Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.     

The combined posterior temporoparietal and galeal fascial flap: a new flap in the elevation of the constructed auricle (second stage of microtia correction).

Over the past few years, the technique of elevating the buried ear framework in the second stage of microtia correction has shifted from skin grafting to the use of flaps and cartilage blocks in the retroauricular sulcus. While the temporoparietal fascial flap should be reserved for secondary procedures and the treatment of complications, the mastoid fascial flap is inadequate by itself and needs an additional cartilage graft. Here, we describe a new flap, the combined posterior temporoparietal and galeal fascial flap, for the elevation of the buried ear cartilage. The flap is robust, with a dependable blood supply based on the posterior branches of the superficial temporal artery. In four cases the flap was rolled up and inset into the retroauricular sulcus, while in three cases an additional conchal cartilage graft was inserted into the roll. All the patients had satisfactory ear projection at follow-up 10-14 months postoperatively. We discuss the surgical technique and the advantages of this flap. We believe that this new flap, which has not been described before, has the potential to replace other flaps in the second stage of microtia correction.     

Successful closure of a bladder neck fistula complicated by urethral and vaginal stenosis, using oxidized cellulose (Surgicel) for reinforcement

We describe a case of a bladder neck fistula in a 25-year-old lady presenting with true urinary incontinence, vaginal constriction and induration, with vaginal length reduced to only 1.5 cm. There was an 8-mm fistula involving upper urethra and bladder neck, with fibrosis all around. Using Schuchardt incision, the fistula was reached and mobilization tried. As there was less available tissue, a 3×2-cm layer of oxidized cellulose was stitched between the bladder and the vaginal mucosa for reinforcement and to achieve a watertight closure of fistula.     

Prosthetic vascular infection complicated or not by aortoenteric fistula: comparison of treatment with and without cryopreserved allograft (homograft).

OBJECTIVES: in patients with vascular prosthesis infection, to compare surgical outcome and long-term results of cryopreserved allograft implantations to conventional surgery. DESIGN: retrospective study. MATERIAL AND METHODS: two asynchronous series of 44 [series I: 1980-1994; 8 patients with aortoenteric fistula (AEF)] and 22 (series II: 1994-1997; 4 patients with AEF) patients were treated for prosthesis infection. All patients had prosthesis excision. In series I, there were 4 in situ reparations, 26 extra-anatomic bypass, 13 excision only, and one death at laparotomy. In series II, in situ cryopreserved allografts were implanted in all patients. RESULTS: operative mortality was 16% in series I and 13.6% in series II. For AEF patients, mortality was 37% in series I and 50% in series II. Among hospital survivors, infection-related late mortality was 13.5% in series I and 5% in series II. For AEF patients, late mortality was 20% in series I and 50% in series II. Incidence of reoperations was 54% in series I and 10.5% in series II (p<0.01). Hospital stay was 47.2+/-26.4 days in series I and 16.6+/-11.5 days in series II (p<0.001). CONCLUSIONS: compared to conventional treatment, incidence of reoperations and length of hospital stay are significantly decreased after cryopreserved allograft implantation. However, closure of aortic stump and extra-anatomic bypass gives better results for patients with AEF.     

扩张后胸三角皮瓣修复面颈部瘢痕的护理

目的：探讨扩张后胸三角皮瓣修复面颈部瘢痕的护理要点。方法：回顾分析102例采用扩张后胸三角皮瓣修复烧烫伤后颈面部瘢痕的患者的护理过程。结果：102例中12例扩张器自切口处外露,但未影响手术效果。皮瓣转移后7例单侧尖端皮瓣血运障碍,自行愈合后色素减退;1例单侧转移,皮瓣坏死;其余效果良好。结论：术前进行心理护理至关重要;术后加强基础护理,积极预防并发症的发生,注意观察皮瓣血运是皮瓣转移成活的关键。     

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula: complications of delayed treatment of a penetrating abdominal injury (case report).

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula complicated delayed treatment of an abdominal gunshot wound. Gastric and duodenal decompression, external drainage of the duodenal repair, and caval ligation are preferred for delayed treatment of combined duodenal and infrarenal vena caval injuries.     

TRISS和ASCOT法预测交通重伤结局差异性探讨

目的　比较TRISS法和ASCOT法预测交通重伤结局的差异,探索适合交通伤结局预测的方法。方法　回顾性分析1997～2 0 0 3年1171例交通重伤患者的临床资料,采用TRISS法和ASCOT法预测交通重伤伤员的预期生存和预期死亡概率,测算误判率,比较各自判别效果。结果　ASCOT法预测伤员预期生存和预期死亡的准确性和敏感性明显高于TRISS法,前者的误判率明显低于后者,P <0 .0 5。结论　ASCOT法对交通重伤结局的预测明显优于TRISS法。     

The value of parietal cell vagotomy compared to simple closure in a selective approach to perforated duodenal ulcer. Operative morbidity and recurrence rate

Of 168 consecutive patients presenting with a perforated duodenal, pyloric or prepyloric ulcer, 123 patients were judged fit or suitable for parietal cell vagotomy (PCV). It was, however, only added to simple closure in 67 patients with a previous history of dyspepsia prone to develop recurrent ulceration, whereas 56 patients with no previous symptoms and an established low risk of recurrence were managed by simple closure only. In the comparable groups, postoperative morbidity did not differ, entailing mortality rates of 4.5% and 5.3% following PCV or simple closure only. An overall clinical grading of 106 patients (91%) followed up (median 4 years, range 1-10 years) revealed equally good results. In patients with previous dyspepsia and an established high recurrence rate if managed by simple closure only, a satisfactory reduction of the recurrence rate was found when PCV was added to suture closure (cumulative recurrence rate 20.7 +/- SD 69 compared to 29% +/- SD 9.4 following simple closure in patients with no previous dyspeptic symptoms). It is concluded that in patients with a perforating duodenal ulcer deemed fit or suitable for PCV, assessed by good clinical judgement, PCV does not carry an added risk and provides a fairly good protection against recurrent ulceration.     

The V.A.C. system (vacuum assisted closure) as bridging between primary osteosynthesis in conjunction with functional reconstructed of soft tissue--open fractures type 2 and type 3

Open fractures are complex injuries affecting the integrity of bones and adjacent soft tissue. The therapeutic goals in dealing with open fractures should consist of primary osteosynthesis in conjunction with functional reconstruction of soft tissue. In a period over 2 years, 26 patients were treated with extensive trauma in an interdisciplinary approach. These patients suffered from open fractures type 2 and 3. All patients were treated by primary osteosynthesis, and temporary wound closure with V.A.C.-system. Definitive wound closure was achieved by day 31 after injury. In contrast to a review of the pertinent literature we report the successful free tissue transfer in 21 patients during the critical period between 72 hours and several months preceded by the use of V.A.C.-system for the temporary coverage of open wounds.     

Potentiation of erectile response and cAMP accumulation by combination of prostaglandin E1 and rolipram, a selective inhibitor of the type 4 phosphodiesterase (PDE 4).

PURPOSE: Phosphodiesterases (PDEs) are an important component of the signal transduction pathway during the erectile response. To determine the PDE isoforms in the corpora cavernosa in the cat and to establish the functional presence of PDE 4 in human cavernosal tissue, the erectile response to intracavernosal phosphodiesterase (PDE) inhibitors alone and the combination of PDE inhibitors and prostaglandin E1 (PGE1) was evaluated in the anesthetized cat. The in vitro formation of cAMP and cGMP in human cavernosal smooth muscle cells (HCSMCs) treated with PGE1 and rolipram in primary culture was also measured. MATERIALS AND METHODS: In pentobarbital-anesthetized cats, increases in intracavernosal pressure, penile length, and duration of erectile response were determined after intracavernosal injections of (i) the type 3 cAMP-specific, cGMP-inhibitable PDE inhibitor, milrinone, (ii) the type 4 cAMP-specific PDE inhibitor, rolipram, (iii) the type 5 cGMP-specific PDE inhibitor, zaprinast, and (iv) the combination of rolipram and PGE1. Systemic arterial pressure was concurrently assessed in these experiments. All responses to PDE inhibitors were compared with a control triple-drug combination comprised of papaverine (1.65 mg.), PGE1 (0.5 microg.), and phentolamine (25 microg.). HCSMCs were incubated with PGE1 (3 microM) and rolipram (10 microM) individually or in combination up to 2 hours at 37C. The intracellular cAMP and cGMP was extracted by cold absolute ethanol and measured (pmol./10(6) cells) by a commercially available EIA kit. RESULTS: Milrinone (3 to 100 microg.), rolipram (3 to 100 microg.), and zaprinast (3 to 100 microg.) induced dose-dependent increases in intracavernosal pressure and penile length (p <0.05) when administered intracavernosally. The maximum increase in cavernosal pressure in response to zaprinast was associated with no significant change in systemic arterial pressure. When rolipram was combined with PGE1 (0.1 microg.), the increases in intracavernosal pressure and the duration of erectile response were significantly higher (p <0.05) and longer (p <0.05) than those observed when rolipram alone was injected intracavernosally. PGE1 (3 microM) and rolipram (10 microM) produced significant increases (p <0.05) in the accumulation of intracellular cAMP levels in HCSMCs in primary culture above those of the baseline values while intracellular levels of cGMP did not change. CONCLUSIONS: PDE inhibitors administered intracavernosally caused dose-dependent increases in cavernosal pressure in the cat. When a specific cAMP PDE inhibitor was combined with PGE1, the erectile response was enhanced and intracellular levels of cAMP were increased in HCSMCs in primary culture. These data suggest further exploration of the combination of various PDE inhibitors and PGE1 in the pharmacologic treatment of erectile dysfunction and provide functional evidence for the presence of PDE 4 isoenzyme in human penile cavernosal cells.     

Detection of polyamines by an enzymatic assay. (6). Fundamental and clinical studies of a simple enzymatic method for determining total polyamines in blood

A simple enzymatic method for determining total polyamines in human blood was established. Polyamines in trichloroacetic acid extract from 1 ml of blood were isolated on an anion-exchange column and measured spectrophotometrically by the end point assay using polyamine oxidase and putrescine oxidase. The recovery was as high as 98.4% and within-run precision (coefficient of variance: 1.82%), and the values obtained by this method were in fair agreement with those obtained by high performance liquid chromatography and the enzymatic differential assay methods previously reported. The polyamine levels were not changed when the blood was stored at -20 degrees C. Blood polyamine levels were measured in 108 patients with genitourinary cancers, 29 patients with benign prostatic hypertrophy, 18 patients with benign urological diseases and 25 normal subjects. Although polyamines were not significantly elevated in the low stage of cancer, elevation was observed at a high stage of malignancy. These results indicate that the determination of total polyamines may be useful to determine biochemically the malignancy of cancers.