Limb-to-crotch. Repost

Israel Sarrió arrived at the Rehabilitation Center of Levante from Hospital Peset in Valencia (Spain) on January 31st of 2004 with an amputation of the left arm 2 inches above the elbow.

Amputated ArmTrunnionrx
Click on images for large size
At 14:00hrs, the microsurgery implant began. The first maneuver consisted in lavage and sterilization of the amputated arm and its connection to the brachial artery by a silicone tube in order to revascularize it.

Later we rebuilt the humerus and repaired the brachial artery, the basilic and cephalic veins, and the three nerves of the arm.

This proccess lasted 21 hours, and the reimplantation was successful. The patient went to the Intensive Care Unit during that night and the next day, he went to a normal room.

first implant
Two days later, we found a wound infection that was seriously compromising the viability of the reimplantation. We talked to the family and they told us that the day of the accident the arm fell in a drain. This contamination was the probable cause of the unfavorable progress. The situation was critical, and we said to the family that there were two different options: reamputate the arm or try to save it by taking it into a healthy zone where it would be possible to nourish it while we cleaned the infected area.

wound infection
The idea of taking the arm to another anatomical location came by reading a similar case published by Michael Wood (Mayo Clinic, Rochester, MN, USA) in which he attached an arm in the groin. The uniqueness of our case consisted of using the procedure to rescue the limb from an infection, called a Deferred Transitory Heterotopic Implant. This was the first such case of involving an elbow.

With the agreement of the family it was decided to transfer the arm to the groin where large blood vessels are readily accessible. In 4 hours we disassembled the reconstruction performed earlier and connected the blood vessels of the arm to those of groin by means of microsurgery.

implant in dangerleg implantleg implantleg implant
The psychological impact on the patient was very important. As soon as he woke up, we told him that the arm was infected and we have to save it in other location on his body. After a couple of hours he realized that the arm was on his leg. He stayed that way for nine days with daily cleanings until it was verified that the stump was clean.

On February 12nd of 2004, we reimplanted the arm in its original place, rebuilding bone, arteries, veins, nerves, muscles and skin in a procedure of 6 hours.

replantpost replant
Afterwards, the patient was doing physically and psychologically well, happy that he have not have to lose his arm.

By this time the patient could move his elbow. From the time of the surgery, the repaired nerve functionality is growing at a speed of 1 milimeter per day. In about 6 months we hope that he will be able to move his hand and fingers.

The function which we hoped to obtain from this procedure was better than those obtained with an amputation and the prosthesis. The patient will be able to grasp objects, to perform normal life functions, such as tie his shoes, all with small orthopedic aids.

final status
The complete surgical team of the Unit of Hand and Reconstructive Surgery was involved in this operation, with Dr. Pedro Cavadas leading the team, and Dr. Navarro, Dr. Soler, Dr. Duke and Dr. Landin as assistants.


FAQ: Understanding Kidney Stones (Part II)

In a previous post, I wrote about: What are kidney stones, how common are kidney stones, kidney stones composition and risk factors for kidney stones disease.

  • A first-time kidney stone (urolithiasis) former is at risk of having another episode?

Yes. First-time stone formers have a 50% risk for recurrence within the sub­sequent 10 years.

  • Which patients need metabolic evaluation (work-up)?

Those that are recurrent stone formers, who have a strong family history of stones, those with chronic diarrhea or with history of pathologic fractures, osteoporosis, urinary tract infection (UTI) with calculi, gout, solitary kidney, urological anatomic abnormalities, renal insufficiency or those with stones composed of struvite, uric acid or cystine.

  • What are the general conservative recommendations for all patients who have had kidney stones (urolithiasis)?

Consume enough fluids to produce at least 2 liters of urine per day. Soda beverages flavored with phosphoric acid may increase stone risk, whereas those with citric acid may decrease risk. Regarding diet, studies have shown a great advantage of a diet with reduced animal protein (meat) intake. Dietary sodium restriction. Have a diet high in fruits and vegetables. Calcium restriction INCREASES stone recurrence risk and calcium supplements should be taken with meals.



FAQ: Understanding Kidney Stones (Part I)


  • What are kidney stones?

Are small (at the beginning), hard mineral deposits that form in the kidney. Urine contains dissolved salts and minerals. If the urine has high levels of this deposits, you can form kidney stones. Stones can stay in the kidney, but eventually can travel down to the ureter, bladder and urethra. If the stone blocks the ureter, it also blocks the urinary flow and can cause excruciating pain.

  • How common are kidney stones?

The lifetime prevalence of having kidney stones is estimated at 1% to 15%. It varies according to race, age, gender and geographic location. Specifically, 114.3 per 100,000 people will have an episode of kidney stones. It is estimated that more than 500,000 people visit emergency departments for kidney stone disease.

  • What are kidney stones made of?

Calcium stones (calcium oxalate by far is the most common) in 80% of cases.  Uric acid stones 5-10%. Struvite 10% mostly related to urinary tract infections. Cystine less than 1% of cases.

  • What are the risk factors for kidney stones?

Men are affected 2-3 times more than women. It is more common in whites, followed by hispanics, asians, and african-americans. It is uncommon before age 20 but peaks in the fourth to sixth decades of life. It has a higher prevalence in hot, arid, or dry climates (mountains, desert, or tropical areas). However, genetic factors and diet may influence this disease. Heat exposure and dehydration are occupational risk factors for kidney stone disease. Also overweight and high body mass index are directed related to kidney stone disease. Despite this risk factors, the most important risk factor is dehydration, so a high fluid intake can prevent urolithiasis.



Don’t miss PART II of this FAQ.


Top 10 Most Prestigious Medical Centers in the World (2016)

The world is full of excellent medical centers all competing to make the newest medical discovery, perform the latest procedure and be a top-performing hospital with the best reputation. These renowned medical centers model excellent clinical practice and dedicated patient care that you just can’t find anywhere. Out of all the prestigious medical centers in the world, these 10 lead the way:

  1. Texas Medical Center: The Texas Medical Center in Houston, Texas, is the largest of its kind. Not only does the TMC have one of the highest volumes of clinical facilities for patient care, basic science and research, but it also has two medical schools, four nursing schools and other specialized institutions. The internationally renowned University of Texas M.D. Anderson Cancer Center is located in the TMC and continually ranks as the No. 1 cancer care hospital in the nation. Patients from all around the world come to the TMC to receive world-class health care from the best doctors around.
  2. Parkway Health Care: Parkway Health Care, located in Singapore, is a world-class health care provider whose16 hospitals span across Asia, Europe and the Middle East. The Singapore medical center has three hospitals with one more under development. Experienced and bright physicians, nurses and scientists make Parkway Health Care a model for patient care and clinical research in Asia and around the world. Parkway also provides a wide variety of specialty care in neuroscience, oncology, cardiology, cellular therapy and many other complex fields of medicine.
  3. Bumrungrad Medical Center: Bumrungrad International Hospital, located in Bangkok, Thailand, is the largest private hospital in Southeast Asia. The prestigious medical center is internationally accredited and has been recognized for its specialty hospitals that offer top-notch care. More than one million patients from all walks of life come to Bumrungrad every year, and a good portion of them are international patients.
  4. American Hospital of Paris: The American Hospital of Paris continues to receive top marks as one of the most prestigious hospitals in the world. It was created in 1906 by a group of Americans living in Paris, who wanted to provide American-trained and English-spoken medical care to other Americans living there. The United States Congress recognized the hospital in 1913, which granted it federal status. Since then, the hospital has grown in size and status in the medical community. The American Hospital of Paris offers superior patient care and continues to be at the forefront of medical research and development.
  5. Mayo Clinic: Mayo Clinic, Saint Marys Hospital and Rochester Methodist Hospital make up the largest integrated medical center in the world, which is the one of the best of its kind. The medical center is located in Rochester, Minnesota, and sees more than 350,000 patients each year. Patients can find just about any medical and surgical specialty here, including its top-ranked departments of pulmonology, orthopedics, kidney disorders and diabetes and endocrinology. Mayo Clinic’s brilliant staff of physicians, nurses, scientists and students makes this one of the most prestigious medical centers in the world, and a model of excellence in patient care, research and medical education.
  6. The London Clinic: The London Clinic is the largest independently owned nonprofit hospital in the United Kingdom and one of the best medical centers in the world. This fully equipped hospital is led by some of the best and brightest physicians, nurses and scientists around. They are experienced and trained to treat a wide range of medical conditions and conduct complex surgical procedures, using state-of-the-art endoscopy tools and robotics. In addition to innovative medical research and procedures, The London Clinic is focused on providing the best individualized patient care possible.
  7. Centro Medico ABC: The ABC Medical Center is a private, not-for-profit institution in Mexico City that’s committed to providing high-quality patient care and educational training in the field of medicine. This prestigious medical center is one of the leading health care systems in Mexico and Latin America. ABC has four specialized medical centers: Neurological, cancer, transplants and nutrition, obesity and metabolic center. Not only does the hospital provide excellent medical care in a wide variety of specialties, but it also has one of the best medical institutions for training future health professionals.
  8. Klinik Hirslanden: Klinik Hirslanden is the principal hospital of the Hirslanden healthcare group in Zurich, Switzerland. The leading private healthcare group in Switzerland is also one of the best medical centers in the world. The medical center is comprised of 13 hospitals and specialized departments that are fully equipped to treat a range of medical conditions. Klinik Hirslanden’s state-of-the-art facilities and modern architecture truly embody the prestige of this excellent medical center.
  9. Matilda Medical Centre: The Matilda Medical Centre is a prestigious medical facility located atop Victoria Peak on Hong Kong Island. This leading name in medicine has a terrific reputation for providing excellent patient care and meeting high clinical and educational standards. The Matilda Medical Centre has a wide range of medical departments, surgical care centers and health assessment services. State-of-the-art equipment, advanced medical procedures and top-notch doctors, nurses and scientists truly make Matilda Medical Centre a model of excellence for the entire medical community.
  10. The Prince of Wales Hospital: The Prince of Wales Hospital (POWH) is Sydney’s major teaching hospital that serves hundreds of thousands of patients yearly. POWH is the recipient of several research grants and is the only Phase I research facility in the Southern Hemisphere. This medical center has about 440 beds and more than 90 percent of them are occupied throughout the year. The brilliant 3,000-person staff handles a wide range of medical conditions inside the hospital and outside through rural outreach services.

Myths: Human Papillomavirus infection

Human papilloma virus (HPV), coloured transmission electron micrograph (TEM).
Human papilloma virus (HPV), coloured transmission electron micrograph (TEM).

Common myths & facts about HPV infection

  1. Not a common problem. Approximately 80% of sexually active adults will have the HPV virus at some point during their life.
  2. Only women get HPV. This infection is common in both sexes.
  3. Condoms prevent HPV infection. If there is a skin-to-skin contact, you can get the infection.
  4. Every type of HPV cause cancer. High-risk viruses (16, 18) can cause cervical, anal, oral and penile cancer.
  5. Only vaginal sex can spread the infection. HPV can be spread through oral, vaginal or anal sex.
  6. Garlic concentrate can cure the HPV. There is no cure for human papillomavirus infection.

Be sure to look for a medical opinion if you think you may have an HPV infection.


Top ten US hospitals in 2011 – 2012

Best Hospitals

  1. Johns Hopkins Hospital, Baltimore
  2. Massachusetts General Hospital, Boston
  3. Mayo Clinic, Rochester, Minnesota
  4. Cleveland Clinic, Cleveland
  5. Ronald Reagan UCLA Medical Center, Los Angeles
  6. New York-Presbyterian University Hospital of Columbia and Cornell, N.Y.
  7. UCSF Medical Center, San Francisco
  8. Brigham and Women’s Hospital, Boston
  9. Duke University Medical Center, Durham, N.C.
  10. Hospital of the University of Pennsylvania, Philadelphia

Best Hospitals by Speciality


  • University of Texas M.D. Anderson Cancer Center. Houston, TX
  • Memorial Sloan-Kettering Cancer Center. New York, NY
  • Johns Hopkins Hospital. Baltimore, MD


  • Cleveland Clinic. Cleveland, OH
  • Mayo Clinic. Rochester, MN
  • Johns Hopkins Hospital. Baltimore, MD


  • Mayo Clinic. Rochester, MN
  • Massachusetts General Hospital. Boston, MA
  • Johns Hopkins Hospital. Baltimore, MD


  • Johns Hopkins Hospital. Baltimore, MD
  • Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital. Boston, MA
  • UPMC-University of Pittsburgh Medical Center. Pittsburgh, PA


  • Mayo Clinic. Rochester, MN
  • Cleveland Clinic. Cleveland, OH
  • Johns Hopkins Hospital. Baltimore, MD


  • Mount Sinai Medical Center. New York, NY
  • Ronald Reagan UCLA Medical Center. Los Angeles, CA
  • Johns Hopkins Hospital. Baltimore, MD


  • Mayo Clinic. Rochester, MN
  • Johns Hopkins Hospital. Baltimore, MD
  • Brigham and Women’s Hospital. Boston, MA


  • Mayo Clinic. Rochester, MN
  • Cleveland Clinic. Cleveland, OH
  • Johns Hopkins Hospital. Baltimore, MD


  • Johns Hopkins Hospital. Baltimore, MD
  • Mayo Clinic. Rochester, MN
  • Massachusetts General Hospital. Boston, MA


  • Bascom Palmer Eye Institute. Miami, FL
  • Wilmer Eye Institute, Johns Hopkins Hospital. Baltimore, MD
  • Wills Eye Hospital. Philadelphia, PA


  • Hospital for Special Surgery. New York, NY
  • Mayo Clinic. Rochester, MN
  • Massachusetts General Hospital. Boston, MA


  • Johns Hopkins Hospital. Baltimore, MD
  • Massachusetts General Hospital. Boston, MA
  • McLean Hospital. Belmont, MA


  • National Jewish Health, Denver-University of Colorado Hospital. Aurora, CO
  • Mayo Clinic. Rochester, MN
  • Cleveland Clinic. Cleveland, OH


  • Rehabilitation Institute of Chicago. Chicago, IL
  • Kessler Institute for Rehabilitation. West Orange, NJ
  • University of Washington Medical Center. Seattle, WA


  • Johns Hopkins Hospital. Baltimore, MD
  • Hospital for Special Surgery. New York, NY
  • Cleveland Clinic. Cleveland, OH


  • Johns Hopkins Hospital. Baltimore, MD
  • Cleveland Clinic. Cleveland, OH
  • Mayo Clinic. Rochester, MN




Basic equipment to perform semi-rigid (endoscopic) ureterolithotripsy for lithiasis of the lower third of the ureter.

We use an ultra-thin uretero-renoscope and a lithotriptor (Swiss Lithoclast 2), the stone is fragmented and extracted from the ureter. Results are excellent.

Soon, I’ll upload a video to show you how it is done.

Recto-Vesical Fistula


Recto-vesical fistula is an anomalous communication (fistulous tract) between the bladder and the rectum. The common etiologies are diverticulitis, Crohn’s disease, irradiation, traumatic, bladder or colo-rectal cancer and tuberculosis.

Common symptoms of presentation are fecaluria (presence of feces in the urine), pneumaturia (passage of gas in the urine), hematuria (presence of blood or clots in the urine), intestinal symptoms, abdominal pain, and fever/chills.

Evaluation: urine test (urinalysis) shows food fibers, fecal particles, bacteria, white blood cells and red blood cells.

Cystography shows fistulous tract and bladder inflammation, as seen in this picture, which is a diagnostic/evaluation method barely used because of availability of CT scans.

Later I will give you the fast facts about treatment of this condition.

SurgeXperiences 3.23

It’s an honor and pleasure to bring you this new edition of The Best Surgical Grand Rounds Carnival.


I would like to express my gratitude to Jeffrey Leow of Vagus Surgicalis (Australian medical student with lots of interest and knowledge of surgery) and the creator of this Great Carnival. Australia is in Group D.

Bongi, a lucky SouthAfrican general surgeon who will host the FIFA World Cup in 12 days, shares a story that will push you to learn Afrikaans. South Africa will be head of the Group A and will play with México, Uruguay and France.

rlbates, my favorite (female) plastic surgeon who lives to sew, wrote an excellent review of Scalp avulsion injuries. USA will play against England, Algeria and Slovenia in Group C.

Techknowdoc, a surgeon part of the Indian Medical Industry, shares his point of view about antibiotics use in abscess drainage. Match ball are made of latex bladder of India.

Julia wrote a comparison between nursing informatics and medical informatics, both are related, they are not exactly the same. Julia is an italian name; Italy is head of the Group F and will play against Paraguay, New Zeland and Slovakia.

Medical Transcriptionist, published an article that states the need for nurses and other medical professionals increase with the demand of elderly health care, as in France. France is part of the Group A and will play with México, Uruguay and the host South Africa.

From DrDJ, a surgical case of a giant condyloma acuminatum (also know as Bushke-Löwenstein tumor) and follow-up. Abraham Buschke was a German dermatologist. Germany is head of Group D.

Agravated DocSurg, wrote his 4th test of OR Rorschach. Very Creative. Hermann Rorschach was a swiss psychiatrist. Swiss is in Group H, with Spain, Honduras and Chile.

From Boobcast; writings of a woman’s bad boob job. Finally she got her nipple reconstruction procedure done which includes a video. She is from US, but in Group C is England.

Madoline Hatter presents 50 Great Sites for Menopause Support posted at Nursing School Search Blog. Magdalena is Madoline in Portuguese. Portugal is in Group G, with Brazil.

Dr. Armughan Riaz is a cardiologist from Pakistan; he wrote an article of foods that can lower blood sugar. The Greek term Diabetes, means “one that straddles”. Greece is in Group B.

I have to thank all participants, all publishers and specially all of our readers.

World Cup objectives:

  • Developing the game
  • Touch the world
  • Build a better future