Fibrin sealant for the reconstruction of fournier's gangrene sequelae

PURPOSE: We describe the use of fibrin tissue adhesive as an adjunct for reconstructing genital skin loss due to Fournier's gangrene. MATERIALS AND METHODS: We treated 2 patients with Fournier's gangrene with repeat surgical débridement and antibiotics. Delayed primary closure was enhanced by using liquid fibrin sealant. In 1 case the sealant was used to obliterate a large testicular thigh pouch that had become infected. In the other case it was used to anchor the under surface of a thigh flap for scrotal reconstruction. RESULTS: In each patient the fibrin tissue adhesive prevented further complications of Fournier's disease. CONCLUSIONS: Fibrin sealant is an effective adjunct for managing extensive genital skin loss caused by Fournier's gangrene.     

肢体高压注射伤的临床治疗

目的 分析肢体高压注射伤的治疗和临床效果.方法 2011年6月-2013年1月,对4例肢体高压注射伤患者.均在伤后4h内给予清创,1例清创两次,以交臂皮瓣覆盖创面;1例清创三次,以游离植皮覆盖创面;1例清创一期闭合创口,术后创口感染皮肤缺损,以局部转移皮瓣覆盖创面;1例直接闭合创口.术后均给予系统康复治疗.结果 4例患者术后随访时间为5～24个月,均未出现肢体坏死,皮瓣及植皮全部成活.2例手部高压油漆注射伤患者术后均存在冷诱导综合征和指端感觉异常,按TAM系统法评定：优1指,良2指.2例足部高压水枪注射伤患者术后下肢负重、走路无异常,已重新回到工作岗位.结论 肢体高压注射伤是一种特殊类型的损伤,需要有经验的临床医师依据具体病情制定相应的治疗方案,要积极早期清创,及早闭创,早期进行康复治疗,降低肢体伤残率.     

Current applications of fibrin sealant in urologic surgery

Biosurgical preparations designed to promote surgical hemostasis and tissue adhesion are being increasingly employed across all surgical disciplines. Fibrin sealant is the most widely studied and utilized biosurgical adjunct in urology. Complex reconstructive, oncologic, and laparoscopic genitourinary procedures are those most appropriate for sealant use. This article details the diverse urologic applications of fibrin sealant in the management of genitourinary injuries, surgery, and complications.     

Hemostatic agents and tissue glues in urologic injuries and wound healing

Biosurgical preparations designed to promote surgical hemostasis and tissue adhesion are now available to the urologist and are increasingly being used across all surgical disciplines. Fibrin sealant and gelatin thrombin matrix are the two most widely used bio-surgical adjuncts in urology. Complex reconstructive, oncologic, and laparoscopic genitourinary procedures are those most appropriate for sealant use. This article details the diverse urologic applications of biosurgical products in the management of urologic injuries and the promotion of wound healing.     

Management of neuromas

After nerve injury and regeneration, significant pain may be associated with the scar and altered sensation observed within the distribution of the injured nerve. A bulbous swelling may form at the severed nerve end, constituting a traumatic neuroma. The development of a painful neuroma may be more disabling to the patient than an area of anesthesia or even loss of motor function. Effective treatment of the painful neuroma remains a difficult problem. Diminished productivity, alterations in patient lifestyle, and possible progression to chronic pain syndromes must be considered within the scope of neuroma management, and treatment must focus on alleviating the pain and restoring the functional loss caused by the nerve injury. Careful patient selection is the cornerstone of successful outcomes. Once the patient has been selected, the surgical management of the painful neuroma throughout the body is based on basic principles that vary only slightly from region to region. Using these tenets, a neuroma management algorithm has been developed based on the pathophysio-logy of the neuroma, the results of experimental studies, review of patient outcomes, and understanding the psychology of pain in the surgical patient.     

Tissue glues and nonsuturing techniques

PURPOSE OF REVIEW: This article details the diverse urologic applications of tissue glues and hemostatic agents over the past 3 years in the management of genitourinary injuries, surgical wounds, and complications. RECENT FINDINGS: Biosurgical agents designed to promote tissue adhesion and hemostasis are being increasingly employed across all surgical disciplines. Fibrin sealant is the most widely utilized biosurgical product. Gelatin matrix thrombin has proven to be an efficacious hemostatic agent. Bovine serum albumin-gluataraldehyde is a new, promising tissue glue. Complex reconstructive, oncologic and laparoscopic procedures are those most appropriate for sealant use in urology. SUMMARY: Tissue glues and hemostatic agents are effective, safe, and their use is increasing. All urologists should have a working knowledge of these adjuncts.     

Repairing the posterior postinfarction ventricular septal defect: a left ventricular approach with a sealant reinforced multipatch technique

An uncommon complication of acute myocardial infarction (AMI), postinfarction ventricular septal defect (PI-VSD), often yields devastating outcomes. Because of the strikingly poor quality of the residual tissue, the repair of PI-VSD poses a surgical challenge and is associated with high operative mortality as well as residual or recurrent shunting. Among the various techniques that have been developed, we prefer a left ventricular approach to repairing PI-VSD by using a multipatch technique reinforced with a sealant as an adjunct to surgical repair. In this method, 3 patches are used: two overlay the left side of the VSD with a sealant (composed of albumin cross-linked to glutaraldehyde) sandwiched between them, whereas a third patch is used to cover the ventriculotomy defect. The rationale is that the use of such a sealant decreases the complications of PI-VSD repair by providing a sturdier surface for suture placement, thereby decreasing suture dehiscence and consequent recurrence of septal rupture. This multipatch technique offers hope in improving the results of the surgical management of PI-VSD.     

Thoracoscopic application of a topical sealant for the management of persistent posttraumatic pneumothorax

BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of blunt or penetrating chest trauma. Currently, most patients are managed with pleural chest tube(s) and suction drainage. Prolonged hospital stay and added cost of care are not uncommon. METHODS: Over a 2-year period, 13 patients with PPP, nonresponsive to conventional management, underwent video-assisted thoracoscopic surgery (VATS). As part of our protocol for PPP, routine preoperative computed tomography of the chest and bronchoscopy to determine the presence of associated injuries were performed in all of the patients. During the VATS procedure, all of the patients underwent drainage of any retained hemothorax, and a topical surgical sealant was applied to the source of the air leak as definitive treatment. RESULTS: A persistent pneumothorax with an air leak was identified in all 13 of the patients. There were 10 patients with blunt and 3 patients with penetrating injuries, respectively. The mean age for the patients was 34 years (range, 13 to 64 years). Parenchymal lacerations were identified in all of the patients ranging in size from 0.5 to 3 cm. After the VATS procedure and application of the surgical sealant, 11 patients had the chest tubes removed within 24 hours of the procedure. In the other two patients, the chest tubes were removed within 48 hours. There was no recurrence of the pneumothorax in any of these patients. The mean length of hospital stay before VATS and the application of the surgical sealant was 6 days (range, 2-14 days). CONCLUSION: Early VATS and the use of a topical sealant in patients with PPP is a safe and effective alternative to the conventional management with prolonged thoracostomy chest tubes or an open thoracostomy. This alternative management, when used early in the appropriate patient, will decrease the length of hospital stay, cost of care, and unnecessary procedures.     

Management of soft tissue infections in the region of the extremities and the trunk

Skin and soft tissue infections (SSTI) are amongst the most common bacterial infections in humans. SSTI have a broad range of aetiology, clinical manifestation and severity. The outcome may be spontaneous resolution or on the other end sepsis with lethal outcome. Useful classifications are those which differentiate SSTI according to urgency of surgical intervention. The definitive diagnosis should be made by the clinical picture of the lesion and the condition of the patient. The key to successful treatment of many severe necrotizing soft tissue infections is based on early detection and prompt surgical debridement. This procedure has to be followed by an optimal wound management. From the early beginning of treatment an adequately calculated antibiotic treatment is mandatory. At the end of the treatment the wound has to be closed by an aesthetic scar with high mechanical load capacity.     

Minimizing complications in the use of fibrin sealant in aesthetic facial procedures

Background: Bulky dressings, drains, and postoperative support garments are commonly used after facial aesthetic surgery. Fibrin sealant has been used as a successful alternative in Europe and Japan for more than 20 years but was only recently approved for use in the United States. Objective: We sought to determine whether application of fibrin sealant would eliminate the need for dressings, drains, and garments and provide satisfactory aesthetic results without an increase in postoperative complications. Methods: Fibrin sealant was used in 105 patients undergoing 128 facial aesthetic procedures, including face lifts, coronal brow lifts, temporal tucks, midface rejuvenations, and neck lifts. The surgical techniques performed were unchanged from those used by the senior surgeon without the use of the sealant. The sealant was applied only after achievement of complete hemostasis. In response to a number of complications, methods were developed to minimize pooling, ensure homogeneous application, and stabilize flaps until the sealant had “set” for a specified time. No drains, dressings, or support garments were used during the postoperative period. Results: Although successful aesthetic results and increased patient satisfaction with the surgical experience were achieved, unexpected complications, including 10 cases of seroma and 5 cases of skin necrosis, occurred early in the series. These complications were traced to problems in the preparation and application of the fibrin sealant, including failure of the sealant material to dissolve properly during preparation, improper patient positioning, inconsistent application of the sealant, and timing of the application. Once these problems were identified and rectified, no further complications occurred. Conclusions: Fibrin sealant can be used effectively in facial aesthetic surgery. Careful attention to the preparation and application of the sealant will prevent postoperative complications.     

Dural sinus thrombosis in a patient with protein S deficiency--case report

A 23-year-old female presented with dural sinus thrombosis caused by protein S deficiency. She suffered superior sagittal sinus thrombosis 6 days after delivering her first child. Past history showed deep vein thrombosis at the age of 20. While conservative management was initiated because of the potential risk of increasing intracranial hemorrhage, several hours later she deteriorated rapidly because of severe brain swelling with massive hemorrhage. The patient died despite surgical decompression. Autopsy disclosed organized thrombus in the superior sagittal and transverse sinuses. Although the total concentration of protein S was normal, the free protein S concentration and protein S activity were decreased. Protein S deficiency is a rare cause of dural sinus thrombosis, but is associated with a high mortality rate, so accurate diagnosis and urgent intervention are required.     

Severe postoperative laryngeal oedema causing total airway obstruction immediately on extubation

We report a case of total upper airway obstruction occurring immediately after extubation after elective bi-maxillary osteotomy. The obstruction was caused by severe, progressive supraglottic oedema, which totally obscured the laryngeal inlet. No swelling had been present at initial laryngoscopy and intubation. Immediate re-intubation of the patient's trachea was difficult but life saving. Subsequent investigations revealed extensive soft tissue swelling, maximal at the level of the hyoid and extending downwards into the trachea. The cause of such severe oedema in this case is not certain, but may be related to vigorous submental liposuction carried out at the end of operation. We have found no other reports of total airway obstruction occurring immediately after extubation as a result of this cause. We review the appropriate literature, describe the postoperative management and suggest precautions in similar patients.      

Reconstruction of the burned lower extremity.

Many of the long-term sequelae and deformities are preventable by early wound closure and aggressive physical managements. Concurrent and associated injuries and medical problems may place a patient with lower extremity burn injury into different clinical subsets. The standard care may have to be modified to accommodate these differences. The scars, the deformities, and the morbidity have decreased dramatically with early aggressive care and physical management. When contractures and deformities are recognized early in the rehabilitation phase, many of these can be satisfactorily corrected by physical means. If the contractures cause functional limitations, surgical release is indicated. The donor defects of free grafts or flaps should not be more deforming than the original injury. The goal is to return the patient to society as normal in function and appearance as possible.     

Tumoral calcinosis of the shoulder

Tumoral calcinosis is a rare clinical and histopathologic syndrome that causes the formation of calcium salt crystal deposits in periarticular soft tissue. This soft tissue calcification typically behaves as a large-sized tumor. However, the mechanism is unknown for the massive periarticular calcification caused by tumoral calcinosis. In addition, tumor calcinosis occurs infrequently in patients who have been on long-term hemodialysis and have end-stage renal disease (ESRD). This report describes a 40-year-old male uremia patient on long-term hemodialysis. This patient developed a huge tumor mass and pain over the left shoulder and was diagnosed with tumoral calcinosis. Although common treatments include management of metabolic levels such as calcium and phosphate, in some cases, surgical intervention may be needed. In this patient case, complete surgical excision was done successfully with an excellent outcome at the 2-year follow-up.     

Extravascular compression of the femoral vein due to wear debris-induced iliopsoas bursitis: a rare cause of leg swelling after total hip arthroplasty

We present a patient with unilateral, spontaneous, late leg swelling that developed 4 years after total hip arthroplasty. The etiology was the compression of the internal iliac vein by a voluminous iliopsoas bursitis caused by polyethylene debris. The expansive lesion was detected by ultrasound, arthrography, and magnetic resonance imaging. An ultrasound-guided aspiration provided transient relief of the patient's symptoms. The patient later required surgical excision through an abdominal approach. A second recurrence was detected and treated with revision surgery. We present the diagnosis and the treatment of this rare cause of late, unilateral leg swelling after total hip arthroplasty together with a review of the literature.     

Fish vaccine injection injuries of the hand.

High pressure injection of oil-based substances can cause devastating injuries of the hand and the necessity for urgent surgical debridement has been well established. We present three cases of injection injury caused by vaccines used in the fish farming industry. Patients presented with pain, swelling and lymphangitis. The marked vascular changes often associated with such injuries were absent. All patients were treated with intravenous antibiotics combined with early surgical debridement and irrigation. We report full recovery in all three patients.     

Grade IV renal trauma in a patient with a solitary kidney

A 60-year-old woman with a grade IV trauma to a solitary kidney was referred to our hospital. After primary conservative management, a continuous decline of the renal function required surgical exploration with decompression and renal reconstruction on the 4th day after the trauma. Postsurgical anuria prompted insertion of a ureteral stent; thereafter the renal function recovered quickly. A urinoma caused by a urinary fistula emerged 6 months after the trauma and was treated by percutaneous drainage, ureteral stenting, and percutaneous occlusion with fibrin sealant. Twelve months after the trauma, the patient is symptom free with a normal renal function.     

Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: A case report

Necrotising fasciitis, widespread necrosis of the skin, subcutaneous tissue, and superficial fascia, may be caused by many factors, among which underlying malignancy is observed rarely. We report a case with necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion. A 62‐year‐old male with newly diagnosed renal cell carcinoma was diagnosed with necrotising fasciitis at the end of 2 days in hospital. One day after debridement surgery, biliary contamination of dressings and tomography demonstrated fistulation from the duodenum to retroperitoneum and then to the right thigh because of renal tumour invasion. The second operation was performed to repair the duodenum. Intravenous antibiotics and hydration were maintained postoperatively. Although there was no surgical complication, the patient died because of respiratory collapse at the 12th day postoperatively. Renal cell carcinoma may invade the duodenum and, with retroperitoneal fistulation, may be the cause of necrotising fasciitis of the thigh. Laparotomy may be needed to control the origin of infection. However, necrotising fasciitis may be fatal in spite of aggressive treatment. The fasciitis should be diagnosed early to initiate timely aggressive treatment, and a possible endogenous source should be kept in mind.     

Perioperative nutrition and the use of nutritional supplements

The poor dietary habits and aging of the US population have caused a steady increase in the incidence of chronic disease. The prevalence of these diseases, such as obesity, diabetes, and heart disease, may have a significant effect on perioperative management, surgical outcome, and complication rates in these patients. Nutritional intervention and supplementation may help curb some of these potential adverse affects of poor nutrition by promoting wound healing; enhancing immunity; reducing swelling, bruising, and inflammation; and reducing oxidation caused by anesthetic agents and surgery. Although a perioperative regimen of dietary supplements may enhance surgical outcomes, it is equally important to know the popular herbal products that are contraindicated in the perioperative period.     

Pectoralis major muscle injuries: evaluation and management

Pectoralis major muscle tears are relatively rare injuries that primarily occur while lifting weights, particularly when doing a bench press. Complete ruptures are most commonly avulsions at or near the humeral insertion. Ruptures at the musculo-tendinous junction and intramuscular tears usually are caused by a direct blow. The patient may hear a snap at the time of injury and report pain, weakness, swelling, or muscular deformity. Physical examination can reveal ecchymosis, a palpable defect, asymmetric webbing of the axillary fold, and weakness on resisted shoulder adduction and internal rotation. A detailed history and physical examination can be augmented by radiologic studies, including magnetic resonance imaging. Nonsurgical treatment is now recommended only for the older, sedentary patient or for proximal muscle belly tears. Surgery, whether early or delayed, consistently yields superior results compared with nonsurgical management. Prompt diagnosis and timely intervention likely will produce improved results.