Breast burn sequelae. Classification and therapeutic indications]

Reconstructive surgery of post-burns scars in female (either young children or adults) is a frequent need in our experience. The problems is to face the consequences by considering the growth of mammary gland either hormonal in case of children or breast reconstruction as if in case of malignancy in adult female. Classifications of post burn scars is helpful to adapt the method of initial treatment, is a real need. The authors have spent part of their experience to treat acute case of thoracic burns, proposing classification of three types and specific treatment for each.     

Breast ptosis. Definition and treatment.

A definition of ptosis of the breast is given which permits differentiation of several kinds of defects to be made: pseudoptosis, partial ptosis, and true ptosis. In case of true ptosis, three degrees are described according to the nipple relation to the submammary fold and skin brassiere. An association with hypoplasia is described. The corrective techniques chosen are different according to the various types of ptosis and their possible association with various types of hypoplasia. The subpectoralis augmentation is used to insert the prosthesis in all cases.     

Palliative surgical indications in bronchial cancer]

Surgical palliation in bronchial carcinoma may be indicated for severe hemorrhage, putrid expectoration in large necrotising tumors, recurrent pleural effusion refractory to conservative treatment and loss of function of an entire lung due to bronchial and vascular obstruction. Alleviation of imminent asphyxia, dyspnea or malaise is the main purpose, whereas prolongation of survival remains uncertain. Palliative surgery is ranging from tumor pleurectomy to total pleuropneumonectomy. Depending on an individual situation this might be done as a primary indication or, if aforementioned complications must be anticipated, during elective surgery in advanced lung cancer instead of merely explorative thoracotomy. Bronchial obstruction with maintained lung perfusion alternatively is an excellent indication for endoscopic laser surgery, mostly combined with subsequent 192Ir afterloading therapy. Twenty-three cases of primary and secondary surgical palliation within a two-year period and 55 cases of laser/afterloading therapy in a three-year period are analyzed. Survival time is limited in the latter. Due to better general and functional state in the small surgical series in several patients not only relief from badly tolerated symptoms was achieved but also surprisingly long periods of survival with good quality of life in several cases. With proper selection operative mortality and morbidity of palliative surgery as well of laser therapy is of minor concern.     

驼峰的分类与整形治疗

OBJECTIVE: To establish a new classification of hump nose and to develop operative techniques based on its characteristics in Chinese patients. METHODS: This paper presents and summarises 68 cases of hump nose. According to the anatomic structure of the hump nose, we classify it into four types: small hump type I and II, moderate hump and large hump. Based on the classification of hump nose, two operative methods were developed-osteotomy and non-osteotomy. RESULTS: From 1990 to 1997, 68 cases of hump nose were operated on. Postoperative follow-up for 1-18 months showed satisfactory results. CONCLUSION: By means of this classification and the operative techniques, good result can be obtained for the correction of the majority of hump noses in the Chinese.     

Diagnosis, classification and surgical indications in acetabulum fractures]

Displaced acetabular fractures may lead to posttraumatic arthritis. Consequently, joint congruency must be restored by either conservative or operative measures. Standardized radiographs of the pelvis are prerequisites for the correct evaluation of the hip-joint. The a. p.-pelvis projection and the Judet views (obturator and iliac oblique) showing the whole pelvis are indispensable and demonstrate radiological landmarks typical of anatomical relationships and fracture characteristics. The two dimensional computertomogram is an adjunctive diagnostic measure and facilitates the evaluation of the hip joint itself. The 3DCT allows the imaging of old acetabular fractures and aids in the planning of reconstructive surgery. With the basic three projections of the hemipelvis, Letournel and Judet developed the acetabular fracture classification now accepted world-wide. Assuming the notion that the acetabulum is supported by two columns, five fracture types and five fracture type combinations are described according to involvement of the anterior or posterior columns respectively. The correct classification precedes the choice of surgical approach and is the basis for preoperative planning. The indications for surgery adhere to the principles of joint surgery. Conservative treatment may be considered only if the weight bearing joint surface of the acetabulum is congruent. Otherwise open reduction and internal fixation are indicated.     

The surgical treatment of lung metastases. The prognostic factors and the indications for the surgical approach]

BACKGROUND: After the liver, the lungs represent the most frequent site of metastasis from primary tumours. Surgical treatment of lung secondary neoplasms leads to a significant improvement in survival. METHODS: Between 1960-1997, 178 patients with lung metastases underwent surgery at the Thoracic Surgery Department of Turin University in a total of 193 operations. A retrospective study was made in order to identify the prognostic factors which influenced final survival in this population. RESULTS: Overall survival was 47% after 2 years and 20% after five years. Prognosis was not influenced by the size of metastases, the type of surgery, adjuvant therapy and the number of operations on the same patient. On the other hand, useful prognostic factors were found to be the histological type of the primary tumour, the original site of the neoplasm, the number of metastases and, above all, the disease-free interval (DFI). CONCLUSIONS: Lung metastasectomy is an important therapeutic aid in selected patients, whereas the preoperative evaluation of the above prognostic factors enables a reasonably precise prognosis to be made in most patients.     

Criteria of evaluation of hemorrhagic portal hypertension and surgical indications]

Massive, active bleeding of the oesophageal varices in cirrhotics requires immediate, comprehensive and continuing appraisal of determining risk parameters (liver function and morphology, hyperdynamic syndrome, renal function, dynamic angiography of the splanchnic circulation). When survival is linked with stopping the haemorrhage, indications must not be looked at restrictively and operation has to be fast. Minor surgical measures aimed at temporary control of the haemorrhage are not satisfactory. Side-to-side portacaval anastomosis is effective in terms of reducing portal pressure and controlling the haemorrhage. Mesenterico-caval shunt with H-dacron graft interposition is sufficient dynamically and has less effect on porto-hepatic flow. Long-term results with this technique requires further study.     

Diagnosis and indications for surgical treatment.

Dupuytren's disease is a common problem in most hand surgery practices. It is usually easily diagnosed by the presence of its primary palmar manifestations: the nodule, the cord, and the digital flexion contracture. The isolated nodule may occasionally require biopsy to rule out the possibility of malignancy, but this is unusual. The nodule is typically the first lesion to appear and is the site of active biologic activity. The cord is the pathologically thickened and shortened normal longitudinal fascial structure of the palm and digit. Its insertion distal to the MPJ or PIP accounts for the progressive flexion contracture of these joints. Secondary findings include knuckle pads, plantar fascial nodules, and penile fascial contracture, which may signal the presence of Dupuytren's diathesis, a particularly aggressive form of the disease. The need and advisability of surgical intervention should be determined in close consultation with the patient after becoming thoroughly familiar with functional deficits and specific functional goals. A flexion contracture of more than 30 degrees at the MPJ or any contracture at the PIP is generally thought to be an indication for palmar fasciectomy. Patients should be aware of potential complications, those in higher risk categories should be identified preoperatively. Details of the operative procedure and variations in technique are discussed in subsequent articles in this issue.     

Severe peptic esophagitis. Classification and therapeutic indications

The place of conservative procedures and resection in the surgical treatment of complicated peptic oesophagitis is still controversial. In order, to propose decisional criteria for the therapeutic choice, we reviewed 102 patients operated on from 1979 to 1987, with strictures (n = 61), Barrett's oesophagus (n = 27) or previous surgical treatment (Heller, resection, repeated fundoplications, n = 33). Patients were classified into 3 grades: a) The first group consisted of low, short, dilatable and reversible strictures without Barrett's, oesophagus, treated by dilatations and fundoplication (n = 36). b) The second group consisted of Barrett's oesophagus, peptic oesophagitis after surgery and acquired short oesophagus with or without dilatable stricture, treated by Roux-en-Y duodenal diversion (n = 60) with dilatation in case of stricture. Collis-Nissen's procedure could be used for such cases, but conservative procedures via a thoracic approach has no indications for us. c) Group 3 was treated by resection (colonic interposition when possible) and consisted of peptic ulcers, extensive sinuous and poorly dilatable strictures or suspected cancer (n = 9). Decisional factors were: stricture (size, height, level, response to preoperative dilatation), ulcer (hemorrhagic or suspicion of carcinoma), acquired short oesophagus, Barrett's oesophagus, previous surgical treatment. Intensity or type of reflux was not decisional. With this policy, only 3 recurrences occurred, all after reposition for stricture, successfully treated by resection or duodenal diversion. The low recurrence rate confirms the decisional value of the chosen criteria.     

Breast cancer screening in surgical patients]

Between January and August 1996, 304 patients of the Department of General and Abdominal Surgery of the University of Mainz who were at least 40 year old, were interviewed about their breast cancer screening behavior. The aim of our investigation was to evaluate the attitude of the target population to breast screening and the value of breast palpation, completed with mammography, during the women's treatment in hospital. 168 (55%) of the interviewed women reported that they had a yearly clinical breast examination in the past. All patients underwent a clinical breast examination. 185 (60%) did not have a mammography in the past or within the past 2 years. These women were offered a mammographic examination during their treatment in the hospital. The investigation revealed one invasive breast cancer. 13 patients had abnormal mammographic or sonographic findings. Our investigation shows, that the compliance of the target population for breast cancer screening is low. Therefore it is necessary to point out the value of breast cancer prevention with clinical examination and mammography also for patients treated in the hospital for an other disease. Every female patient should undergo breast examination. But early detection of breast cancer before micrometastases have occurred is only possible by mammography.     

Congenital cysts of the liver. Their instrumental diagnosis and the indications for surgical treatment]

The authors report their experience of 8 cases of congenital cysts of the liver describing instrumental examinations used for diagnosis and different surgical operation performed. The Authors believe that the choice of surgical procedure, performed in symptomatic patients and large cysts, has to be according to different parameters as morphology and localization of the cysts and coexisting pathologies. Being non-malignant pathology, conservative surgery often avoids the complications of liver resection.     

上睑皮肤松弛下垂手术的疗效分析

目的 探索一种适合矫正上睑皮肤松弛下垂的有效方法.方法 回顾2000年7月至2010年7月,对624例上睑皮肤松弛下垂患者采用眉部皮肤切除术、切开法重睑成形术或二者联合术式的临床效果,并对其疗效进行分析,选择矫正上睑皮肤松弛的良好方法.结果 在624例患者中,587例对术后效果满意或较满意(满意率为94%),37例不满意(6%).其中,瘢痕明显者4例,重睑线不流畅者13例,皮肤松弛改善不明显者20例.结论 对于上睑皮肤松弛的手术治疗,只有根据患者的皮肤松弛程度、眉形的变化等具体情况选择不同的手术方法,才能取得良好的效果.     

Diagnosis, classification and indications for surgical treatment of pelvic ring fractures]

In cases of high-energy trauma, it is well known that there is a high incidence of pelvic fractures. The mechanism of injury, inspection and physical examination of the victim at the accident site direct attention to a pelvic fracture. In most cases, the first radiological examination (A.P. X-ray of the pelvis, oblique view of the obturator and oblique view of the ilium) shows the extent of the bony lesion. The diagnosis and therapy of lesions of the urinary tract, of intra-abdominal organs and blood vessels are vitally important. For the definitive operation of unstable pelvic ring fractures, additional diagnostic means, i.e., CT scans to distinguish posterior instability, can be necessary. Osteosynthesis can only be successful in the pelvis if one has a biochmechanical understanding of the physiological flux of force from the neck of the femur via the acetabular fossa to the sacroiliac joint. The sacroiliac ligaments have a particularly important support function. For assessing stability and classifying the traumatic patterns, it is helpful to use Pennal's classification, which takes the direction of the action of force into account. Three basic forms can be distinguished: anteroposterior compression, lateral compression and vertical avulsion. Depending on the extent of the traumatic pattern, one can distinguish three subtypes: type 1 is treated conservatively while types 2 and 3 require surgical treatment. The biochmechanics, traumatic patterns, diagnostics and treatment techniques applied are described clearly and with good illustrations.     

Gluteal augmentation surgery: indications and surgical management.

The most common surgical techniques performed for gluteal augmentation employ the use of implants and a combination of liposuction/lipo-injection procedures. We review the major literature concerning this subject with emphasis on gluteal implants, the various indications, surgical techniques and complications are discussed and we present some of our cases. Contour reconstruction, indications such as malformation, asymmetry, trauma and radiotherapy may require custom-made or regular implants, liposuction or lipo-injection procedures and sometimes free flaps. Gluteal implants for aesthetic purposes are widely used, particularly in South America, are easy to perform with a high success rate, whereas lipS200osuction and lipo-injection procedures require considerable experience in Coleman fat injection.     

Diagnosis, surgical indications and treatment of lumbar stenosis.

A diagnosis of vertebral lumbar stenosis is based on clinical and instrumental data derived from radiographic studies, CT scan, magnetic resonance, and myelography. Indications are based on an overall evaluation of clinical and instrumental data, in the search for a precise correlation between neurological symptoms and images. Conservative treatment includes medical and physical therapy, and use of a brace. Problems related to surgical treatment substantially consist in how many levels to open and how far to laterally release the nervous structures.     

儿童上睑下垂的病因、病理和手术治疗

先天性上睑下垂在人群中发病率为0.12%,是一种常见的眼部畸形。在平视前方时,上睑覆盖角膜上缘超过2mm,可诊断为上睑下垂。因提上睑肌功能部分或全部丧失,患侧上眼睑遮盖部分或全部瞳孔,使患眼视力受损。先天性上睑下垂的患者,由于上睑部分或全部遮盖视野,患者往往养成视物时的仰头、蹙额、扬眉等习惯,长期可导致额部皱纹增多,     

Expanding the indications for the surgical treatment of gastric peptic ulcer]

A group of patients operated upon for ulcer disease of the stomach was selected from 1279 patients with this disease in which the nearest results of the surgical treatment were followed-up retrospectively. Seven patients died. The average period of postoperative treatment in the hospital was (17.7 +/- 1.5) days. Complications developed in 78 patients. A comparison of results of preoperative examinations with the conclusions of the morphologist according to data of studying the operative specimens has established low sensitivity of the current methods of diagnosing the cancerous nature of ulcers--as low as (72 +/- 5)%. The final diagnosis of a malignant ulcer was made in 81 patients, only in 58 of them the malignization was suspected before operation, in 23 patients the tumoral process was a "chance" finding. This fact speaks in favour of widening the indications for operative treatment of noncomplicated gastric ulcers.