Anomalous left main coronary artery arising from the pulmonary artery in an adult: treatment by direct reimplantation

We herein report the case of a 37-year-old woman in whom an anomalous origin of the left coronary artery from the pulmonary artery was surgically corrected. A magnetic resonance angiogram showed the left main coronary artery connecting to the right posterior portion of the pulmonary trunk, and exercise-stressed thallium-201 perfusion scintigrams demonstrated a large reversible anterior defect. She was successfully treated by direct aortic reimplantation of the abnormal left coronary artery. We were able to obtain a sufficient length of the left main trunk by excising the large cuff of pulmonary artery wall surrounding the ostium of the anomalous left coronary artery while transecting the pulmonary artery. Postoperative angiograms demonstrated a widely patent left coronary artery, a decrease in the size of the right coronary artery, and no collaterals, and exercise-stressed thallium-201 perfusion scintigrams demonstrated no remaining ischemic defect at all. Direct aortic reimplantation is an ideal operation but is still limited by the anatomical position of the left coronary artery. In this case, magnetic resonance angiography was an excellent method for deciding the optimum operative procedure for the anomalous left coronary artery. In addition, exercise thallium-201 scintigraphy was found to be useful in recognizing the revascularized effect of the left ventricle.

Microsurgical replantation of the avulsed scalp: report of 20 cases

Our 4-year experience with 20 patients who had suffered avulsion of 75 percent or more of the scalp is reviewed. All patients underwent replantation using microsurgical technique with 100 percent survival in 16, partial survival in 3, and failure in only 1 case. The emergency management and indications for replantation are demonstrated. The roles of sufficient preoperative preparation, generous debridement of damaged vessels, interpositional vein grafts, and the shortening of operative time in contributing to this success are emphasized. We developed a new surgical procedure called simultaneous vein grafts on donor and recipient sites in an effort to use less time in the anastomosis of interpositional vein grafts. Furthermore, we anastomosed the extra artery of the scalp to the vein on the recipient head when no suitable vein could be found. Intraoperative repair of the scalp sensory nerve and no postoperative use of any vasodilator or anticoagulant are discussed.

Temporary ectopic implantation for salvage of amputated digits

Temporary ectopic implantation for salvage of amputated parts is a fascinating idea. The first successful case, to our knowledge, of preserving digits by means of temporary ectopic implantation to the contralateral forearm is presented and this treatment concept is discussed. The indication for temporary ectopic implantation is an amputation injury with associated extensive soft tissue damage in which immediate replantation with either adequate shortening or preservation of length does not seem feasible, although the amputated part itself is uninjured and should therefore be salvaged. The groin, axilla and lower arm are compared as possible recipient sites for ectopic implantation. Early replantation of the ectopic implanted parts will provide superior functional results although replantation may be technically more demanding. The function of a replanted extremity after ectopic implantation will probably always be inferior to a comparable, immediately replanted extremity.

Complications and salvage of an ectopically replanted thumb

The ectopic replantation of a thumb is described after a mutilating hand injury. The case was followed by a series of complications and surgical procedures to treat these complications. Through perseverance and multiple microsurgical procedures the patient attained a functional hand. The patient's psychological and physical course is described.

Nail regeneration in digits replanted after amputation through the distal phalanx

Nail regeneration was studied in 48 digits replanted after amputation through the distal phalanx. Twenty-seven were amputated through Tamai's zone I, at the nailbed level, and 21 digits were amputated through zone II, proximal to the nail. The nails of 9 digits in zone I and 14 in zone II showed almost normal nail regeneration. We observed that replantation after amputations distal to the lunula will show near normal nail regeneration if there is minimal postoperative circulatory disturbance. Amputations proximal to the lunula, however, have a greater chance of causing damage to the germinal matrix, which results in more problems with nail growth.

[Double kidney-total pancreas transplantation with bladder reimplantation. 25 cases]

Twenty five double kidney-pancreas transplantations were performed according to the total pancreas transplantation technique with drainage of exocrine secretions into the bladder via a vesicoduodenostomy. 72% of kidney-pancreas grafts were functional at one year and 59% were functional at four years. The authors observed a slightly higher rejection rate (0.56 versus 0.34) and a higher incidence of urinary tract infection (60% versus 35%) following double pancreas and renal transplantation than after isolated renal transplantation. Complications were rare: two venous thromboses and two cases of urethritis requiring of rediversion of the duodenum into the intestine. These good results, comparable to those reported in the international registry, reflect the value of the pancreatic and renal transplantation technique using a total pancreas drained into the bladder. It would probably be preferable to transplant patients earlier, when chronic renal failure secondary to insulin-dependent diabetes induces end-stage renal failure and the need for haemodialysis.

The use of immediate frozen autogenous mandible, for benign tumour mandibular reconstruction

Reimplantation of frozen autogenous lesioned mandible was performed in 31 patients with mandibular bone cysts and tumours. 26 reimplanted grafts survived without complications following surgery. Two cases had postoperative infections which were resolved following appropriate antibiotic treatment. Three grafts were removed due to the severe infection and wound dehiscence. The follow-up from 6 months to 4 years showed that there was no recurrence of the primary lesion in the 28 successful cases. Satisfactory facial contour after surgery was achieved in 19 patients, while other patients showed relatively mild facial disfigurement. The inferior alveolar nerve was repaired in 4 cases and a functional evaluation was made using an acupuncture pressure tester.

Microsurgical replantation of avulsed scalps

Four cases of extensive scalp avulsion were successfully replanted in this reported series. All patients were female, with the youngest 3 years of age. All replanted scalps survived, with some marginal necrosis due to tissue destruction. Postoperative venous congestion of the involved ear in one patient was managed with anticoagulant therapy. Another patient underwent severe congestion of the whole replanted scalp and was treated with thin skin-graft shaving in the parietal area. In the follow-up period, all patients obtained hair growth in the scalp with light touch sensation.

Microvascular replantation of a traumatically amputated ear

We describe the replantation of a traumatically severed auricle using microvascular anastomosis to reestablish blood flow to the ear. Microvascular reattachment of the severed auricle occurred 10 hours after the trauma. Postoperatively, adjunctive measures, including anticoagulation and the use of medicinal leeches, were used to relieve venous congestion of the replanted auricle. The replanted auricle healed completely with 100% survival, resulting in an essentially normal-appearing external ear. In the management of a traumatically severed auricle, microvascular replantation should be considered as the intervention of first choice in selected cases. If the procedure is successful, the cosmetic results are excellent; if it is not successful, a number of other reconstructive techniques remain as options.

Above-elbow arm replantation during pregnancy

We report a successful replantation of an above-elbow amputated left arm in a 26-year-old female with a good, functional, long-term result. The patient was at 18 weeks estimated gestational age at the time of surgery. Major upper extremity replantation during pregnancy has not been previously described in the literature. Current operative and perioperative aspects, including considerations that favored microsurgical replantation in this unusual case, are discussed.

Replantation of a completely detached degloved thumb

Injuries resulting in the degloving of digits, particularly the thumb, offer the reconstructive surgeon a significant challenge, as the restoration of both digital function and appearance is often difficult. This paper is a case report describing the successful microvascular replantation of a completely degloved thumb, the result of an avulsion injury caused by a drill. Aspects of the preoperative assessment, the operative procedure and the appropriate sequence of artery and vein repair are discussed.

Microsurgical replantation of the amputated penis and scrotum in a 29-year-old man

A 29-year-old mentally ill farmer underwent microsurgery for the resuturing of the penis and testicles which he himself had chopped off with an ax. Microsurgery of the urethra, corpora cavernosa, arteries and veins was begun 10 h after the trauma. The veins, arteries and testicles were anastomosed and covered with a free flap of the scrotum skin. Three weeks after surgery, the anastomosed tested showed good healing. However, in 65% of the penis, necrosis had occurred.

Avulsive amputations of the thumb: comparison of replantation techniques

Twenty-five cases of avulsive amputation of the thumb are reported. Twenty-one of the 25 cases were categorized as Grade I avulsions (little or no skin defect) and four were categorized as Grade II avulsions complicated by a large skin defect. Three different replantation techniques were used and compared: (1) direct vessel anastomosis, (2) arterial anastomosis between the superficial branch of the radial artery and distal end of the thumb, and (3) arterial anastomosis after artery transfer from other digits. The authors concluded that direct vessel anastomosis was not the preferred method and that technique 2 could be used in any case but was especially suited to Grade II reconstructions. Technique 3 is mainly used in Grade I avulsions.

Penile replantation after self-inflicted complete amputation: case report

A case of penile replantation is reported in which a 37-year-old man suffered a self-inflicted complete penile amputation. Replantation was successfully performed; at 3 months after surgery, a urethrocystogram demonstrated the absence of urethral stricture. Although complete erection has yet to be obtained, no other functional impairments have been encountered at 7 months after replantation. Reconstruction of the venous system is considered to be one of the most important factors in achieving a successful penile replantation.

[Pregnancy after transposition and repositioning of the ovaries in a patient with clear-cell adenocarcinoma]

A young woman with a history of in utero exposure to distilbestrol was diagnosed with vaginal clear-cell adenocarcinoma. Management consisted of limited excision of the tumor followed by brachytherapy after transposition of the ovaries. The patient had a successful pregnancy after reimplantation of the ovaries in their normal position and right adnexectomy for Chlamydia infection. The child was delivered by cesarean section. This is probably the first case with a pregnancy after repositioning of the ovaries in Europe and perhaps even in the world.

Early results with split-cuff nipple ureteral reimplants in urinary diversion

PURPOSE

A split-cuff nipple technique was developed for ureteral reimplantation in urinary diversion.

MATERIALS AND METHODS

Ureteroenteric anastomosis was performed with a uniform split-cuff nipple technique in 46 ureters of 24 adult patients undergoing various forms of conduit or continent urinary diversion. The outcome of 42 reimplants in 22 patients (mean followup 22.5 months, minimum 10) was analyzed. The technique is described in detail.

RESULTS

Reflux was prevented in 97.6% and 95% of cases at initial and 2-year followup, respectively. Neither anastomotic leakage nor obstruction occurred. There were 2 episodes of pyelonephritis in the early postoperative period. Results are compared with those in the literature of ureteroenteric anastomoses in general and of various split-cuff nipple techniques.

CONCLUSIONS

The technique is easy to perform. Favorable early results warrant continued use of the procedure. Long-term followup in a larger number of patients is indicated.

Cold induced vasospasm in replanted digits: a comparison between different methods of arterial reconstruction

Nineteen patients each of whom had had a single digit replanted were examined after replantation. The arterial reconstruction had been done with long grafts (n = 10) or short grafts or no graft (n = 9). The effect of local or whole body cooling on the replanted and uninjured opposite digits was monitored (9-46 months after the replantation), and the patients were given a questionnaire (9-95 months after replantation) designed to explore the development of their cold related symptoms in relation to time. All patients were troubled by cold intolerance, and improvement occurred in only 60% of the cases. Pathological (vasospastic) arterial reactions to cold measured as finger systolic pressure, were less common after replantation with long grafts. Perceived cold intolerance was significantly more pronounced in the group of patients (60%) who had evidence of cold induced arterial spasm in the replanted finger.

[Heterotopic replantation]

In multidigital amputations, it is sometimes better to replant an amputated finger to a different proximal part if a better function can be expected in this position. In our clinical material between October 1991 and March 1994, heterotopic replantation was performed in twelve digits in eleven patients. Three fingers were replanted to the thumb, three to the index, four to the middle, and two to the ring fingers. The functional results were satisfying. The total active range of motion was on an average 24% of a normal finger. Static two-point discrimination was 8.5 mm on an average, and the values for the Semmes-Weinstein test ranged between 3.61 and 6.5. A heterotopic replantation is of special value for primary thumb reconstruction.

Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm replantation

The results of replantation at the wrist and distal forearm are reported to be better than at the metacarpal level, in part because the latter involve direct injury to the intrinsic muscles. This study evaluates a new post-operative protocol for replantation at the metacarpal, wrist and distal forearm levels. 3 days after replantation, the patient was placed in a dynamic crane outrigger splint with MP joint control, compensating for intrinsic muscle function loss. From 4 to 12 weeks, an anticlaw splint alternated with the outrigger splint. After 12 weeks, a dynamic wrist extension orthosis was added to the anti-claw splint. 11 patients (four replantations at the transmetacarpal level, three at the wrist and four in the distal forearm) had this protocol between 1988 and 1993. For distal forearm replantation, TAM of fingers averaged 216 degrees, grip strength 42 lb, and pinch strength 7.2 lb with 75% good or excellent results. For wrist replantations, TAM of fingers averaged 243 degrees, grip strength 37 lb and pinch strength 10.6 lb with 100% good or excellent results. For transmetacarpal replantations, TAM of fingers averaged 189 degrees, grip strength 37 lb and pinch strength 5.6 lb, with 75% good and excellent results. Early protected mobilization, as described here, preserves tendon gliding, muscle strength and excursion. Our results support this protocol for wrist and distal forearm replantation and especially for transmetacarpal replantation, the results of which tend to be poor according to the medical literature.

Free tissue transplantation in the 90's

Free tissue transplantation is now a well-established discipline and a common phrase in the medical literature. Only as recent as two decades ago, free tissue transplantation with microvascular anastomosis was a daring venture attempted by a selected few. It was considered to be a heroic effort of last resort when other reconstructive options were exhausted. Reconstructive surgeons were limited by tissue availability before free tissue transplantation with microsurgical techniques. With pedicle flaps, patients were subjected to multiple operations and hospitalizations and long periods of immobilization. The possibility of moving a large block of tissue to another body location by anastomosing its vascular pedicle with local blood vessels was tantalizing to reconstructive surgeons. The ability to perform anastomosis on small vessels had to be mastered before such a dream could be realized.

The effect of exposure time on microsurgical anastomoses of experimentally crushed arteries

Replantation after crushing amputation has a relatively low success rate. Although the mechanism of trauma is a major factor in failure, the time lapse before vessel anastomosis may also be a contributing factor. In this study, we observed the influence of the interval between vessel injury and surgical treatment on thrombus formation and healing after controlled crushing. Seventy-five Sprague-Dawley rats were used. A segment of femoral artery was clamped to create warm ischemia for 8 hours and crushed with a 15 kg load for one hour. After the loading device was removed the crushed segments were transected and the vessel ends exposed to the adjacent tissues and blood for 0, 2, 4 and 6 hours (groups II-V, respectively) prior to being anastomosed with standard microsurgical technique. The vessel samples were harvested at days 1, 2 and 7, respectively, and evaluated by light microscopy and scanning electron microscopy (SEM). The patency rate of the anastomoses was 97.3% at harvest and reendothelialization was completed at day 7. Three anastomoses with 4 or 6 hours exposure showed thrombosis, or clotting. The results indicated that up to 6 hours exposure time did not have a significant influence on thrombus formation or the healing process of vessels under the controlled conditions of this study.

Tissue changes at different periods of ischemia

A multidisciplinary study was done to examine the following: (a) pathophysiological changes in muscle and nerve response following different periods of normothermic and cold ischemia; (b) alterations in the release of enzymes (K, LDH), CA++, K=and lactate under these conditions; and (c) histological alterations of vessels, nerves and muscles after different periods of normothermic and cold ischemia. The results demonstrate that hypothermic ischemia greatly reduces both the leakage of enzymes, cellular damage and pathological responses. We infer that amputated parts containing muscular masses may be replanted with good prognosis for satisfactory functional results within 4-5 hours at room temperature. By reducing the temperature, the time between cooling and revascularization may be doubled. Parts without muscles may be replanted 10-12 hours after normothermic ischemia and up to 24 hours or even longer after cold ischemia.

Scalp replantation after traumatic injury

A 30-year-old female patient lost her scalp in an industrial accident. Surgeons used a microscope to reconnect the arteries and veins in her scalp and to reattach the scalp to the patient's cranium. The patient tolerated the procedure without complications, although she developed venous congestion in her right ear while she was in the neuroscience intensive care unit. After several days of leech therapy, the patient experienced an uneventful postoperative course. One month after discharge from the hospital, the patient's hair was growing back in and her incision lines were fading.