To date, absent inferior mesenteric vein (IMV) has not been reported in the literature as a cause of or being associated with lower gastrointestinal (GI) bleeding. We describe a case of 13 year-old girl who presented with hematochezia and was subsequently found to have widespread colonic varices involving the ascending, transverse and proximal descending colon. The upper GI tract, small bowel, and rectum were not involved. Delayed venous phase of mesenteric angiography revealed an absent inferior mesenteric vein. The patient underwent laparoscopic extended right hemicolectomy with ileosigmoid anastomosis. No bleeding from recurrent varices occurred during a 1-year period of follow up. We conclude that extended right hemicolectomy is a potential curative surgical option in patients presenting with lower GI bleeding from colonic varices caused by absent IMV. Upper GI and small intestinal involvement should be excluded to prevent future bleeding from missed varices these sites.
Background: The frequency, pattern, and treatment of pediatric hand fractures are rarely reported. We sought to review our institution’s experience in the management of pediatric hand fractures. Methods: A retrospective review of children and adolescents (younger than 18 years) treated for hand fractures between January 1990 and June 2017 was preformed. Fractures were categorized into metacarpal, proximal/middle phalanx, distal phalanx, or intra-articular metacarpophalangeal (MCP)/proximal interphalangeal (PIP)/distal interphalangeal (DIP) fractures. Patients were categorized into 3 age groups (0-5, 6-11, and 12-17 years). Results: A total of 4356 patients were treated for hand fractures at a mean ± SD age of 12.2 ± 3.5 years. Most fractures occurred in patients aged 12 to 17 years (n = 2775, 64%), followed by patients aged 6 to 11 years (n = 1347, 31%). Only 234 (5%) fractures occurred in children younger than 5 years. Most fractures occurred in the proximal/middle phalanx (48%), followed by metacarpal (33%), distal phalangeal (12%), and intra-articular MCP/PIP/DIP joints (7%). Proximal/middle phalangeal fractures were the most common in all age groups. About 58% of intra-articular MCP/PIP/DIP fractures in patients aged between 0 and 5 years required open reduction ± fixation, and the remaining 42% fractures were amenable to closed reduction. In patients older than 5 years, about 70% of these fractures were amenable to closed reduction. All age groups included, most metacarpal (93%), proximal/middle phalangeal (92%), and distal phalangeal (86%) fractures were amenable to closed reduction alone. Conclusions: The frequency, pattern, and treatment of hand fractures vary among different age groups. Understanding the pattern of these fractures helps making the right diagnosis and guides choosing the appropriate treatment.
Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG.
Abstract Background The non‐weight‐bearing (NWB) Achilles tendon and weight‐bearing (WB) heel pad regions are technically challenging to reconstruct with distinct functional and aesthetic considerations that have not been previously considered in the literature. This study is the first to characterize the long‐term clinical and patient‐reported outcomes of these components to better inform patients about the postreconstruction period. Methods A retrospective review of medical records and phone‐based survey of adult patients who underwent free flap reconstruction of the heel/ankle with 6‐month minimum clinical follow‐up was performed. Results Forty‐three patients, with 31 (72.1%) NWB and 12 (27.9%) WB defects, treated from January 1, 2000 to February 28, 2017 were included. Muscle flaps were more common than fasciocutaneous flaps ( N = 36 [83.7%] vs. 7 [16.3%]). Flap survival rate was 95.3% and limb salvage rate was 93.0% at median follow‐up of 12.0 months (interquartile range [IQR] 6.2, 25.5). Flap ulceration occurred more frequently in the WB region (41.7 vs. 6.5%, p = .0123). The survey response rate was 63.6%. The majority of patients complete daily tasks with no/little impairment (76.2%), walk half a mile or more (85.7%), returned to work (86.6%), and fit shoes “fair” or “well” (71.4%). Most patients were “very satisfied” with heel/ankle function (71.4%) and would “very likely” undergo the same procedure if needed (76.2%). Conclusions Free flap reconstruction in both the NWB Achilles tendon and WB heel pad has excellent limb salvage and flap survival rates. Patients were satisfied with heel/ankle function, but additional counseling is recommended for variance in appearance and higher ulceration rates in WB defects.
Introduction: The use of CT scanning in pediatric craniofacial patients increases lifetime risk of carcinogenesis as well as having potential effects on bone growth. Black Bone MRI is an alternative for surgical planning that does not require exposure to radiation. However, the air-containing paranasal sinuses have limited acquiring high resolution Black Bone magnetic resonance imaging. Therefore, this technology has not been widely utilized to create three-dimensionally (3D)-printed guides. The aim of this research was to optimize Black Bone MRI for maxillary imaging as well as comparing the accuracy of this technique to traditional CT imaging in a series of cadaver LeFort 1 advancements. Methods: A mock single-segment maxillary advancement using Le Forte 1 osteotomy was virtually planned and performed in 10 fresh cadavers. For five specimens, planning was performed and three-dimensionally–printed guides and splints were created using Black Bone magnetic resonance imaging scans. Five other specimens underwent standard planning using computed tomographic scans. The postoperative reconstructions underwent computed tomography imaging and three-dimensional reconstruction. Surgical accuracy was then compared to the virtually-planned surgery. All surgeries were performed by the three authors to ensure consistency. Results: The deviation of the preoperative Black Bone magnetic resonance imaging scan from the preoperative computed tomographic scans did not reach statistical significance (p < 0.05). There was no statistically significant difference in the accuracy of guides and final splint fit between magnetic resonance imaging versus computed tomography– created guides. The difference in average deviation of postoperative anatomy from the preoperative plan for both magnetic resonance imaging– and computed tomography–created guides did not reach statistical significance (p < 0.05). Conclusion: This study demonstrates that high quality maxillary imaging can be obtained using Black Bone magnetic resonance imaging. Virtual surgical planning and three-dimensional surgical guide and splint creation for maxillary surgery can be performed using Black Bone magnetic resonance imaging with accuracy comparable to that of computed tomography. This can significantly reduce the risk of radiation exposure in children and adults undergoing maxillary surgery using virtual surgical planning and expand the utilization of Black Bone magnetic resonance imaging in craniofacial virtual surgical planning
Abstract Advances in computer-aided design and computer-aided manufacturing software have improved translational applications of virtual surgical planning (VSP) in craniomaxillofacial surgery, allowing for precise and accurate fabrication of cutting guides, stereolithographic models, and custom implants. High-resolution computed tomography (CT) imaging has traditionally been the gold standard imaging modality for VSP in craniomaxillofacial surgery but delivers ionizing radiation. Black bone magnetic resonance imaging (MRI) reduces the risks related to radiation exposure and has comparable functionality when compared with CT for VSP. Our group has studied the accuracy of utilizing black bone MRI in planning and executing several types of craniofacial surgeries, including cranial vault remodeling, maxillary advancement, and mandibular reconstruction using fibular bone. Here, we review clinical applications of black bone MRI pertaining to VSP and three-dimensional (3D)-printed guide creation for craniomaxillofacial surgery. Herein, we review the existing literature and our institutional experience comparing black bone MRI and CT in VSP-generated 3D model creation in cadaveric craniofacial surgeries including cranial vault reconstruction, maxillary advancement, and mandibular reconstruction with fibular free flap. Cadaver studies have demonstrated the ability to perform VSP and execute the procedure based on black bone MRI data and achieve outcomes similar to CT when performed for cranial vault reshaping, maxillary advancement, and mandibular reconstruction with free fibula. Limitations of the technology include increased time and costs of the MRI compared with CT and the possible need for general anesthesia or sedation in the pediatric population. VSP and 3D surgical guide creation can be performed using black bone MRI with comparable accuracy to high-resolution CT scans in a wide variety of craniofacial reconstructions. Successful segmentation, VSP, and 3D printing of accurate guides from black bone MRI demonstrate potential to change the preoperative planning standard of care. Black bone MRI also reduces exposure to ionizing radiation, which is of particular concern for the pediatric population or patients undergoing multiple scans.
Purpose: Patients with facial paralysis suffer a high degree of psychological strain from their facial disfigurement and missing facial expressions. Current outcomes still leave room for improvement, regardless of a multidisciplinary team approach and full patient cooperation. Previous studies have demonstrated not only the feasibility of muscle re-innervation by direct suturing of a nerve into denervated muscle but also that adjacent muscles can re-innervate denervated, neighboring muscles. Based on these findings, the question arose whether muscles in close proximity may re-innervate a denervated muscle by redirecting nerve fibers from one muscle to another via a nerve graft. Despite promising results in the literature, muscle-nerve-muscle neurotization fell into oblivion and is currently not included in standard care. The aim of this study was to investigate its efficacy in reinnervating the orbicularis oris muscle to counteract muscle weakness or synkinesis in facial paralysis patients. Methods: Four consecutive cases of muscle-nerve-muscle neurotization of the orbicularis oris muscle carried out from 2022 to 2023 were included in this study. During the surgery, a sural nerve graft was harvested by a skip-incision approach and divided into equally long segments. In the face, two to four 5 mm vertical incisions were made intraorally on the upper lip and two to three incisions on the lower lip to expose the orbicularis oris muscle on both sides. A tunnel was bluntly dissected to enable passing through the nerve graft. Multiple nerve grafts with epineural windows were placed in the upper and lower lip and secured in contact with the muscle before incision closure. Surgical outcomes were evaluated 6 months and 12 months postoperatively by utilizing an automated facial landmark recognition software (Emotrics). Results: There were four female patients in the cohort, of which two suffered a traumatic facial paralysis, one patient was diagnosed with bell's palsy and the fourth patient experienced facial paralysis following an acoustic schwannoma resection. The average age at the time of surgery was 51 (range 21 to 75) years. The primary complaint of two patients was oral incontinence and speech problems, whereas the other two desired to improve their smile. All patients presented with significant orbicularis oris muscle weakness preoperatively, of which two were related to persistent facial palsy and two to facial synkinesis. Following 6 months after the surgery, patients reported a positive Tinel sign when tapping on the unaffected orbicularis oris muscle. All patients reported an improvement in speech and oral incontinence and were overall satisfied with the result. Conclusion: Muscle-nerve-muscle neurotization is a simple technique that achieves satisfactory reinnervation following facial paralysis and synkinesis. Despite the small patient cohort, this procedure showed promising potential as additional technique for facial reanimation.
Cholecystocolonic fistula is a rare condition and is found in roughly 1 in every 10,000. It represents 6.3% to 26.5% of all cholecystenteric fistulas (Chowbey et al., 2006; Angrisani et al., 2001; Yamashita et al., 1997). Cholecystocolonic fistula is the second most common intestinal fistula after cholecystoduodenal fistula (Costi et al., 2009). Rarity of this condition, atypical presentation, diagnostic and management challenges, makes it a unique surgical entity.A 77-year old male presented with progressive abdominal distension and diarrhea. After initial evaluation, a cholecystocolonic fistula was suspected. Further diagnostic studies including Hepatobiliary Imino-Diacetic Acid (HIDA) scan and Endoscopic Retrograde Cholangiography (ERC) revealed complete occlusion of the cystic duct that could not be relieved. Shortly after, the patient developed septic shock likely of biliary origin and required an urgent open partial cholecystectomy and segmental resection of the involved colonic segment.In this particular case, the acute presentation together with the inflammatory features around the gallbladder pointed toward an acute inflammatory process and therefore we have tried to delay any operative intervention to allow the inflammation to subside and avoid operating in an inflamed field. Furthermore, our aim was to relieve any sort of biliary obstruction to allow the fistula -if present- to heal by minimizing bile flow through the fistula. Relieving biliary obstruction was not successful in our patient.Based on our experience with this particular case, we could safely conclude that an operation for cholecystocolonic fistula presence in the setting of biliary obstruction that failed decompressive attempts should be performed in an urgent fashion to avoid biliary sepsis development.
