Forum: dermopigmentation or medical tattooing. Needles and ink]

Tattooing has been performed since ancient times. It has survived religions, development of education, wars and all forms of repression. Tattooing has gained a new lease of life at a time when this practice appeared to be dying out; why? In reality, tattooing corresponds to a need to be different, to make oneself attractive and to see oneself as a unique being and the age of uniformity in which we live is a very important factor for requests for dermography. Techniques have progressed together with conditions of asepsis and sterilisation. Until the profession of tattooist is officially recognised, it will always be associated with the idea of sordid techniques in makeshift quarters. The very survival of this artistic profession requires serious training and standards of hygiene. Failure to recognise this profession would result in its prohibition in the short-term, leading to clandestine activity in which standards would obviously not be respected.     

Forum: dermopigmentation or medical tattooing. In practice ... how to perform medical tattooing?]

Dermopigmentation is now part of the therapeutic armamentarium of plastic surgeons. In good indications and when applied according to a few simple rules, every surgeon can obtained reliable and reproducible results with medical dermography. This therapeutic procedure is performed on an outpatient basis, usually in several sessions; subsequent revisions are always possible provided certain basic errors are avoided. The authors describe each step of this technique.     

Elimination of monocular diplopia by corneal tattooing

Corneal tattooing to eliminate monocular diplopia secondary to surgical peripheral iris defects was performed successfully in two patients who were unable to tolerate contact lenses. The technique is simple, safe, cosmetically satisfactory, and eliminates the need for patient compliance with contact lens care. Although corneal tattooing is usually considered to have only cosmetic value, these patients demonstrate that it can be therapeutic as well.     

The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992-1997

BACKGROUND: The population level frequency of adverse events after antireflux procedures and its relationship to surgical experience has not been well studied. STUDY DESIGN: Two parallel retrospective, population-based cohort studies were conducted using the Washington State discharge database and the United States Health Care Utilization Project (HCUP) database. All adult patients assigned ICD-9 procedure codes for antireflux surgery from 1992 to 1997 were included. The frequency of case fatality, splenectomy, and esophageal injury was measured. In Washington State, the relationship of adverse outcomes to the cumulative number of procedures performed by a given surgeon (case-order) was determined. RESULTS: Nationwide, an estimated 86,411 patients underwent antireflux surgery between 1992 and 1997. Splenectomy was performed in 2.3%, suture of esophageal laceration in 1.1%, and in-hospital death occurred in 0.8%. Adverse events were significantly more likely when procedures at case-order less than or equal to 15 (median) were compared with those at case-order greater than 15. As case-order increased by 1, the risk of death decreased by 1.7% (p = 0.001), and the risk of splenectomy and injury repair decreased by 1.6% (p = 0.001). If performed at case-order less than 15, the odds ofsplenectomy were 2.7 times, esophageal laceration repair 2.3 times, and death 5.6 times greater than the odds of adverse outcomes for procedures performed at later case-orders. CONCLUSIONS: On a national level, morbidity and mortality associated with antireflux surgery performed in the 1 990s was quite low, but was somewhat higher than suggested by case series. Surgical experience with the procedure was linked to better outcomes.     

A new technique for double lung transplantation. "The bilateral single lung transplantation". Apropos of ten operations]

The technique of enbloc double lung transplantation described by the Toronto team, with cardiopulmonary bypass, cardioplegia, and tracheal suture is complicated by problems of tracheal anastomosis for its authors. Single lung transplantation has a more straight forward postoperative course and bronchial complications are moderate. We present a new technique of lung transplantation, the "bilateral single lung transplantation". It consists, via a single anterior horizontal incision, of successively performing two single lung transplantations without bypass. This operation has been performed ten times since November 1989. As expected, bronchial healing has been excellent.     

Endoscopic tattooing of the colon. An experimental study

Methods of "tattooing" the colon endoscopically were evaluated in a series of studies on dogs. Injections were performed through a sigmoidoscope using a 25-gauge sclerotherapy needle. The first phase showed excellent staining with methylene blue; however, after 24 hours the stain had completely diffused and was no longer visible. In the second phase, eight agents were evaluated for durability at the site of injection. Only indocyanine green and india ink remained visible on the serosal surface of the bowel after 48 hours. While indocyanine green showed no adverse tissue reaction, india ink caused a significant inflammatory infiltrate with microhemorrhage and thrombosis. The final phase confirmed the staining qualities of indocyanine green. The dye persisted for seven days, and no adverse reactions were noted, either macro- or microscopically. Based on our findings, indocyanine green is an excellent agent for use in tattooing the colon to facilitate intraoperative localization of small colonic lesions. Clinical trials to evaluate the efficacy and safety of this agent in humans are warranted.     

The use of Munsell colour charts in nipple-areola tattooing.

Tattooing is an excellent, simple and quick option in nipple-areola reconstruction. Colour mismatch is one of the commonest problems with this procedure. Use of Munsell colour charts allows the premixing of common colours for different patient populations using pigments from various manufacturers. There are significant correlations between nipple colour and Fitzpatrick skin type and between nipple colour and parity. Three nipple-areola colours were more common than others and were found in 50% of patients; these can be premixed ready for use. Adjustment of premixed colours for individual patients can be performed prior to tattooing, speeding up the procedure. Accurate recording of colours also facilitates audit.     

Forum: dermopigmentation or medical tattooing. Dermopigmentation with an esthetic aim. Apropos of 420 cases]

420 cases of chromatic skin corrections for medical or aesthetic reasons have been documented over the last 1-5 years. The author analyses cases based on local anatomy classification, so that good and poor results of the technique are clearly revealed. Results are then regrouped in a synthetic study, without distinction of anatomical area. This synthesis establishes a check list of defects inherent in the technique: pain or discomfort, poor smoothing-out of skin defects, far from natural chromatic variations of the skin, dull lacklustre colours, short-lasting pigmentation, and chromatic instability of dyes. All these pigmentations were performed using basic techniques and medical pigments. The author suggests that in the future these defects should be corrected by: more systematic use of dyes used by tattoo artists, addition of a gloss in the dyes, transparent technique, anaesthetic skin cream.     

VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection

Introduction  

Video-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness.     

Infusion of prostacyclin reduces in vivo thrombus formation following arteriotomy/intimectomy in small arteries An experimental study in the rabbit

Summary The antithrombotic effect of prostacyclin infusion on severely traumatized vessels has been evaluated. A group of 3 rabbits was used to establish a prostacyclin dose which produced platelet antiaggregating effects without significantly affecting blood pressure. Twenty-seven central arteries of rabbit ears were prepared and ³²P-labelled platelets infused. Arteriotomy (7 mm)/intimectomy (5 mm) were performed and in vivo platelet accumulation followed for 2 h. Fifteen of the vessels served as control. Bleeding times, platelet accumulation, patency and deposits of thrombus material were recorded. Following prostacyclin infusion bleeding times were significantly prolonged, patency significantly improved and platelet accumulation somewhat lower than in the control group. Prostacyclin thus has an antithrombotic effect but due to its other properties is complicated to use clinically.This paper was supported by grants from the Swedish Medical Research Council (B87-17X-00759-22B)a the Medical Faculty, University of Lund, Lund, Sweden and Ake Wiberg's Foundation, Stockholm, Sweden     

Pediatric esophageal leiomyosarcoma: a case report

Esophageal leiomyosarcoma accounts for only 0.5% of all esophageal tumors. This rare tumor has been reported in middle-aged or elderly patients. In contrast, pediatric esophageal leiomyosarcomas have never been reported. The case described herein is the first report of an esophageal leiomyosarcoma in a pediatric patient with its own characteristics. The patient had symptoms of mild cough without dysphagia. The lesion grew rapidly and reached dimensions of 7.0 cm × 5.0 cm × 6.0 cm in a 3-month period. On computed tomography scan of the chest, the mass exhibited mild enhancement after injection of a contrast agent. More evident enhancement was found on the 3-minute delayed enhanced computed tomography scan. A Phemister operation (transthoracic esophagectomy and esophagogastrostomy) was performed on the patient. The patient did not receive adjuvant postoperative radiotherapy or chemotherapy. He has been followed for 3 years and is free of disease.     

Radiofrequency Milligan-Morgan haemorrhoidectomy in the outpatient setting

The demand for shorter admissions and quicker recoveries prompted us to adopt a new approach, favouring day surgery as the preferred organisational modality. Since 2004, 312 Milligan-Morgan haemorrhoidectomies have been performed at our department of surgery. The operations were performed at our proctological outpatient unit by means of LigasureTM with immediate discharge. In our study we observed postoperative bleeding in 3 cases (0.96%), while 4 patients (1.28%) required an ordinary admission. There were no cases of acute urinary retention in our experience. Operating time is about 12-16 minutes; and recovery time around 60-70 minutes. Over the period 1992-2003, 978 Milligan-Morgan haemorrhoidectomies were performed at our department of surgery using diathermy. Historical comparison of the results of the two groups shows a reduction in complications, operating times and recovery times. On the basis of our experience, radiofrequency ablation causes less postoperative pain and makes for shorter recovery times compared with diathermy, because of its lower tissue damage. The aim of the present study was to verify the safety and effectiveness of day surgery haemorroidectomy in selected cases.     

Do facet joint capsular ligaments contain estrogen receptors? Application to pathogenesis of degenerative spondylolisthesis.

Studies showing that degenerative spondylolisthesis is 4 to 5 times more common in females than in males have suggested that hormonal influences account for this gender difference. Estrogen has been shown to play a role in other instabilities, such as those of the anterior cruciate ligament and the shoulder capsular ligaments, and estrogen receptors have been identified in these tissues. We wanted to assess facet joint capsular ligaments for the presence of such receptors. Accordingly, we collected facet joint capsular ligaments from 14 consecutive patients undergoing lumbar spinal fusion. Tissue sample analysis was performed by immunohistology using prediluted estrogen monoclonal antibody (Vantana) and automated immunostaining on a Vantana instrument. None of the specimens analyzed contained estrogen receptors. We conclude that, though degenerative spondylolisthesis may have hormonal influences, estrogen seems not to play a direct role in its development.     

Preoperative embolization with gelfoam powder for intracranial meningioma causing unusual peritumoral hemorrhage--with reference to the mechanism of hemorrhage

Preoperative embolization for intracranial meningioma has been performed at many institutions and its effectiveness has been well recognized. The complications of embolization such as facial pain, fever and facial nerve palsy, et al, were mild and temporary except embolus migration into intracranial vessels, but a peritumoral hemorrhage due to preoperative embolization was extremely rare. Recently we have experienced such an unusual complication, then we describe this complication here and discuss the mechanism of hemorrhage briefly. A 73-year-old female who had the left falx meningioma underwent preoperative embolization with gelfoam powder through the transfemoral route. About 10 hours later, she developed disturbance of consciousness and right hemiplegia. At that time, CT scan showed peritumoral hemorrhage and an increase in midline shift. An emergency craniotomy was performed and total removal of the falx meningioma (Simpson grade II) and evacuation of the hematoma were done. The postoperative course was uneventful. We conclude that gelfoam powder (average particle size 40-60 mu) is a useful material for preoperative embolization but may at times cause peritumoral hemorrhage.     

Lung donation after medical assistance in dying at home

Organ donation after medical assistance in dying (MAID) has only been possible for patients having the MAID procedure performed at a hospital facility due to prohibitive warm ischemic times. Herein, we describe a protocol for lung donation following MAID at home and demonstrate excellent postoperative outcomes. Lung donation following MAID at home is possible and should be considered by transplant programs.     

Scaphoid fractures: A bibliometric analysis of the most influential papers

Scaphoid fractures are commonly seen following a fall on an outstretched hand and often missed on initial presentation. An untreated scaphoid fracture may result in avascular necrosis of the scaphoid due to its retrograde blood supply. Published articles guide our investigation and management of these injuries. A citation analysis was performed on the top 30 articles relating to scaphoid fractures ranked by citation number. The 30 articles have been cited a total of 4595 times originating from 9 different countries. The leading article was cited 443 times with an average of 12.66 citations/year. Although this may not directly correlate with study quality, it does provide an insight to the influence which a paper has had on the scientific community. This list may prove invaluable to clinicians involved in the treatment of patients with scaphoid fractures and those actively furthering the development of the field.     

Pentoxifylline increases extremity blood flow in diabetic atherosclerotic patients

Pentoxifylline, a new trisubstituted methylxanthine derivative known for its hemorrheologic action, has been shown to improve exercise tolerance in atherosclerotic patients. We examined the responses of diabetic atherosclerotic patients to pentoxifylline administration, measured by Doppler waveform analysis and exercise tolerance. Standard exercise tolerance and Doppler waveform analytic studies of the lower extremity, specifically the right dorsalis pedis artery, were performed before and after three months of pentoxifylline administration (400 mg three times a day). The study group comprised ten subjects (six men and four women) with a mean (+/- SD) age of 60 +/- 3.3 years. Data were analyzed using a paired Student t test. All ten subjects showed a significant increase in exercise tolerance after pentoxifylline treatment. Eight of ten subjects demonstrated a significant increase in right dorsalis pedis arterial flow.     

Using the Sustained Attention to Response Test to detect cognitive dysfunction after day case surgery

BACKGROUND AND OBJECTIVE: Cognitive dysfunction has been reported after general anaesthesia, but its assessment is time consuming and difficult to evaluate. This pilot study assessed the feasibility of using the Sustained Attention to Response Test to assess 35 ASA I-II adults (mean age 31.6 yr) undergoing day case surgery under general anaesthesia, and 25 ASA I-II adults (mean age 47.8 yr) undergoing day case surgery under local anaesthesia. METHODS: The Sustained Attention to Response Test was performed before surgery and repeated 2 h after surgery. RESULTS: When patients repeated the test after surgery under local anaesthesia, the number of incorrect responses increased, but reaction times decreased (P < 0.05). Following general anaesthesia, the number of incorrect responses increased (P < 0.05), but reaction times remained unchanged. CONCLUSIONS: The Sustained Attention to Response Test is simple to administer and may be a useful tool when comparing different anaesthetic techniques and their effects on postoperative deficits in sustained attention.     

Therapeutic guide line for hemoptysis

We report the result of treatment for thirty-two patients whose chief complaint was hemoptysis and represent the therapeutic guide line for hemoptysis. In thirty-two cases, there were twenty men and twelve women and average of age was fifty-two years old. Twenty-nine of them were chronic lung diseases such as tuberculosis and bronchiectasis and only three cases have malignant tumors. Two of them recovered with conservative therapy and bronchial arteriography (BAG) have been performed in thirty patients in order to determine the bleeding foci, BAG was failed in two cases, but these two cases have been recovered with following up, BAG was succeeded in twenty-eight cases and twelve cases of them could not been determined the bleeding foci by angiography and could be controlled using hemostatic and antibiotic agents. Embolization of bronchial arteries with gelatin sponge have been performed in sixteen cases and made success in eleven cases. In ten of these cases, BAE was effective less than two times. Only one of silicosis with restrictive lung function was considered contraindication of surgery and recovered by three times of BAE. Four cases of five uneffective BAE (rebleeding after two times of BAE) have been treated by operation in good course. But one case complicated with WPW syndrome has died because of aspiration pneumonia without operation. In our institute, the rate of operation for hemoptysis was low as 13% of thirty-two cases. In order to consider the indication of surgery, bronchial arteriography was essential to determine bleeding foci and BAE was effective in over 80% of hemoptysis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preliminary results of the European Multicenter Study on UW solution in liver transplantation. The Study Group

The introduction of UW solution in clinical liver transplantation has had a tremendous impact on clinical practice. The preliminary evaluation of data in this interim report with UW solution in the European setting does confirm the clinical results as reported by the Belzer and Starzl groups. These data on the UW solution in its original composition concern in already 43% a population of liver transplant procedures performed with cold ischemia times of more than 12 hours without clinical evidence of detrimental effects due to preservation times up to 26 hours. A comprehensive analysis of the results of this study will be performed upon completion of the 1 and 3 month follow-up. In this analysis all preservation related characteristics will be presented and statistically evaluated.