CONTRACTION AND MYOFIBROBLASTS IN RESTORED SKIN

We have developed an allogeneic cultured dermal substitute (CDS) that was prepared by plating fibroblasts on to a spongy collagen matrix and culturing them for 7 to 10 days. The matrix was freeze-dried from a 1% aqueous solution of bovine-hide atelocollagen. This study was designed to evaluate the efficacy of promoting epithelialisation clinically on 26 donor-site wounds for split-thickness skin grafts. One half of a wound was covered with an allogeneic CDS and the other half side was covered with a commercially-available freeze-dried porcine dermis (FPD). Both macroscopically and histologically the epithelialisation on the area of the donor site that was covered with allogeneic CDS was more rapid than that covered with FPD. In a representative donor-site wound covered with allogeneic CDS, there was a stratified structure of epithelial cells on the underlying connective tissue on day 5, and the epithelium had matured by day 12. When covered with FPD a stratified structure of epithelial cells was noted on day 8, and the epithelium had matured by day 15. We conclude that allogeneic CDS provides a good environment for epithelialisation.     

Laparoscopic therapy of diaphragmatic rupture on both sides

Summary The usual treatment for operative repair of diaphragmatic injuries is laparotomy or thoracotomy. We report on a 26-year-old patient, who was treated by laparocopic surgery for a rupture on both sides of the diaphragm. The operation was without complications and the advantages of minimally invasive laparoscopic surgery were clearly evident. There was much less strain on the patient and the postoperative recovery period was short. In addition, for unclear findings there is a high diagnostic potential in laparoscopy. The rupture on the right side of the diaphragm was not diagnosed until laparoscopy, although our patient underwent extensive diagnostics prior to the intervention.      

Multiple paraganglioma of the urinary bladder

A 77-year-old woman who was treated for malignant melanoma was incidentally found to have a bladder tumor on a screening computed tomography (CT). On CT and magnetic resonance imaging (MRI), the tumor was detected as a well-enhanced tumor (4 x 5 cm at horizontal plane) on the left side of the bladder wall. Cystoscopy revealed a small non-papillary pedunculated tumor on the posterior wall and a submucosal tumor on the left side of the wall. We performed transurethral resection of the tumor on the posterior wall and biopsy of the tumor on the left side wall. The pathological diagnosis was paraganglioma of the urinary bladder. Serum and urine levels of noradrenaline and dopamine were elevated. 123I-metaiodobenzylguanidine (MIBG) scintigraphy showed a significant uptake on the left side of the bladder. Blood pressure was normal at rest but elevated after micturition. No pelvic lymph node swelling or distant metastasis was detected. We performed partial cystectomy for the tumor on the left side wall. After operation, serum catecholamine level was normalized and post-voiding fatigue that was present before operation disappeared. Six months after operation, a followup CT revealed a small well-enhanced tumor on the anterior wall of the bladder. Her serum noradrenaline level was slightly elevated. However, she was normotensive and had no symptoms. Therefore, a careful follow-up continued for 2 years there after has revealed no increase in tumor size and no symptoms.     

Clinical evaluation of an allogeneic cultured dermal substitute composed of fibroblasts within a spongy collagen matrix.

We have developed an allogeneic cultured dermal substitute (CDS) that was prepared by plating fibroblasts on to a spongy collagen matrix and culturing them for 7 to 10 days. The matrix was freeze-dried from a 1% aqueous solution of bovine-hide atelocollagen. This study was designed to evaluate the efficacy of promoting epithelialisation clinically on 26 donor-site wounds for split-thickness skin grafts. One half of a wound was covered with an allogeneic CDS and the other half side was covered with a commercially-available freeze-dried porcine dermis (FPD). Both macroscopically and histologically the epithelialisation on the area of the donor site that was covered with allogeneic CDS was more rapid than that covered with FPD. In a representative donor-site wound covered with allogeneic CDS, there was a stratified structure of epithelial cells on the underlying connective tissue on day 5, and the epithelium had matured by day 12. When covered with FPD a stratified structure of epithelial cells was noted on day 8, and the epithelium had matured by day 15. We conclude that allogeneic CDS provides a good environment for epithelialisation.     

Laparoscopic radical nephrectomy for renal cell carcinomas; report on two initial cases]

We recently performed a laparoscopic radical nephrectomy (LRN) on two patients with a renal cell carcinoma. Case 1, a 72-year-old man, was diagnosed as having a renal cell carcinoma 2.5 cm in diameter in the right kidney, and also a submucosal tumor of the cecum. LRN and laparoscopically assisted ileocecal resection were performed using a transperitoneal approach on September 28, 1999. Total operation time and blood loss during the operation were 308 minutes and 320 ml, respectively. The operation time needed for LRN, which was calculated as the total operation time minus the time spent on ileocecal resection, was 199 minutes. There were no complications after surgery, and the patient was recommended for discharge on the 7th postoperative day, but was actually discharged on the 10th postoperative day. Case 2, an 81-year-old man, was diagnosed as having a renal cell carcinoma 3.0 cm in diameter in the right kidney. He had been undergone a total gastrectomy for a gastric carcinoma at age 77, and a sigmoidectomy for a sigmoid colon carcinoma at age 79. A transperitoneal approach was applied for LRN to detect any recurrence of previous carcinomas on September 30, 1999. During adhesiolytic procedures, the colon was injured due to an inappropriate maneuver of the grasping forceps. A small laparotomy (5 cm) was required for repair of the colon. The total operation time and blood loss during surgery were 370 minutes and 850 ml. The operation time calculated from the video of LRN was 274 minutes. Two additional surgical procedures were required in this case. The first was for a postoperative intraperitoneal hemorrhage due to the hemoclip dropping out of the small vein. The second was for hemorrhage in the abdominal wall. Fortunately, the clinical course after surgery was good and the patient was discharged on the 8th postoperative day. There were no complications in case 1. Omitting ileocecal resection was considered to speed up oral intake, leading to earlier discharge. However, major complications occurred in case 2. It is important to clarify the cause of postoperative hemorrhage by careful observation of the video recording, in order to suggest safer procedures in laparoscopic surgery. Although these are only two LRN experiences, we are convinced that LRN can improve postoperative QOL (Quality of life) and is an acceptable alternative for the treatment of renal cell carcinomas.     

A laparoscopic duodenojejunostomy for a duodenal obstruction from lymphoma

A patient with lymphoma in one-third of the duodenum causing a duodenal obstruction is described. The patient had a partial response with chemotherapy, but still was obstructed and unable to eat. He was losing weight, and chemotherapy had to be stopped. A gastrostomy tube was inserted for drainage because the stomach was quite distended. A jejunostomy tube was passed through the gastrostomy tube for feeding, but the patient did not tolerate the feeding. A laparoscopic bypass of the duodenumduodenal obstruction (from duodenum to jejunum) for this patient is shown on a video. The patient did very well after this bypass was provided. He was able to tolerate an oral diet on postoperative day 2, and on postoperative day 4, he was discharged home. He has since resumed chemotherapy, and is doing well, at this writing, 2 months after surgery. Electronic supplementary material is available for this article at     

Late-onset chylothorax following extrapleural pneumonectomy for mesothelioma

We report a 64-year-old woman treated with surgical intervention for late-onset chylothorax following a pleuropneumonectomy. The patient underwent an extrapleural pneumonectomy for diffuse malignant mesothelioma and was uneventfully discharged on postoperative day 29. Pleural effusion aspirated on postoperative day 9 was dark red. A chest roentgenogram taken at our outpatient clinic revealed a mediastinal shift on postoperative day 56. No bacterial infection was found in the milky effusion. We made a diagnosis of postoperative late-onset chylothorax based on the laboratory data obtained from tests of the pleural fluid. A repeat thoracotomy to ligate the lymphatic duct was performed because conservative management with chest tube drainage and no oral feeding was unsuccessful. The patient was discharged after the operation with a good clinical course.     

Desmoid tumors: diagnostic and therapeutic difficulties. Apropos of an unusual case]

This observation has been previously reported as a multifocal and recidivant desmoid tumor. The first time, the patient was operated on for a desmoid tumor situated on his left thigh. He was reoperated on fourteen years later for a recurrent tumor implanted on the same place and a new one on the right arm. Recently bilateral pulmonary tumors were discovered. As far as this evolution was concerned, its exceptional pattern induced a new analysis of the microscopic data and the diagnosis of fibrohistiocytic sarcoma was established. This observation suggest to the authors some comments about the difficulty of diagnosis and therapy of such soft tissue tumors.     

Laparoscopic therapy of diaphragmatic rupture on both sides

The usual treatment for operative repair of diaphragmatic injuries is laparotomy or thoracotomy. We report on a 26-year-old patient, who was treated by laparocopic surgery for a rupture on both sides of the diaphragm. The operation was without complications and the advantages of minimally invasive laparoscopic surgery were clearly evident. There was much less strain on the patient and the postoperative recovery period was short. In addition, for unclear findings there is a high diagnostic potential in laparoscopy. The rupture on the right side of the diaphragm was not diagnosed until laparoscopy, although our patient underwent extensive diagnostics prior to the intervention.     

The effect of increasing distraction on digital motion after external fixation of the wrist

PURPOSE: Although several factors have been related to the development of digital stiffness after external fixation of distal radius fractures, distraction can be considered one of the most important. This study determined a threshold for distraction during external fixation of distal radius fractures and documented the effect of distraction of the wrist on metacarpophalangeal (MCP) joint motion. METHODS: Eight fresh-frozen cadaveric forearms were mounted on a testing frame and the flexor digitorum superficialis (FDS) tendon of each finger was pulled individually until a 90 degrees flexion at the MCP joint was generated. A load cell was used to record the force applied on the tendons. Tendon displacement was calculated by using a linear potentiometer. Sequential distraction across the wrist was applied through a distraction outrigger on the external fixator and was measured both on the external fixator in millimeters and on fluoroscopic images. Finger motion was captured by using a 2-dimensional motion tracking system. The experiment was repeated at different levels of wrist distraction (increments of 2 mm to a maximum of 14 mm). RESULTS: There was a significant difference in the effect of distraction on the individual fingers. For the index finger the load required for the FDS to produce a 90 degrees flexion at the MCP joint was increased linearly between 0 and 8 mm of wrist distraction. For the other fingers a threshold of distraction was found. A significant increase in the load was noticed after 5 mm of wrist distraction. CONCLUSIONS: More than 5 mm of wrist distraction increases the load required for the FDS to generate MCP joint flexion for the middle, ring, and small fingers. For the index finger, however, as much as 2 mm of wrist distraction significantly increases the load required for flexion at the MCP joint.     

Closure of a pharyngocutaneous fistula using a sternomastoid muscle flap

Presented here is a case of a pharyngocutaneous fistula which was closed primarily using a sternomastoid muscle flap, without skin coverage, thus obviating the need for a three-layered closure. Providing an intermediate cover was sufficient for the closure because the mucosal lining on the inside and the cutaneous covering on the outside grew using the muscle for support.     

Predictive factors for arm pain, neck pain, neck specific disability and health after anterior cervical decompression and fusion

Summary Background. Predictive factors for a low arm and neck pain, and good health after anterior cervical decompression and fusion (ACDF) with a cervical carbon fibre intervertebral fusion cage (CIFC) are still lacking. Method. A prospective consecutive study to investigate which preoperative factors that could predict a good outcome with regard to arm pain, neck pain, Neck Disability Index (NDI) and general health three years after ACDF with CIFC was conducted. Thirty-four patients were included before surgery. Measurements took place the day before, six months, one year and three years after ACDF. Findings. In multivariate analysis, to be a non-smoker before surgery was the most important factor for a low postoperative arm pain, a low pain frequency was the most important factor for low postoperative neck pain, normal rating on Distress and Risk Assessment Method (DRAM) was the most important factor for high function on NDI and a low initial pain intensity was the most important factor for good postoperative health. For all outcome variables a normal rating on DRAM was an important factor for a good outcome. Conclusions. Non-smoking, a low pain level and normal rating on DRAM were the best preoperative predictors of a good outcome in ACDF. Inclusion criteria for surgery should be based on a bio psychosocial model and DRAM seems to be useful for including the traditional inclusion criteria.     

Spindle cell carcinoma of the pancreas

We experienced a rare case of spindle cell carcinoma of the pancreas. The patient was a 74-year-old man who complained of abdominal pain and loss of weight. Ultrasonographic scans revealed a hypoechoic solid mass in the head of the pancreas, 4 cm in diameter, with a high echoic spot suggestive of central necrosis or hemorrhage. The mass was hypodense on enhanced computed tomographic scans and hypovascular on angiograms. At laparotomy, the tumor had invaded to the mesocolon, but dissemination and distant metastasis were not found. We therefore performed pylorus-preserving pancreatoduodenectomy and ascending colectomy. The patient was discharged on postoperative day 26 after an uneventful recovery. Two months later, he was readmitted because of ascites, with positivity of spindle cells shown on cytology; he died on day 92 after surgery. In the resected specimen, the tumor had a mostly sarcomatous component, consisting of spindle-shaped cells, and a small glandular component. Immunohistochemically, both components were positive for cytokeratin and epithelial membrane antigen, but negative for vimentin and desmin. The tumor was diagnosed as a spindle cell carcinoma of the pancreas. Perinural invasion, lymphatic permeation, and blood vessel invasion were found, but lymph node metastasis was not found. Although a curative operation was performed, the outcome in this patient was very poor. Received for publication on April 14, 1999; accepted on Dec. 28, 1999     

A novel technique to determine pressure in pressure garments for hypertrophic burn scars and comfort properties

Current recommendations state that pressure garments should be worn for up to 2 years for hypertrophic burn scars. Thermo-physiological properties of pressure garments were assessed by the thermo-physiological tests and a comparison of the fabric with a sportwool which is a single-jersey knitted fabric was performed. In this novel technique, it was aimed to determine the exact pressure of pressure garments on the applied body part. For the theoretical part of this study, the Laplace equation was used with an optimum pressure of 20 mmHg and a relationship between change in length versus circumference was calculated. To determine the change in length a ruler was prepared for each predetermined circumference value using this relationship. Grid printed fabric samples were prepared with an interval of 2 cm in width direction to be used for the calculation of mean pressure on a Mannequin Leg. The resultant mean pressure calculated experimentally on Mannequin Leg as 24 mmHg was compared to the optimum pressure of 20 mmHg. It was observed that the two values were not statistically significantly different.     

Survival of patients who have been on a waiting list for renal transplantation.

INTRODUCTION: Survival of transplanted patients is generally much better than for those on dialysis. This comparison is, however, incorrect, as in order to be accepted for renal transplantation the patient has to be in a relatively good condition and in addition transplanted patients are usually younger. We compared survival of all renal replacement therapy (RRT) patients who had undergone an identical medical check-up, been accepted, and put on the waiting list for cadaveric-kidney transplantation at Huddinge University hospital. A comparison with patients who were transplanted with a kidney from a living related donor (LD) is also included. METHODS: All patients (n=608) accepted and on the waiting list for renal transplantation between January 1987 and April 1996 formed the basis of the study. Follow-up was terminated on 31 December 1997. Survival was recorded from the date that the patients were accepted and put on the waiting list. As long as the patient was not transplanted and remained on dialysis treatment, survival was considered as 'survival on dialysis', and if transplanted, subsequent survival was defined as 'survival after cadaveric-kidney transplantation'. A patient who had been transplanted remained in that group for the rest of the observation period even if the transplantation had failed and the patient had to go back to dialysis after the surgery. RESULTS: Five-year survival was considerably better after LD-kidney transplantation (94%), than after cadaveric-kidney transplantation (76%) or on chronic dialysis (60%). Cox hazard regression analysis gave an age-adjusted relative risk for death of 0.46 for LD-transplanted and 1.49 for remaining on dialysis compared with cadaveric-transplanted patients. Transplanted patients, however, experienced a higher mortality during the first year after the transplantation than patients still on dialysis. CONCLUSIONS: LD-kidney transplantation is clearly associated with a superior survival. Mortality is relatively high after cadaveric-kidney transplantation, especially during the first months after surgery. Nevertheless, in the long term cadaveric kidney transplanted patients have a better survival than those remaining on dialysis.     

Posterior pancreatic head excision in malignant duodenal gastrinoma

Summary. We report on a case of malignant gastrinoma located on the posterior surface of the descending duodenum, presenting with Zollinger-Ellison syndrome. The tumor was not evident on preoperative imaging studies, metastasis was not present and there was no coincidence with multiple endocrine neoplasia type-I. As the gastrinoma was located on the posterior surface of the pancreatic head, to obtain a sufficiant safety margin, partial excision of this region was necessary. Under preservation of the Oddi's sphincter, the reconstruction was completed by direct suturing of the duodenal wall to the pancreatic surface without need for enteral diversion procedures. This technique represents a possible non-invasive resection modality for benign and malignant duodenal gastrinomas located close to the pancreatic head region.      

Active infective endocarditis due to Erysipelothrix rhusiopathiae: zoonosis caused by vancomycin-resistant gram-positive rod

A 42-year-old female who was a voluntary worker in a school for handicapped children was referred to us for surgery for active infective endocarditis. Trans-esophageal echocardiography showed 2 large mobile vegetations on the aortic valve and severe aortic regurgitation. Aortic valve replacement was performed to prevent septic embolism and deterioration of congestive heart failure. The empiric therapy with vancomycin, ampicillin, and gentamycin was initiated because a pathogen was not identified. But Erysipelothrix rhusiopathiae (gram-positive rod) was isolated on the 4th day after surgery. The target therapy with penicillin G and clindamycin was started and continued for 4 weeks after surgery. The inflammatory parameters improved steadily and the patient was discharged on the 36th day after surgery. Infective endocarditis due to gram-positive rods can be easily mistaken for streptococci or dismissed as a skin contamination. But, E. rhusiopathiae endocarditis should be considered in the differential diagnosis.