The use of the platysma and the skin of the neck as a myocutaneous flap in reconstructing cheek defects. Technic and results apropos of 5 cases

Skin defects of the cheek are commonly the result of a radical surgical resection of extensive neoplasms of the parotid gland, the mandible or the skin, such as melanomas and squamous cell carcinomas. For the reconstruction of these defects, we have devised a myocutaneous flap which enables us to perform a radical neck dissection at the same operation. The transposed flap which involves the cervical skin, the platysma muscle and the superficial cervical fascia, has a wide pedicle on the lateral and dorsal side of the neck near the upper border of the Trapezius muscle. The border of the flap runs from the distal part of the defect and travels parallel and close to the midline of the neck down to the middle of the sternum. The border of the flap runs parallel and nearly 3-4 cm below the clavicle and as far as its acromial end. The advantages of this flap are: 1) better operative field for radical neck dissection; 2) good vascularization; 3) does not prolong the operative time; 4) does not need any "delay" procedure; 5) gives a good functional and cosmetic result, as it covers; the thickness of the cheek defect as well as protecting the neurovascular bundle of the neck.     

Hereditary pancreatic endocrine tumours.

The two main types of hereditary pancreatic neuroendocrine tumours are found in multiple endocrine neoplasia type 1 (MEN-1) and von Hippel-Lindau disease (VHL), but also in the rarer disorders of neurofibromatosis type 1 and tuberous sclerosis. This review considers the major advances that have been made in genetic diagnosis, tumour localization, medical and surgical treatment and palliation with systemic chemotherapy and radionuclides. With the exception of the insulinoma syndrome, all of the various hormone excess syndromes of MEN-1 can be treated medically. The role of surgery however remains controversial ranging from no intervention (except enucleation for insulinoma), intervening for tumours diagnosed only by biochemical criteria, intervening in those tumours only detected radiologically (1-2 cm in diameter) or intervening only if the tumour diameter is > 3 cm in diameter. The extent of surgery is also controversial, although radical lymphadenectomy is generally recommended. Pancreatic tumours associated with VHL are usually non-functioning and tumours of at least 2 cm in diameter should be resected. Practice guidelines recommend that screening in patients with MEN-1 should commence at the age of 5 years for insulinoma and at the age of 20 years for other pancreatic neuroendocrine tumours and variously at 10-20 years of age for pancreatic tumours in patients with VHL. The evidence is increasing that the life span of patients may be significantly improved with surgical intervention, mandating the widespread use of tumour surveillance and multidisciplinary team management.     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

Volume matters: The influence of different botulinum toxin‐A dilutions for sialorrhea in amyotrophic lateral sclerosis

Introduction: We aimed to determine the effect of different botulinum toxin‐A (BTX‐A) dilutions on the treatment efficacy and side effects for amyotrophic lateral sclerosis (ALS) related sialorrhea. Methods: Ten patients were enrolled in the study. BTX‐A dilution for Group A was 100 U in 1 ml of saline, whereas the dilution for Group B was 100 U in 2 ml of saline. Both groups received 20 U of BTX‐A in each parotid gland, and assessments were made by means of the Drooling Impact Scale, items 1 and 3 of the ALS functional rating scale, and visual analog scales for drooling and swallowing function. Results: Although both groups exhibited a similar improvement in drooling, Group B had a mild but significant deterioration in bulbar function that was not evident in Group A. Conclusions: These results suggest that BTX‐A has a safer profile when reconstituted with 1 ml instead of 2 ml of saline. Muscle Nerve, 2013     

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

Background Non-alcoholic duct destructive chronic pancreatitis is a rare entity with specific pathological features. The majority of the patients are from Japan. We report a case with involvement of the distal bile duct, the gallbladder, the duodenum and the ampulla, and present a review of patients from Europe and the USA since 1997.Case presentation A 56-year-old man presented with a 3-month history of mild acute pancreatitis and obstructive jaundice, followed by increasing weight loss, lethargy and epigastric pain. CT showed a mass in the head of the pancreas. ERCP demonstrated a smooth stricture of the intra-pancreatic main bile duct and an irregular, incomplete, stricture in the main pancreatic duct. A pancreatic cancer could not be reliably excluded, and, therefore, he underwent a pylorus-preserving Kausch–Whipples pancreatoduodenectomy.Results Histopathology showed typical peri-ductal T cell-rich lymphoplasmacellular and eosinophilic infiltration of the pancreas, with involvement of the distal bile duct but, also, unusual inflammatory infiltration of the gallbladder, the duodenum and the ampulla.Conclusion The inflammatory process in non-alcoholic duct-destructive chronic pancreatitis can affect the entire pancreato-biliary region and mimics pancreatic cancer. Currently, there are no definitive criteria for pre-operative diagnosis, so it is very difficult for one to avoid resection.     

Fatal Chest Injury with Lung Evisceration during Athletic Games in Ancient Greece

The “Olympic idealism” that dominates modern athletic culture is a myth. The true aims of the athletes in ancient Greece were rewards and life-long appointments to various positions in the military or the city administration. Competitions in the athletic games included, among others, wrestling, boxing, and pangration (a combination of wrestling and boxing). Occasionally, these games resulted in severe trauma or death. Two cases of extreme violence resulting in fatal chest trauma are presented and commented on from both surgical and social points of view.     

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status

BACKGROUND: The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy. METHODS: Patients undergoing resection for primary pancreatic ductal adenocarcinoma or intrapancreatic bile duct adenocarcinoma were identified from a prospective database (September 1997-May 2003). RESULTS: Thirteen of 54 and ten of 44 evaluable patients had metastatic involvement of lymph nodes 8a and 16b1 respectively. Metastatic involvement of lymph node 8a was associated with a significantly shorter median survival (197 versus 470 days; P = 0.003) but metastatic involvement of lymph node 16b1 did not affect survival (457 versus 503 days; P = 0.185). Multivariate analysis showed lymph node 8a status to be the strongest predictor of outcome (P = 0.006). Median survival of those with metastatic lymph node 8a was not significantly different from that of 81 patients with overt metastatic periampullary cancer at the time of diagnosis (98 days; P = 0.072) CONCLUSION: Lymph node 8a was an independent prognostic factor in patients with periampullary malignancy, but lymph node 16b1 was not. Survival in those with metastatic lymph node 8a was not significantly different from that in patients with metastatic disease at presentation. Preoperative determination of lymph node 8a status may have important implications in selecting patients for treatment.     

Fungal infection but not type of bacterial infection is associated with a high mortality in primary and secondary infected pancreatic necrosis

INTRODUCTION: Knowledge of microbiology in the prognosis of patients with necrotizing pancreatitis is incomplete. AIM: This study compared outcomes based on primary and secondary infection after surgery for pancreatic necrosis. METHOD: From a limited prospective database of pancreatic necrosectomy, a retrospective case note review was performed (October 1996 to April 2003). RESULTS: 55 of 73 patients had infected pancreatic necrosis at the first necrosectomy. 25 of 47 patients had resistant bacteria to prophylactic antibiotics (n = 21) or did not receive prophylactic antibiotics (n = 4), but this was not associated with a higher mortality (9 of 25) compared to those with sensitive organisms (4 of 22). Patients with fungal infection (n = 6) had a higher initial median (95% CI) APACHE II score compared to those without (11 (9-13) verus 8.5 (7-10), p = 0.027). Five of six patients with fungal infection died compared to 13 of 47 who did not (p = 0.014). With the inclusion of secondary infections 21 (32%) of 66 patients had fungal infection with 10 (48%) deaths compared to 11 (24%) of 45 patients without fungal infection (p = 0.047). CONCLUSION: Whether associated with primary or secondary infected pancreatic necrosis, fungal but not bacterial infection was associated with a high mortality.     

Surgical treatment of pancreatic fistula

BACKGROUND: Pancreatic fistula remains a significant problem in pancreatic disease, trauma and surgery. Whilst improved diagnostic and treatment techniques, including endoscopic approaches, have resulted in considerably improved outcomes, surgical intervention remains an important aspect of treatment but has been relatively poorly documented. AIMS: The aims were to review the recent world literature on the relative incidence of pancreatic fistula and the results of surgical treatment. RESULTS: The pancreatic fistula rate following partial pancreato-duodenectomy was 421 (12.9%) in 3,268 patients in 13 large series; 80 (13.0%) in 671 patients after left pancreatectomy in 6 large series, and 28 (11.9%) in 243 patients after pancreatic trauma in 4 recent series. The success rate of surgical procedures for external pancreatic fistulae was 101 (90.2%) in 112 patients with an overall mortality of 7 (6.3%) reported in 9 series. For internal pancreatic fistulae the success rate of surgical treatment was 61 (92%) in 66 patients with an overall mortality of 6 (9%) reported in 7 series. CONCLUSIONS: The treatment of established pancreatic fistula remains challenging. Although surgical treatment is reserved for patients who have failed all other treatments, the success rate is 90-92% but with a mortality of 6-9%.