THE ROLE OF OMENTAL TRANSFER IN BUERGER'S DISEASE: NEW DELHI'S EXPERIENCE

Background: Buerger's disease is a specific, idiopathic, recurrent, segmental, inflammatory, obliterative vascular disease involving medium-sized arteries and veins of the limbs. We performed omental transfer on a group of patients with Buerger's disease that had previously undergone lumbar sympathectomy and the results are described. Methods: Between January 1988 and December 1993, 100 cases of peripheral vascular disease (PVD) diagnosed as Buerger's Disease were subjected to femoral angiography. Fifty cases of angiographic intermediateldistal type blocks underwent omental transposition. Results: Of 50 patients subjected to omental transfer all had intermittent claudication, 40 had rest pain of whom 36 had non-healing ulcers, 8 had gangrene and 32 had bilateral lower limb involvement. Fifteen patients underwent bilateral omental transfer and posterior tibial artery biopsy was performed in 40. All patients showed improved skin temperature, rest pain decreased in 36 and claudication distance increased in 48. Ulcers healed in 32 of 36 patients and the line of demarcation receded in six of eight patients with gangrene. Conclusions: Omental transfer improved skin and muscle microcirculation and forestalled the need for amputation by providing symptomatic relief and clinically arresting the progress of Buerger's disease. Omental transfer should be considered seriously as an alternative to other modalities of therapy to delay the ischaemic complications of Buerger's disease.     

小隐静脉原位旁路术治疗下肢动脉缺血症

为探讨下肢动脉缺血症旁路重主新的移植材料,笔者于１９９２年５月至１９９７年５月,应用小隐静脉原位旁路术治疗下肢动脉闭塞严重缺血症１８例２４条肢体并监测随访１－５年。结果：１８例近期缺血症状均显著改善,临床有效率达８８．８％,远期疗效优良率达８３．３％,经寿命青法统计分析,移植物１,３,５年通畅率分别为９５．８％,７９．６％和７０．０％,认为以小隐静脉移植材料重建因肢体循环具有不受长度限制,我需预破     

桡骨远端瘤段切除后单纯自体腓骨移植与吻合血管腓骨移植重建桡腕关节疗效比较

目的分析单纯自体腓骨移植与吻合血管腓骨移植在桡骨远端瘤段切除后修复桡骨远端缺损和重建桡腕关节远期效果.方法 1979年1月～2002年9月对15例桡骨远端肿瘤患者行瘤段切除后,6例行单纯自体腓骨移植,9例行吻合血管腓骨移植重建桡腕关节.随访1年,参照Enneking系统及国际肢体修复讨论会所制定的同种/带血管蒂骨移植的影像学评价方法,进行肢体功能、影像学及供区的功能评价.结果 8例吻合血管腓骨移植恢复肢体功能的80%,6个月内完成骨愈合;6例单纯自体腓骨移植恢复肢体功能的67%,其中4例移植骨在5 cm以内术后6个月骨愈合可,2例骨移植超过12 cm者愈合延迟,分别为13个月和16个月;1例术后2个月行肘下截肢术.结论应用腓骨头替代桡骨远端重建腕关节是合适的;吻合血管腓骨移植重建桡腕关节不受骨缺损长度影响,且植骨愈合率高、时间短,无骨吸收.可作为桡骨远端肿瘤手术治疗的一种有效手段.     

BUERGER'S DISEASE IN HONG KONG: A REVIEW OF 89 CASES

Background : A retrospective analysis of 103 case records from 1978 to 1996 with a provisional diagnosis of Buerger's disease was undertaken at the Department of Surgery, University of Hong Kong, Queen Mary Hospital. The aim of the study was to elucidate the clinical course and evaluate the results of surgical intervention of Buerger's disease in Hong Kong Chinese people. Methods : Fourteen patients were subsequently excluded from the study because of inability to fulfil our diagnostic criteria. Data on clinical presentation, investigations, indications and results of surgical intervention were reviewed. Sympathectomies and arterial reconstructions were performed on 42 and four patients, respectively, for critical ischaemia or rest pain. Outcome was analysed with respect to the rate of ulcer healing, pattern of recurrence and limb loss. Results : The patients were all young male heavy smokers with a mean age of 36.5 years. The majority of patients (80%) presented with ischaemic ulceration or gangrene. Vascular reconstruction was undertaken in four patients and satisfactory long-term results were obtained in three patients. Sympathectomy was able to relieve symptoms in 87% of operated patients and ischaemic ulceration healed in 2.6 (mean) ± 1.7 (SD) months after the operation. If the patient continued to smoke, surgical intervention did not exempt the patient from a relapse or amputation. Conclusion : Sympathectomy provides short-term pain relief and promotes ulcer healing in patients with Buerger's disease but carries no long-term benefit. Complete abstinence from smoking is the only means of arresting the progression of the disease.     

带蒂大网膜包裹胰肠吻合在胰十二指肠切除术中的应用

目的 探讨降低胰十二指肠切除术后胰肠吻合口漏的预防措施。方法 回顾性分析1999～2004年间施行的46例胰十二指肠切除术中采用大网膜包裹胰肠吻合口的手术方法。结论 46例患者术后出现胰漏1例,占2．17％,无围手术期死亡。结论 带蒂大网膜包裹胰肠吻合口,覆盖操作简单,对预防胰十二指肠切除术后胰肠吻合口漏有良好效果。     

HEMISPHERECTOMY: A FURTHER MODIFICATION USING OMENTUM VASCULARIZED FREE FLAPS

This report describes the authors' technique designed to further prevent the late complications of hemispherectomy. A vascularized omental free flap is used to fill the extradural dead space left following the procedure advocated by Adams. This procedure may provide further stability to the residual brain and reduce infective complications.     

游离空肠移植重建喉咽和颈段食管：初步报道

采用小血管吻合技术行游离空肠移植，在喉咽癌切除以后，重建喉咽和颈段食管３例，均成活。术后伤口愈合好，并发症少。吞咽功能恢复良好。手术一期完成，成功率高，安全可靠，近期效果良好。     

ARTERIAL RECONSTRUCTION FOR LOWER LIMB ISCHAEMIA IN HONG KONG CHINESE

Background : Lower limb ischaemia due to peripheral arterial disease is uncommon in Chinese people, and few arterial bypass operations have been performed. The management of a consecutive series of patients who were admitted to our department with severe lower limb ischaemis between March 1990 and October 1996 is reported here. Methods : A total of 91 primary arterial bypass operations were performed for 83 patients (eight patients had bilateral, or two procedures). Of these, 84 operations were for foot salvage and seven operations were for debilitating claudication. There were 80 infra-inguinal bypasses, 10 of which required additional femoro-femoral crossover grafts to improve in-flow. The remaining 11 bypass procedures were performed for aorto-iliac occlusion, which included aortobifemoral bypass (5), axillobifemoral bypass (3) and cross-femoral bypass (3) grafts. There were 46 male and 37 female patients, with a median age of 70 years (36–94). Results : Six patients died (6.6%) postoperatively, all of whom were in the foot salvage group. The overall cumulative foot salvage rate and graft patency was 84 and 56%, respectively, at 5 years. Conclusions : These results justified the use of the same aggressive approach that was adopted in Western countries for the treatment of peripheral arterial disease, which seemed to be an emerging problem in Hong Kong.     

DIAGNOSTIC FAILURE IN COLONOSCOPIES FOR MALIGNANT DISEASE

Background: While colonoscopy has become established as more accurate than double contrast barium enema for detecting colonic polyps and cancers, as well as offering the opportunity for therapy, there are occasional instances where colonoscopy is misleading. The present study is to determine what problems occur, with a view to finding a solution. Methods: The records of the Colorectal Project at the Princess Alexandra Hospital indicate retrospectively that 346 patients have been correctly diagnosed with cancer of the colon and rectum by colonoscopy in the 5 years up to October 1996. During the same time eight patients (2.3%) were recorded at the same hospital as being misdiagnosed by colonoscopy, the lesion being either missed completely or misplaced. Results: In five of these patients there was failure to recognize that the whole colon had not been examined endoscopically, thereby missing a more proximal lesion. In two patients the lesion was missed although the entire colon was examined. In one patient the lesion was discovered but inaccurately sited. Six of these mistakes would have been obviated by the routine use of fluoroscopy to confirm the totality of the colonoscopy and to site any lesions found. The other two cases occurred because of failure to remember that colonic examination during withdrawal should be performed meticulously back as far as the anal canal. Failure to diagnose a colon cancer on the initial colonoscopy led to an average delay of 6 months for definitive care. Conclusions: It is recommended that fluoroscopy be used routinely during colonoscopy to site accurately any lesions found, and to confirm the completeness of insertion if reliable landmarks, including terminal ileum, are not clearly identified.     

OMENTAL TRANSPOSITION FLAP FOR GROSS LOCALLY RECURRENT BREAST CANCER

Background : The omentum has been employed to cover the defect produced after resection of gross breast cancer recurrence for nearly three decades. Methods : A series of 11 patients undergoing omental transposition flap for very wide resection of gross local recurrence (LR) of breast cancer is reported. The median age was 39 years, with a short interval (median = 21 months) from the treatment of the primary tumour to LR. Local recurrence was gross and predominantly inflammatory. Results : All except one patient had lymphovascular invasion in the recurrent tumour. The omental graft was 100% viable but one patient required re-application of further split-thickness skin graft. The mean hospital stay was 16 days. Two cases of seroma formation were encountered. New recurrence developed around the periphery of the flap in eight patients after a median duration of local control of only 2.5 months. Eight patients died with metastatic disease after a median period of 6 months, six patients with uncontrolled local disease. Five patients were free from LR in over half of their remaining period of life. Conclusion : Omentoplasty is a safe and reliable procedure but the length of palliation achieved is often far from satisfactory.     

四肢恶性肿瘤的保留肢体手术治疗

１９７４年１１月￣１９９３年１２月，对经病理证实的１１０例四肢恶性肿瘤，做保留肢体的手术治疗。其中４２例肿瘤局限于软组织内，采用肿瘤彻底切除后，带血管蒂或吻合血管的皮瓣或肌皮瓣修复。５１例肿瘤局限于骨组织内，手术切除后的骨缺损，采用自体长骨植骨，吻合血管的骨移植术，深低温保存的同种异体骨及人工假体置换术等多种形式来替代。骨愈合时间为２．５￣３．５个月。对１７例病变累及骨及软组织的，施行短缩肢体的瘤     

FASCIOCUTANEOUS ISLAND FLAPS FOR ORTHOPAEDIC MANAGEMENT IN LOWER LIMB RECONSTRUCTION USING DERMATOMAL PRECINCTS

This paper describes a technique of fasciocutaneous island flaps used in reconstruction of the lower limb. It is very versatile and some 26 individual flaps in 22 patients have been used to reconstruct skeletal and soft tissue problems from the popliteal fossa to the ankle joint. These longitudinally designed flaps made up of a trilaminate of skin, subcutaneous fat and fascia are aligned within the dermatomal precincts. The most important location for such flap design is along the peroneal compartment sitting within the L5 dermatome and incorporating the superficial peroneal nerve. It can be lengthened as far as the lateral malleolus and is an excellent reconstructive method to close defects over the lower third of the tibia. The medial compartment of the leg employing the saphenous nerve (L4 dermatome) is another area for fasciocutaneous island flap reconstruction, but use is restricted to the upper two-thirds of the tibial area. Posteriorly the island flap design sits along the S2 dermatome, this time incorporating the sural nerve to reconstruct defects of the calf and can be extended to include problems of the popliteal fossa. In the overall flap technique, the age of the patient is not a contraindication and cases with peripheral vascular disease have been treated successfully. The flaps may extend up to a 5:1 ratio in dimension. The operating time can be considerably shortened.     

LIMB LENGTH DISCREPANCY IN CONGENITAL TALIPES EQUINOVARUS

A retrospective analysis was performed to establish the prevalence and clinical significance of limb length discrepancy in congenital talipes equinovarus. Of 536 patients with the diagnosis of congenital talipes equinovarus, 259 were unilaterally affected and 277 bilaterally affected. Fifty-eight patients were identified with limb length discrepancy greater than 0.5 cm. Forty-six patients had unilateral foot deformity and in 12 cases that was bilateral. This represented a prevalence of documented limb length discrepancy in 18% of unilateral cases and 4% of bilateral cases. The discrepancy resulted in a surgical procedure to equalize the limb lengths in fourteen unilateral cases (5%). A further six unilateral cases were deemed likely to require limb length equalization, increasing the rate to 8%. Only three bilateral cases required or will require surgery for equalization (1%). There was a weak but significant correlation between the number of operations undergone and the magnitude of discrepancy. The tibia was as important in its contribution to the shortening in these patients as the foot. A total of 89% unilateral cases studied had at least 0.3 cm of tibial shortening and 43% had ipsilateral femoral shortening of at least 0.3 cm.     

横向乳腺真皮蒂瓣治疗巨乳症

设计横行乳腺真皮蒂瓣治疗巨乳症８例，均取得蒲意效果。该术式适用于中度和重度的巨乳症，术后仅在乳腺下缘遗留横弧形瘢痕，被下垂乳房遮挡，外观效果好。该皮瓣的血供及神经支配保持良好，术后无１例发生乳头坏死，４例随访半年以上，其中２例乳头、乳晕感觉完全恢复，１例部份恢复，１例尚未恢复。     

COVERAGE OF THE MEDIAN NERVE WITH FREE AND PEDICLED FLAPS FOR THE TREATMENT OF RECURRENT SEVERE CARPAL TUNNEL SYNDROME

Fifteen patients (10 women and 5 men; median age 46 years; range 28-55), with recurrent severe carpal tunnel syndrome, were operated on with re-exploration and cover of the median nerve with free or pedicled flaps (five pedicled ulnar flaps, one pedicled dorsal forearm flap (served by the posterior interosseus artery), one groin flap, three free scapular flaps, and five free lateral arm flaps). The patients were followed up by a self-administered questionnaire at 3 months-14 years (median 8.5 years) after operation and replies were obtained from 14 patients. There was a significant improvement in pain ( p = 0.01) and percussion tenderness at the wrist ( p = 0.02), but no significant improvement in allodynia and cold intolerance in the hand as evaluated by the use of a visual analogue scale (VAS). Three of the 14 patients had less numbness/paraesthesiae and four had subjectively improved sensory function in the hand and fingers since the procedure. Ten patients had problems from the donor site, including a cosmetically unacceptable scar, allodynia, and itching. Four patients had worked before the operation and nine patients returned to ordinary or light work afterwards. In conclusion, 10/14 patients considered themselves as somewhat better, better, or cured, while four felt that they were unchanged or worse. We conclude that cover with vascularised fat may be worthwhile in some patients with recurrent severe carpal tunnel syndrome, preferably with a simple pedicled ulnar flap.     

碱性成纤维细胞生长因子在自体脂肪游离移植中血管生成的早期作用

应用碱性成纤维细胞生长因子于自体脂肪游离移植，以刺激移植体早期的血管形成。移植脂肪在对照侧单纯加入纤维蛋白；实验侧加入含有ｂＦＧＦ的纤维蛋白。动物术后存活５、７、１０天。各期动物经心脏主动脉插管，灌注墨汁。结果显示各期实验侧移植物中血管生成密度均明显高于对照侧。