable prognosis in vulvar squamous carcinomas.

Ischemic stroke in young adults: an overview of etiological aspects

Stroke affects mainly people aged over 65 years, and atherosclerosis predominates as the main etiopathogenic factor in ischemic stroke (IS). On the other hand, cardiac embolism and arterial dissection are the most frequent causes of IS in patients aged less than 45 years. However, inappropriate control of traditional vascular risk factors in young people may be causing a significant increase of atherosclerosis-related IS in this population. Furthermore, a variety of etiologies, many of them uncommon, must be investigated. In endemic regions, neurocysticercosis and Chagas' disease deserve consideration. Undetermined cause has been still reported in as many as one third of young stroke patients.

Resultados da gastrectomia D2 para o câncer gástrico: dissecção da cadeia linfática ou ressecção linfonodal múltipla?

RACIONAL: A literatura oriental é notável por apresentar taxas de sobrevida para o tratamento cirúrgico do adenocarcinoma gástrico superiores àquelas apresentadas nos países ocidentais. OBJETIVO: Analisar o resultado a longo prazo após a gastrectomia D2 por câncer gástrico. MÉTODOS: Duzentos e setenta e quatro pacientes foram submetidos à gastrectomia com dissecção linfonodal D2 como tratamento exclusivo. Os critérios de inclusão foram: 1) remoção dos linfonodos de acordo com dissecção linfática padronizada Japonesa, 2) operação potencialmente curativa descrita no prontuário como dissecção D2 ou mais linfonodos; 3) invasão tumoral da parede gástrica restrita ao órgão (T1-T3); 4) ausência de metástases à distância (N0-N2/M0); 5) mínimo de cinco anos de acompanhamento. Dados clinicopatológicos incluíam sexo, idade, localização do tumor, classificação de Borrmann do tumor macroscópico, o tipo de gastrectomia, as taxas de mortalidade, tipo histológico, classificação e estadiamento TNM de acordo com a UICC TNM 1997. RESULTADOS: Gastrectomia total foi realizada em 77 casos (28,1%) e subtotal em 197 (71,9%). O tumor foi localizado no terço superior em 28 casos (10,2%), no terço médio em 53 (19,3%), e no terço inferior em 182 (66,5%). Borrmann foi atribuído cinco casos (1,8%) como BI, 34 (12,4%) BII, 230 (84,0%) BIII e 16 (5,9%) BIV. Os tumores foram histologicamente classificados como Laurén tipo intestinal em 119 casos (43,4%) e como o tipo difuso em 155 (56,6%). De acordo com a UICC TNM foram câncer gástrico precoce (T1) foi diagnosticada em 68 casos (24,8%); 51 (18,6%) T2 e 155 (56,6%) T3. Nenhum envolvimento linfonodal (N0) foi observado em 129 casos (47,1%), enquanto 100 (36,5%) eram N1 (1-6 linfonodos) e 45 (16,4%) N2 (7-15 gânglios linfáticos). O número médio de linfonodos dissecados foi de 35. A sobrevida em cinco anos para os estádios de I a III B foi de 70,4%. CONCLUSÃO: Cirurgiões digestivos devem ser estimulados a realizarem gastrectomias D2 para não deixar de lado o único tratamento para adenocarcinoma gástrico que provou ser eficiente os dias atuais. Deve ser enfatizado que a padronização da dissecção linfática de acordo com a localização do tumor é mais importante do que apenas o número de gânglios removidos

Estudo da anatomia do nervo tibial e seus ramos ao nível do terço distal da perna

OBJETIVO: Determinar, através de dissecção em cadáveres frescos, a anatomia topográfica do nervo tibial e seus ramos ao nível do tornozelo, em relação ao túnel do tarso. MÉTODOS: Foram realizadas dissecções bilaterais em 26 cadáveres frescos e as localizações da bifurcação do nervo tibial e seus ramos aferidas em milímetros, com relação ao eixo maleolar-calcaneal (EMC). Para os ramos calcâneos, a quantidade e seus respectivos nervos de origens também foram analisados. RESULTADOS: A bifurcação do nervo tibial ocorreu sob o túnel em 88% dos casos e proximalmente em 12%. Quanto aos ramos calcâneos, o medial apresentou-se com um (58%), dois (34%) e três (8%) ramos, com a origem mais comum do nervo tibial (90%) e o inferior com ramo único por perna, tendo o nervo plantar lateral como origem mais comum (70%). Nivel de Evidência V, Opinião de especialista.