Free microvascular tissue transfer. Clinical significance in reconstructive surgery of the head and neck

Free microvascular anastomosed tissue transfer has improved the reconstruction of soft tissue defects dramatically. For reconstruction of facial and cervical soft tissue defects numerous free flaps are available to the head and neck surgeon, however, most of the reconstructive problems can be solved by using a limited number of reliable and versatile techniques. In microvascular tissue transfer, the scapular flap offers similar advantages as to reliability and versatility as the pectoralis major flap in pedicled tissue transfer. In contrast to the scapular flap the groin flap is more bulky, its skin is soft and may carry pubic hair on its medial aspect. After partial maxillectomy or in facial dysplasia facial contour may be restored satisfactory with a completely or partially de-epithelialized scapular flap. In total hypopharyngeal and cervicoesophageal defects the jejunum transplant provides an ideal tubular replacement. If after resection of an intraoral carcinoma with partial mandibulectomy an osteocutaneous transfer has to be achieved the mandibular defect may be reconstructed with bone from the iliac crest or from the radius while the intra- and extraoral tissue defect may be closed with the adjacent skin flaps. For the closure of large penetrating defects of the cheek the inferior epigastric abdominal wall flap in particular has proved a versatile and reliable flap. This flap offers both, a cutaneous and a peritoneal surface. Latter is used for the replacement of the intraoral lining.     

Calciphylaxis – a topical overview

'Calciphylaxis', a calcification syndrome associated with ischaemic cutaneous necrosis, is acquired naturally in humans in disease states. It is a life and limb-threatening complication, usually observed in patients with renal disease and secondary hyperparathyroidism, but known to occur in the absence of renal or parathyroid disease. The reported mortality rate, which ranges from 60-80%, relates to wound infection, sepsis and organ failure. It is a small-vessel vasculopathy, which is estimated to occur in about 4% of haemodialysis patients. Clinically, violaceous, reticulate areas of cutaneous necrosis and eschar may be evident, particularly in the extremities. In addition to the clinical picture, a raised calcium phosphorous product, an elevated parathyroid hormone level, radiographic evidence of vessel and soft-tissue calcification and the finding of mural calcification affecting small arteries and arterioles on histopathology help to confirm the diagnosis of this entity which generally has a poor prognosis. A high index of suspicion and an active multidisciplinary management approach, with rigorous attention to wound care and prevention of sepsis, are vital in the management of these patients. In this overview, we discuss the pathophysiology, clinical features and associations, risk factors, diagnosis and management issues relating to calciphylaxis.     

The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis

Backround  

Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.