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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_994_Библиотеки_им_академика_М_И_Перельмана
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390
C. A. Ríos et al.
Fig. 27.5 Scintigraphy in patient with biopolymers
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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Fig. 27.6 MRI in patient
with biopolymers. Notice
how the biopolymers
location are visualized as
radiodense areas in
the MRI
391
Although there is still a long way to go, in clinical research of diagnostic aids and
evidence-based medicine, it could be considered that Nuclear Magnetic Resonance
(MRI) is the gold standard test in the diagnosis and progression of adjuvant disease.
The STIR sequence allows us to evaluate the magnitude and severity of tissue
involvement, the migration, as well as to perform surgical planning of the areas we
can and cannot intervene. The resonance shows us collections of liquid, purulence,
silicone, areas of tissue with edema and commitment of vital structures (Fig.27.6).In
the process of surgical resection, it is important to determine the location of the
granulomas, because these are not evident to the rst sight, being confused with the
tissues. MRI evaluates the patient’s evolution during the postoperative period and
the disease’s progression over time [18, 19].Additionally, positron emission tomography could support the diagnosis for inltration and migration of the adjuvants [20].
27.8 Perioperative Stress Test
Functional capacity decreased by different stressful factors, increases the likelihood
of death. The Perioperative Cardiopulmonary Stress Test provides a measurable
indication of maximum oxygen consumption (VO2 Max.) during exercise, predicts
postoperative outcomes, indicating the physiological reserve available to respond to
the stress of surgery and the recovery period [23].
An important predictor of functional capacity, is Maximal Oxygen Uptake (The
maximum aerobic capacity– VO2 Max.), which implies the highest amount of oxygen that can be breathed, transported by the cardiovascular system, and used by the
cellular metabolism, thereby evaluating the functional capacity of these vital organs
as well as the exibility of the metabolism, the health status of different tissues,
nutritional status, response to medications, orthopedic limitations, among others.
VO2 Max. is not easily accessible, for this reason, an indirect measurement alternative is the maximum stress test with measurement of the metabolic equivalents
METs [24]. Metabolic equivalents (METs), is the energy requirement for normal
daily activities. In general terms, patients who have a maximum aerobic functional
capacity below 4 METs during the stress test, are at increased risk of cardiac and
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long-term postoperative complications; therefore, they should be studied in
more detail.
These diagnostic aids can be extrapolated to others clinical scenarios in which
the probability of complications, and even survival, depends on the functional
capacity required to maintain homeostasis. In our private practice, patients who
have less than 4.1 METs, are delayed in removal of adjuvant surgery, even if all
other tests are normal; are only rescheduled if they achieve in the 4–8 weeks rehabilitation program, an increase of their minimum functional capacity by 1 MET
[23].But, ¿what to do if you do not have access to the stress test? Indirect determinations should be used through questionnaires such as the Duke Activity Status
Index (DASI), whose correlation with VO2 Max. and METs is good, corroborated
by prospective studies [25].
27.9 Medical andSurgical Treatment
Without further consideration in this regard, it must be directly recognized that, to
date, there is no specic treatment for ASIA syndrome; additionally, much of this
pathology is still unknown, and even in some academic circles its existence as an
independent disease is controversial.
However, patients should be treated with the few direct interventions that have
been observed, with various degrees of effectiveness, or at least face the therapeutic
dilemma, according to indirect treatments taken from other diseases (Concept of
Indirect Evidence), where it has been determined Its utility. In this way, little by
little, the current scientic evidence was partially built, which in terms of statistical
power, should be classied in most cases as “LOW in favor”, and in others as “LOW
to MODERATE in favor”, according to the GRADE system scale: Classication of
quality of evidence and strength of recommendation.
Although the 12 diagnostic criteria proposed by Shoenfeld and Agmon-Levin in
2011, for which the disease is also called Shoenfeld syndrome, and the subsequent
modications by Alijotas-Reig, are in the process of being validated with suitably
designed studies, academically they help to clarify that the therapeutic approach
should be oriented in the rheumatological, immunological elds, or by exception
from the infectious point of view, derived from a local and systemic reaction to a
foreign body, as has already been mentioned throughout the chapter.
Thus, and even with some knowledge gaps in the pathophysiological bases,
patients have been treated medically, at conventional doses already known in the
aforementioned pathologies, with: non-steroidal anti- inammatory drugs NSAIDs,
amitriptyline, systemic or local corticosteroids such as prednisone, hydroxychloroquine, allopurinol, antihistamines, minocycline, methotrexate, 5-uorouracil,
isotretinoin, imiquimod, etanercept, intravenous immunoglobulins. Cases resistant
to medical management may evolve to tacrolimus, and sometimes to antibiotic
therapy.
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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393
It is observed that there is a mixed response of patients treated with these analgesia, neuro and immunomodulation schemes, some analyzed series report up to 70%
improvement with directed syndromatic treatments, with permanence and free of
symptoms up to two years after having suspended therapy[8].Other patients do not
respond favorably, their evolution is torpid, or they manifest a slight improvement.
In this situation, and/or when accompanied by severe local or systemic lesions, the
surgical option is the way to go.The removal of the adjuvant, and operative resection of the severely compromised tissue, could be related to the interruption of the
vicious circle generated by the progressive damage of the constant injury, which in
turn, is caused by the local immunological reactionin the presence of biopolymers;
the procedure breaks with the progression and degeneration of the affected areas,
additionally, due to still unknown mechanisms, it also impacts systemic
manifestations.
In surgery there is a basic therapeutic principle, in the event of a reaction to a
foreign body that produces acute or chronic injuries of considerable magnitude.
This principle refers to the extraction by different means of the agent that produces
the unwanted reaction. In the case of ASIA syndrome, there are no experimental
studies that compare head to head with optimal methodological design, medical
treatment versus treatment by semi- invasive or non-invasive procedures, and in turn,
against wide resection and open extraction surgery, which is the current proposal.
Pending these experimental results of high methodological quality, for now, it
can be afrmed in the retrospective observational eld and with several years of
local follow-up, soon to be published, that the surgical removal of as much as possible of the injected aggressor agent, in together with the removal of damaged and
unrecoverable tissue, it shows high recovery rates in the short, medium and long
term; ostensibly surpassing the torpid or null response of those patients with secondary failure of medical treatment. Preliminary descriptive results in the rst cut or
segmental analysis of the ongoing observational study, somewhat similar to an
interim analysis of randomized controlled clinical trials, report progressive and consistent improvement over time, for 70 to 80% of individuals analyzed, variable or
unsatisfactory evolution in 10 to 15%, and no recovery or failure secondary to surgical treatment in 5% of patients.
27.9.1 Surgical Management
For the removal of the adjuvants, several extraction techniques have been proposed,
such as thick needle multipuncture, LAL laser-assisted liposuction: (CO2, Diode,
Erbium, Neodymium, Cold), UAL (Ultrasound-Assisted Liposuction), VAL
(Vibration-Assisted Liposuction—Vibro Liposuction). In our clinical practice we
have observed that up to 71.4% of patients had been operated before consulting for
a new adjuvant’s removal, 65% with liposuction, 29% with laser technique, and
10% had open surgical technique [4].
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We conducted in vivo and invitro tests with each of the proposed methods,
reproducing the scenario and the technique. We performed punctures with 18-gauge
thick needle, to anatomical pieces removed from patients with secondary granulomas to adjuvants, without obtaining the aspiration of the material. We used tumescent liposuction techniques with each of the devices described, both in the material
removed from patients as well as inthose that after liposuction, underwent open
surgery with large incisions. In thesecases, were able to check that the adjuvant
material was not aspirated or destroyed, the affected tissue remained unchanged;
therefore we conclude that with these techniques the material is not shattered by the
energy applied nor aspirated by the liposuction cannula (Figs.27.7 and 27.8). The
emission of energy through the liposuction cannulas did not show signicant
improvement in the result of adjuvant removal.
During invitro tests, the foreign body shaped as adjuvant spheres surrounded by
scar tissue, was blasted with CO2, Diode, Erbium, Neodymium, and Cold
lasers,without observing any transformation even at potencies higher than those
tolerated in surgical procedures. When a sample of adjuvant was bombarded with
the CO2 laser, a large quantity of volatile substances was generated, covering the
space where the experiment took place, and the original adjuvant still looked intact.
The previously named techniques; needle puncture or liposuction assisted, are
not very reliable in terms of diminishing pain, discomfort, improvement and prognosis of the patient’s clinical condition. In fact, these techniques have been shown
to potentially aggravate the disease by early or late complications such as skin pigmentation disturbances, deformities, severe brous reactions. What makes the clinical condition of a patient with gluteal involvement become catastrophe, is due to
massive migration to the genitals, thighs, calves, ankles, and feet, as well as the
back, anks, and abdomen. For this reason, a group of surgeons advocate for open
reconstructive surgery as the best alternative for the removal of the largest number
of modeling agent, with fewer complications [26–33].
27.9.1.1 Surgical Technique
Extensive surgical resection of the biopolymers is the keystone of the treatment,but
this is not possible with the needle aspiration or liposuction-assisted technique. On
the other hand, the removing of the material by open or endoscopic surgery is an
effective treatment; however, the resection of extensive tissue block could produce
deformities in the area to be treated.
Tissues affected by brosis include fatty tissue, dermis, fasciae, aponeurosis,
muscles, and vascular-nervous bundles. Resection of granulomas and degraded tissue should be performed as a block unit. This produces a signicant loss of volume
that will generate aesthetic consequences or deformity secondary to the resection
[34–36].
Preoperative diagnostic images such as MRI allow us to determine the areas to
be treated. In a complementary way, during surgery, the use of ultrasound can guide
a b
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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395
c
Fig. 27.7 (a) J-Plasma direct application against biopolymer. (b) Needle puncture. (c) Laser direct
application. In all three scenarios the biopolymer capsule remained almost intact despite using the
devices with the maximum possible power
Fig. 27.8 Appreciate the
diameter of the biopolymer
capsule that is large
enough to not trespass the
cannula holes
us with greater precision to discover hidden, non-visible or non-palpable granulomas, improving the efciency of the surgical intervention.
Due to the deformity caused by the resection of the tissue block, it will be necessary at least two surgical times, the rst for the remove of the material and severely
compromised tissue, and the second one aimed to repair the normal anatomy of the
area by reconstruction of the resulting deformities, using aps, grafts, or even
implants.
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C. A. Ríos et al.
27.9.1.2 Video Endoscopy Tissue Resection
Endoscopic surgeries have been part of the reconstructive and aesthetic plastic surgery toolbox for the past few decades. Endoscopy could be used in cavities such as
the chest, abdomen, or hollow viscera, as well as solid tissues such as muscle and
subcutaneous tissue. In the area of the back and buttocks we can perform a dissectionwith resection of granulomas and areas of tissues in a block, assisted by endoscopic vision [37–39].
This technique is indicated for patients with localized involvement that do not
have signicant skin damage, or that which the MRI does not show total muscle
involvement; also, in patients with previous interventions thatused energy emission
(Laser, Vaser, etc.). This technique allows to treat during the same surgical procedure different areas such as lumbosacral region, buttocks, and hips, by resecting
tissues and granulomas in segmental blocks [40–43].
We use a laparoscopy system; the incisions for the trocars are set as follows: one
(medial) in the intergluteal crease and two (laterals) on the anks (Fig.27.9). We
perform gas insufation in the lumbar and gluteal region. Subsequently,dissection
with electrosurgical knife, scissors, and graspers of the demarcated areas, lumbosacral region, upper third, and middle third of the buttocks, sparing the inferior buttock third.
We prepare a 2–3cm thick ap, detach it at the level of the fascia, performing
fasciectomies when the fascia has been affected by the allogeneic substance
(Fig.27.10). The ap is removed in a single block or separated (Fig.27.11). We
perform meticulous hemostasis and once the bleeding has been controlled, then we
proceed to the placement of lower Penrose drains and bilateral Hemovac. Then we
putBaroudi sutures with 2–0 vicryl and CT1 needle to close the dead space. We
recommend to the patients the use of a compression garment for 2 months
(Fig.27.12).
27.9.1.3 Large Incisions Tissue Resection
Large incisions surgery, is reserved for patients that present symptomatic infection,
stulas, necrosis, deformities, or that have undergone other surgical techniques
without improvement of the clinical condition. Based on the severity of the skin
damage and the ndings of the MRI, we perform a transverse incision, that could
extend from the midline to the posterior axillary line on each side (Fig.27.13).
We dissect the ap as far as the aponeurosis of the paravertebral muscles and the
quadratus lumborum muscle, then we elevate the upper ap to t10–t11 level, inferiorly to the union of the middle third with the lower third of the gluteus and laterally,
we dissect the ap as far as the aponeurosis of the tensor fasciae latae muscle,raising it to the level of the hips (Fig.27.14).
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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Fig. 27.9 Patient position
on the surgical table, the
trocars for endoscopy are
set on the lateral anks and
in the intergluteal crease.
The delimited yellow area
is the main zone where the
resection should be
performed
Fig. 27.10 Dissection of
the ap during video
endoscopy
397
Fig. 27.11 Flap resected
in block
398
a
C. A. Ríos et al.
b
Fig. 27.12 A 32-year-old, female patient that underwent to videoendoscopic surgery to remotion
of biopolymers material. (a) Preoperative picture, appreciate the deformities of the gluteal area. (b)
6weeks postoperative of reconstructive surgery, in this case we performed liposuction of approximately 5500cc and fat grafting of 200cc in each gluteus, observe the natural look and the scarless
harmonious appearance
We perform a block resection of the upper and lower ap according to the markings (Fig.27.15), checking the tissue elasticity that will allow the closure of the
skin. Once the ap of subcutaneous tissue has been resected, we mark the supercial fascia in the back as well as in the buttocks, and dissect it to the limit of
the fascia.
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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Fig. 27.13 Large incisions
for open surgery
Fig. 27.14 For open
surgery the ap is dissected
in accordance with the
extension of the
biopolymer presence in
the body
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