Andre Panossian

Efficacy of doxycycline and sodium tetradecyl sulfate sclerotherapy in pediatric head and neck lymphatic malformations

OBJECTIVES Lymphatic malformations are congenital vascular anomalies that occur from abnormal development of the lymphatic channels. Studies have shown that sclerotherapy can be a reliable alternative to surgery. The purpose of this retrospective study is to evaluate the safety and efficacy of percutaneous sclerotherapy with doxycycline and 3% Sotradecol as primary treatment for pediatric head and neck LMs, and to assess outcomes based on lesion classification, location and sclerosant used. STUDY DESIGN This study was a single center, retrospective, case series study. MATERIALS AND METHODS The medical records of 38 children who underwent percutaneous sclerotherapy of LMs in the head and neck region at our tertiary care center between 1/1/2006 and 1/31/2011 were reviewed. A mean average of 2.9 (range 1-10) sclerotherapy sessions per child were performed. LMs involved primarily the face (61.3%), posterior neck (48.4%), submental area (45.2%), and anterior neck (35.5%). RESULTS Twenty-nine subjects had adequate follow-up data, with 51.7% demonstrating complete resolution, 27.6% moderate improvement, and 20.7% no response. There was no significant difference in the outcome based on the sclerosant agent used or location of the lesion. Lesion type did affect outcome and macrocystic lesions were found to have a significantly higher resolution rate (95.2%) than microcystic or mixed lesions (p < 0.05). The total number of complications was similar between agents and all were minor. CONCLUSION Our results indicate that percutaneous therapy with doxycycline and Sotradecol is safe and effective for children with LMs of the head and neck. Better outcomes were observed with macrocystic LMs. LEVEL OF EVIDENCE 4.

Vascular anomalies of the extremities

Vascular anomalies of the extremities are not uncommon and can significantly impede limb function. Currently, misdiagnosis is a frequent cause of delay in treatment or initiation of incorrect treatment that may detrimentally affect patients. With accurate diagnosis, the appropriate treatment can be implemented with good functional outcomes in most types of vascular anomalies. The goal of this paper is to review the classification, diagnosis, and treatment of vascular anomalies, with particular focus on recent innovations and multimodal management. By clarifying the classification system and developing an algorithmic approach, successful management of vascular anomalies can be achieved. The complexity of these disorders requires communication across multiple disciplines for coordination of care and timely interventions. A typical multidisciplinary team will include an orthopaedist, plastic surgeon, general surgeon, interventional radiologist, dermatologist, oncologist, and geneticist, among others.

Limited-incision surgical debulking of lymphatic malformations using ultrasound-assisted liposuction.

the distal interphalangeal joint into four categories. Based on the classification of Moiemen and Elliot, the new surgical technique led to excellent or good results in 25 cases, two with fair results. No further treatment was needed. All wounds healed primarily and the scar on the pulp and dorsa was noted to be comfortable without sensation and apparent appearance disorder. There was no tendon avulsion or rupture, no infection or suture reaction, and no nail deformities (Table 1). The new technique with palmaris longus tendon to rebuild the flexor digitorum profundus tendon is a reliable alternative method for the treatment of isolated acute or chronic rupture of flexor tendons in zone 1. DOI: 10.1097/PRS.0b013e31826d172e

Perirectal arteriovenous malformation treated by angioembolization and low anterior resection.

We present a case of a child with ongoing lower gastrointestinal bleeding caused by a rectosigmoid arteriovenous malformation. To reduce perioperative bleeding, we performed preoperative angioembolization followed by subsequent resection by low anterior resection. Here we present the case and review the literature regarding neoadjuvent embolization for gastrointestinal and pelvic arteriovenous malformations.

Lengthening Temporalis Myoplasty for Single-Stage Smile Reconstruction in Children with Facial Paralysis.

Background: Free muscle transfer for dynamic smile reanimation in facial paralysis is not always predictable with regard to cosmesis. Hospital stays range from 5 to 7 days. Prolonged operative times, longer hospital stays, and excessive cheek bulk are associated with free flap options. Lengthening temporalis myoplasty offers single-stage smile reanimation with theoretical advantages over free tissue transfer. Methods: From 2012 to 2014, 18 lengthening temporalis myoplasties were performed in 14 children for smile reconstruction. A retrospective chart review was completed for demographics, operative times, length of hospital stay, and perioperative complications. Results: Fourteen consecutive patients with complete facial paralysis were included. Four patients underwent single-stage bilateral reconstruction, and 10 underwent unilateral procedures. Diagnoses included Möbius syndrome (n = 5), posterior cranial fossa tumors (n = 4), posttraumatic (n = 2), hemifacial microsomia (n = 1), and idiopathic (n = 2). Average patient age was 10.1 years. Average operative time was 410 minutes (499 minutes for bilateral lengthening temporalis myoplasty and 373 for unilateral lengthening temporalis myoplasty). Average length of stay was 3.3 days (4.75 days for bilateral lengthening temporalis myoplasty and 2.8 for unilateral lengthening temporalis myoplasty). Nine patients required minor revisions. Conclusions: Lengthening temporalis myoplasty is a safe alternative to free tissue transfer for dynamic smile reconstruction in children with facial paralysis. Limited donor-site morbidity, shorter operative times, and shorter hospital stays are some benefits over free flap options. However, revisions are required frequently secondary to tendon avulsions and adhesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Refractory Kaposiform Hemangioendothelioma Associated with the Chromosomal Translocation t(13;16)(q14;p13.3).

We report a 7-year-old male with a history of recurrent kaposiform hemangioendothelioma (KHE) in the sacral area and multiple thoracic vertebral lesions. Tumor karyotyping revealed the balanced translocation t(13;16)(q14;p13.3). He had mildly decreased platelet counts but never experienced any episodes of Kasabach-Merritt phenomenon. He was treated with vincristine for 1 year but improvement was minor. Significant clinical improvement was seen with sirolimus therapy. To the best of our knowledge, this is the first report to demonstrate that KHE is associated with a clonal karyotypic abnormality.

Vascular Malformations and Associated Syndromes The Role of the Orthopaedic Surgeon

Vascular anomalies are among the most common congenital abnormalities in infants and children. The management of vascular anomalies requires interdisciplinary care and collaboration between orthopaedic surgeons, general surgeons, plastic surgeons, interventional radiologists, dermatologists, oncologists, and child life specialists, leading to the establishment of vascular anomaly teams at tertiary centers. Vascular anomalies are a heterogeneous group of conditions, with similar clinical appearance but substantially different manifestations. The development of an appropriate classification system has helped to reduce confusion regarding terminology, thus improving diagnosis and management. There are two groups of vascular anomalies: (1) vascular tumors and (2) vascular malformations. Differentiating between these two types, and their subtypes, is essential because of their distinct natural history and treatment1. The goal of this review is to highlight the role of the orthopaedic surgeon in the approach and treatment of extremity vascular malformations and to discuss diagnostic strategies and management at a multidisciplinary level. We also review the most common associated syndromes seen in the orthopaedic practice, including Klippel-Trenaunay syndrome, Proteus syndrome, Maffucci syndrome, Gorham-Stout disease or syndrome, Parkes Weber syndrome, and Bannayan-Riley-Ruvalcaba syndrome. In 1863, Virchow was the first to classify vascular anomalies into groups on the basis of their histopathologic appearance2. However, this nomenclature was confusing and often led to misdiagnosis with consequent inappropriate treatment. Mulliken and Glowacki proposed a classification system based on biological behavior …

Extremity amputations for vascular anomalies in children: a single-center experience over 10 years

Background:Amputation often is a treatment of last resort for vascular anomalies of the extremities and, as such, infrequently is indicated. Our purpose was to review our institutional experience with amputations for vascular anomalies in children, specifically identifying indications and reviewing outcomes. Methods:A retrospective chart review was conducted of all amputations for vascular anomalies at a tertiary pediatric surgery referral center over a 10-year period. Demographics, clinical characteristics, diagnostic imaging, operative details, and outcomes data were collected and analyzed. Results:Eight extremity amputations were performed in six patients. The male-to-female ratio was 1:1. Median age at amputation was 10.7 (2.3-16.1) years. The indications for surgery included refractory pain, nonfunctional limb, inability to ambulate, ischemia, and bleeding. The most common preoperative radiographic study obtained was MRI. Nonoperative management options such as steroid injections, sclerotherapy, or embolization failed in several patients. The median length of follow-up was 3.7 (0.6-7.9) years. One mortality occurred 1 year after amputation secondary to multiorgan system failure in a child with Bannayan-Riley-Ruvalcaba syndrome. Conclusions:Extremity amputation is a radical form of resection for complications of vascular anomalies. However, most patients experience resolution with an acceptable outcome and an improved quality of life.

Colonic venous malformation and portal hypertension: Association, management, and review of the literature

We present a case of an adolescent with lower gastrointestinal bleeding caused by a colorectal venous malformation (VM) with concomitant portal hypertension. After an episode of massive gastrointestinal bleeding, we performed an extended right hemicolectomy and resection of the VM and selective portosystemic shunt. Here, we present the case and review the literature regarding portal hypertension and gastrointestinal vascular malformations. Additionally, we discuss the physiologic and hemodynamic effects of gastrointestinal vascular malformations on the portal system.