Cirurgia

#Pioneering #minimally invasive tissue injection could repair #damaged organs

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Engineers have achieved a breakthrough in the development of fully functional engineered tissues that are injectable.

A new injectable tissue patch may negate the need for an invasive surgical approach, such as open-heart surgery, when it comes to repairing damaged organs.

Research published in Nature Materials showed that a flexible scaffold could be injected to successfully deliver functional cardiac tissue while maintaining cell viability and function.The microfabricated lattice design meant the patch held a “shape memory”, allowing it to unfold into the correct shape upon emerging from the needle.
Biomedical engineers at the University of Toronto developed the flexible patch using a biocompatible, biodegradable polymer. When injected via an orifice as small as 1mm, it significantly improved cardiac function following myocardial infarction in a rat, compared with untreated controls. The injection of cardiac patches was equivalent to open surgery when comparing vascularization, macrophage recruitment and cell survival.

The researchers also achieved minimally invasive delivery of human cell-derived patches to the epicardium, aorta and liver in a porcine model.

They noted that the injection would still have to take place under general anaesthesia, but said the approach also holds promise for the delivery of immunosuppressives, and could be used in other forms of laparoscopic surgeries.

#Tras una #reducción de estómago puede ser recomendable someterse a #cirugía estética

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Una vez transcurridos doce meses desde la intervención o después de haber logrado el peso deseado y ser capaz de mantenerlo.

La cirugía bariátrica abarca reducciones de estómago, balón gástrico o balón ajustable y, ante la cantidad de personas que son obesas en el mundo, esta parece “imponerse” para erradicar esta enfermedad, una intervención en la que puede ser recomendable someterse a una cirugía estética posterior en función del consejo del especialista, según el cirujano estético, Jordi Mir.

Estas alternativas para adelgazar se entienden como intervenciones quirúrgicas que no pueden contemplarse como un tratamiento individual, sino como parte fundamental de un proceso global, que contempla un seguimiento completo del paciente. “Por eso, se abarca no solo el pre y post operatorio, sino, por supuesto, la posterior re-educación alimenticia, el diseño de un plan de ejercicio personalizado y, por último, pero no menos importante, una propuesta estética si el paciente así lo desea”, ha concretado el experto.

En este sentido, el retoque estético se recomienda una vez transcurridos los doce meses desde la intervención o después de haber logrado el peso deseado y ser capaz de mantenerlo, teniendo en cuenta que “lo mejor” es tomarse el tiempo necesario para adelgazar, si se exceptúan los casos en los que los indicadores de salud son “tan malos” que se necesita una pérdida de peso “urgentísima”.

Así, tras una reducción de estómago u operación similar, las zonas más intervenidas en cirugía estética son el abdomen y la zona baja de la espalda, la cara interna de los muslos y la de los brazos. Además, “este tipo de intervenciones pueden generar un pérdida de los tejidos blandos faciales, con descolgamiento de los tercios medio e inferior”, ha explicado el Dr. Mir.

“Por lo tanto, se solicitan abdominoplastias, ‘lifting’ de brazos y muslos y ‘body lift’, un tratamiento completo de cirugía de contorno corporal destinada a la reducción de los excesos sobrantes de piel y a recuperar el tono y elasticidad de la misma”, ha añadido.

El especialista ha subrayado que el grado de satisfacción después de estas intervenciones, según su experiencia, es “altísimo”, tanto en cirugía como en medicina estética. Sin embargo, ha lamentado que sean pocos los centros públicos que reconocen la importancia de su contribución asociados a la cirugía bariátrica.

#Obese cardiac surgery patients require significantly more #ICU resources

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Patients with higher levels of obesity are four times more likely to require extra time in the ICU.

Pre-emptive strategies should be put into practice when treating cardiac surgery patients who are obese, including closer postoperative monitoring and preoperative discussions about the unique surgical risks that such patients may face.

That is according to Brandon R. Rosvall, the lead author of a new study, which has highlighted how obese cardiac surgery patients require significantly more intensive care unit (ICU) resources than those with normal body mass index.

After examining data relating to 5,365 patients who underwent cardiac surgery at a Canadian hospital, researchers found patients with higher levels of obesity were four times more likely to require extra time in the ICU, three times more likely to need additional time on mechanical ventilation, and three times more likely to be readmitted to the ICU. These patients also experienced longer overall hospital lengths of stay and discharges with home care.

“More in-depth conversations regarding surgical risks and alternatives to surgery should take place with obese patients so that they are aware of the true impact of increased obesity,” said Rosvall.

The findings are published in The Annals of Thoracic Surgery .

#Cesarean Complications Lower With #Poliglecaprone 25 Suture (II)

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When the researchers looked at the wound complication rate by actual suture received, the rate of wound complications was also lower in the poliglecaprone 25 suture group (8.3%) compared with the polyglactin 910 counterpart (13.8%), for a 40% reduction in the relative risk of developing a complication during the first 30 days postdelivery.

In this analysis, however, the difference between the two suture groups was no longer statistically significant (P = .05).

Lack of Braiding

Poliglecaprone 25 is a monofilament suture that is absorbed within 91 to 119 days postoperatively, the authors explain. The polyglactin 910 in turn is a braided suture which is absorbed much more quickly within 56 to 70 days after surgery. “Cesarean incision closure with poliglecaprone 25 suture is associated with a significantly decreased rate of wound complications when compared with polyglactin 910 suture,” they write. “We speculate that this significant difference was the result of the lack of braiding in the poliglecaprone 25 suture that allowed for increased resistance to infection.”

In an accompanying audio clip, Nancy Chescheir, MD, editor-in-chief of Obstetrics & Gynecology, observed that most wound complications show up early, not 56 to 119 days after the wound has been closed.

“When I was a medical student, surgeons made a big deal out of time to dissolution of absorbable sutures,” she said. “So the fact that the length of time it takes the suture to dissolve in the wound isn’t the issue here, there’s something else going on earlier in the process of wound healing that is making the difference here,” she noted. “Some of the simple things make the best science,” She added.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;130:521-526. Abstract


#Cesarean Complications Lower With #Poliglecaprone 25 Suture (I)

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In women who undergo elective cesarean delivery, wound complications are lower in Pfannenstiel incisions closed with poliglecaprone 25 suture compared with in those who receive polyglactin 910 suture, a randomized comparative trial found.

“The incidence of wound complications after cesarean delivery comparing suture and staple skin closure has been extensively studied with suture being superior,” Arin Buresch, MD, from Kaiser Permanente San Diego, California, and colleagues report.

“[And now we’ve] found that for skin closure after delivery, poliglecaprone 25 suture was associated with a 40% reduction in the rate of wound complications when compared with polyglactin 910 suture,” they add.

The researchers present their findings in an article published online August 4 and in the September issue of Obstetrics & Gynecology.

The primary outcome was a composite outcome of a wound complication during the first 30 days postoperatively that included one or more of the following: a wound separation of 1 cm or more in length, hematoma, seroma, or surgical site infection.

In an intention-to-treat analysis, 8.8% of women who underwent subcuticular closure of their Pfannenstiel skin incision with the 3-0 poliglecaprone 25 (Monocryl) suture experienced the primary outcome compared with 14.4% of women in whom a 4-0 polyglactin 910 (Vicryl) suture was used (relative risk, 0.61; 95% confidence interval, 0.37 – 0.99; P = .04).

Surgeons would need to treat 18 women with the poliglecaprone 25 suture to prevent one composite wound complication after caesarean section.

The study was carried out in labor and delivery units at two medical centers in California. During slightly more than 1 year, 275 women were randomly assigned to undergo cesarean delivery in which the poliglecaprone 25 suture was used, and another 275 women were randomly assigned to the same procedure with skin closure using the polyglactin 910 suture.

The final analysis included 263 women in the poliglecaprone 25 suture group, 231 of whom underwent the procedure with the assigned suture, and 257 women in the polyglactin 910 group, 209 of whom received the assigned suture.

Groups were well balanced in terms of demographics, comorbidities, and perioperative characteristics, the researchers note. The investigators calculated outcomes by intention-to-treat analysis as well as by the actual suture received. In the intent-to-treat analysis, rates of specific wound complications were usually higher in the polyglactin 910 suture group as well.

Table. Wound Complication Rates: Intent-to-Treat Analysis

Complication Poliglecaprone 25 Polyglactin 901
Surgical site infection 6.1% 9.7%
Hematoma 0.4% 1.2%
Seroma 0.8% 0.4%
Separation 2.7% 5.1%

#Enxerto de gordura em glúteos: atenção é necessária

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quatro cirurgioes pronto para operar

Enxerto de gordura em glúteos: atenção é necessária

Nos últimos anos o uso de enxerto de gordura autóloga para aumentar a região glútea vem aumentando de forma bastante significativa. Os fóruns online mostram grande satisfação dos pacientes com o resultado da cirurgia. Entretanto, pacientes e cirurgiões podem não estar totalmente cientes do risco de complicações sérias envolvendo esse procedimento.

O primeiro caso descrito de embolia pulmonar fatal após enxerto de gordura foi publicado na literatura médica em 2015. Desde então outros casos foram notificados sem uma estatística oficial.

Entre 2011 e 2015 houve um aumento de 280% nesses procedimentos nos Estados Unidos, conhecido como “Brazilian Butt Lift”devido ao trabalho pioneiro de Toledo em 1985.

A normatização inicial da técnica sugeria injeção em planos profundos para aumentar a viabilidade do tecido adiposo enxertado, e uso de cânulas de 2mm. Em geral, complicações peri-operatórias são incomuns, entretanto complicações sérias como lesão de nervo ciático foram reportadas. Em 2016, Sinno et al publicaram um estudo comparando aumento glúteo com implantes de silicone e com enxerto de gordura. Concluíram que há mais complicações com implantes de silicone, entretanto complicações fatais ocorreram apenas em casos de lipoenxertia.

Um estudo retrospectivo realizado por cirurgiões plásticos mexicanos e pelo Registro de Autópsias da Colômbia por Cárdenas-Camarena identificou 22 óbitos por embolia gordurosa pulmonar em um período de 10 e 15 anos, respectivamente. Esses autores sugeriram que a embolização gordurosa macroscópica era resultado da migração de partículas de gordura do espaço extravascular de alta pressão para o sistema venoso de baixa pressão, em decorrência de lesão vascular.

Em exames necrológicos verificou-se transecção da veia glútea superior em um paciente e lesão da veia glútea inferior em outro. É possível que uma veia seja canulada diretamente durante a cirurgia, mas o mais provável é que haja migração de gordura por gradiente de pressão após uma lesão vascular. O volume de gordura injetada não parece estar relacionada com esses eventos fatais. Nesse estudo o volume médio injetado foi de 214ml.

Alguns estudos mostram mortalidade entre 1:2351 e 1:6241, entretanto ainda não há dados fidedignos estabelecidos. É certo que o Brazilian Butt Lift tem o maior índice de mortalidade entre os procedimentos cirúrgicos estéticos, ultrapassando a abdominoplastia que até hoje era o procedimento com maior índice de mortalidade em nossa especialidade.

Com isso foram criadas algumas orientações para serem seguidas nessa cirurgia:

  1. Evitar injeção em planos profundos
  2. Usar cânulas maiores que 4mm
  3. Evitar angular para baixo a cânula
  4. Posicionar o paciente e as incisões de modo a evitar injeção profunda
  5. Manter constante visão tridimensional da ponta da cânula
  6. Só injetar com a cânula em movimento
  7. Considerar embolia pulmonar em pacientes clinicamente instáveis
  8. Revisar anatomia vascular glútea
  9. Incluir o risco de embolia gordurosa no consentimento informado

Mais estudos clínicos, anatômicos e post-mortem são necessários para confirmar esses achados e identificar técnicas que tornem o procedimento mais seguro.

Enquanto novas estatísticas não são publicadas, deve se considerar esse procedimento de alto risco. Todas as medidas necessárias devem ser tomadas para a segurança do paciente. A banalização da técnica também deve ser evitada, procurando utilizá-la com indicações precisas. E os pacientes devem ser informados dos riscos inerentes ao procedimento com especial ênfase na embolia gordurosa, potencialmente fatal.

Autor:

André Mattos  Cirurgia Plástica

Referências:

  • Toledo LS Gluteal augmentation with fat grafting: the Brazilian buttock techinique : 30 years experience . Clin Plast Surg 2015;42(2):253-261
  • Filomeno LTB, Carelli CR, Silva NCLF, et al. Fat embolism: a review for current orthopaedics practice. Acta Ortop Bras. 2005;13:196-208.
  • Zenker FA. Beitrage zur Anatomie und Physiologie de Lung. Dres- den, Germany: J Braunsdorf. 1861:31.
  • Bergmann VE. Ein fall todlicher fettenbolic. Berl Klin Wochen- scher. 1873;10:385-6.
  • Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology. 2000;55:1172-9.
  • Buchholz S, Shakil A, Figtree GA, et al. Diagnosis and manage- ment of patent foramen ovale. Postgrad Med J. 2012;88:217-25.
  • Shaikh N. Emergency management of fat embolism syndrome. J Emerg Trauma Shock. 2009;2:29-33.
  • Bederman SS, Bhandari M, McKee MD, et al. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long bone fractures? Can J Surg. 2009;52:386-93.
  • Platt MS, Kohler LJ, Ruiz R, et al. Deaths associated with lipo- suction: case reports and review of the literature. J Forensic Sci. 2002;47:205-7.

Five Deaths Tied to# Intragastric Balloons, FDA Says

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Megan Brooks

The  US Food and Drug Administration (FDA)said today that it has received five reports of unanticipated deaths that occurred from 2016 to the present in patients who received a liquid-filled intragastric balloon system to treat obesity.

Four reports involve the Orbera Intragastric Balloon System (Apollo Endosurgery) and one report involves the ReShape Integrated Dual Balloon System (ReShape Medical), the FDA said in a safety alert.

All five patients died within 1 month or less of balloon placement. Three patients died 1 to 3 days after the balloon was placed.

“At this time, we do not know the root cause or incidence rate of patient death, nor have we been able to definitively attribute the deaths to the devices or the insertion procedures for these devices (e.g., gastric and esophageal perforation, or intestinal obstruction),” the FDA said.

The FDA has also received two additional reports of deaths from 2016 to the present related to potential complications associated with balloon treatment: one gastric perforation with the Orbera Intragastric Balloon System and one esophageal perforation with the ReShape Integrated Dual Balloon System.

The FDA is working with both companies to better understand the issue of unanticipated death and to monitor the potential complications of acute pancreatitis and spontaneous overinflation.

Additionally, as part of the ongoing, FDA-mandated postapproval studies for these devices, the FDA will obtain more information to help assess the continued safety and effectiveness of these approved medical devices.

Today’s safety alert follows an FDA alert sent to healthcare providers in February, in which the agency recommended close monitoring of patients with liquid-filled intragastric balloon systems used to treat obesity for the potential risks of acute pancreatitis and spontaneous overinflation. Since then, both companies have revised their product labeling to address these risks, the FDA said.

For now, the FDA continues to recommend that healthcare providers closely monitor patients treated with these devices for complications and report any adverse events related to intragastric balloon systems through MedWatch, the FDA Safety Information and Adverse Event Reporting Program.