Risk factors and survival of early bleeding after esophageal variceal ligation

BACKGROUND/AIMS

In cirrhotic patients, esophageal variceal bleeding (EVB) is still unpredictable and continues despite initial adequate treatment that is associated with great mortality. Bacterial infections are frequently diagnosed in cirrhotic patients with gastrointestinal bleeding (GIB). The aims of this study were to analyze the clinical risk factors and survival of early bleeding after endoscopic variceal ligation (EVL).

METHODOLOGY

A total of 96 cirrhotic patients with esophageal varices who received elective or emergent EVL procedure were analyzed. The variables for risk factors analysis included bacterial infection, hepatocellular carcinoma (HCC) with or without portal vein thrombosis, etiology of cirrhosis, Child-Pugh status, and basic laboratory data. There were 19 patients with bleeding episode or rebleeding within 14 days after EVL. The remaining 77 patients were without bleeding event after EVL.

RESULTS

Patients with Child C cirrhosis (odds ratio, 7.27; 95% CI, 2.20-24.07, P = 0.001) and bacterial infection (odds ratio, 130.29; 95% CI, 14.70-1154, P < 0.001) were independently associated with the early bleeding after EVL. However, there was no significant difference in long-term survival between patients with and without early bleeding after EVL.

CONCLUSIONS

Bacterial infection and end-stage liver cirrhosis (Child C) are the independent risk factors for early bleeding after EVL. We should closely monitor the symptoms/signs of infection and empirical antibiotics should be administered once infection is suspected or documented, especially in cirrhotic patients with poor liver reserve.

An integrated MELD model including serum sodium and age improves the prediction of early mortality in patients with cirrhosis

The Model for End-Stage Liver Disease (MELD) is widely used to predict the short-term mortality in patients with cirrhosis, but potential limitations of this score have been reported. The aim of this study was to improve the score's prognostic accuracy by assessing new objective variables. Data of 310 consecutive patients with cirrhosis who underwent elective transjugular intrahepatic portosystemic shunt placement between July 1995 and March 2005 were analyzed retrospectively. Bivariate and multivariate analyses were performed by proportional hazard Cox regression models. The area under the receiver operating characteristic curve (auROC) and the likelihood ratio test were used to evaluate the performance of the models for predicting early mortality. Findings were validated in a cohort of 451 consecutive patients with cirrhosis on waiting list for liver transplantation. Bivariate analyses showed that the following variables correlated with time to death: age, serum bilirubin, serum creatinine, international normalized ratio of prothrombin time, serum albumin, serum sodium, and MELD. Multivariate analysis revealed that MELD, serum sodium, and age were independently associated with the risk of death. The integrated MELD model (iMELD, incorporating serum sodium and age) was better than original MELD in predicting 12-month mortality: auROC increased by 13.4% and the likelihood ratio statistic from 23.5 to 48.2. The improved accuracy of iMELD was confirmed in the validation sample of 451 patients with cirrhosis on the waiting list for liver transplantation by increasing auROC (+8%) and likelihood ratio statistic (from 41.4 to 82.0). This study shows that in patients with cirrhosis, serum sodium and age are predictors of mortality independent of the MELD score. The incorporation of these variables into the original MELD formula improves the predictive accuracy of time to death.

Simultaneous pediatric kidney transplantation and ureterocystoplasty in a 20-month-old boy

Kidney transplantation (KT) in children with end-stage renal disease and an abnormal bladder poses a complex management challenge. Ureterocystoplasty (UC) has been previously reported in older children with non-compliant bladders, but the timing and technique of repair are controversial. This case reports the youngest patient, a 20-month-old boy to undergo successful single-stage UC and living-related KT. UC was performed because of a fibrotic, non-compliant bladder. A temporary vesicostomy was placed to provide adequate drainage in the presence of urethral stenosis. The patient developed a single episode of pyelonephritis within the first six months post-operatively, but there were no other urologic complications. At 13 months, the renal function is excellent with a mean glomerular filtration rate of 100 mL/min/1.73 m(2) and no clinical evidence of rejection. This case demonstrates that simultaneous UC and KT can be safely performed even in infants with non-compliant bladders and renal failure.

Valve repair for mitral insufficiency secondary to idiopathic juvenile polyarthritis

A female patient in whom idiopathic rheumatoid polyarthritis was diagnosed at the age of 8 years required surgery for severe mitral valve insufficiency 16 years later. Intraoperative analysis revealed a fibrotic endocarditis involving mainly the posterior leaflet. Granulomatous vegetations as well as a large thrombus which filled the left ventricular apex and simulated endomyocardial fibrosis were noted. Valve repair was achieved using an anterior leaflet augmentation with a patch of mitral homograft associated with a prosthetic ring annuloplasty. Postoperatively, a severe pericardial effusion required surgical drainage. Eight years later, the patient had no cardiac symptoms and echocardiography confirmed a normally functioning mitral valve.

ORIGINAL RESEARCH—SURGERY: Penile Prosthesis Implantation in Cases of Fibrosis: Ultrasound-Guided Cavernotomy and Sheathed Trochar Excavation

INTRODUCTION

Implantation of a penile prosthesis into fibrosed corpora cavernosa is a difficult and risky procedure. Specialized instruments that assist safer and more efficient excavation include Otis Urethrotome and various cavernotomes, all of which operate underneath the tunica albuginea, out of sight. The blind use of such instruments can result in perforation of the tunica albuginea or injury to the urethra.

AIM

This work describes the utility of ultrasonography for adding visual monitoring to any of the above-mentioned instruments, maintaining them in the mid-corpus cavernosum position to avoid perforation, and describes the application of alternative sheathed, sharp instruments that allow fast, efficient, and visually monitored drilling into fibrous tissue.

MAIN OUTCOME MEASURES

Clinical outcome data were examined.

METHODS

Surgery was performed on five cases with extensive fibrosis of the penis. Initial blunt dilatation by Hegar dilators faced considerable resistance. An ultrasound probe was applied to the ventral aspect of the penis. A laparoscopy sheath was advanced under ultrasound guidance up to the fibrous tissue. A sharp laparoscopy trochar was inserted through the sheath. Its tip was oriented in the mid-corpus cavernosum by longitudinal and transverse sonography sections, as it drilled into the fibrous tissue. Laparoscopy scissors were used in the same fashion to cut fibrous tissue lumps. After full excavation, penile prosthesis was implanted.

RESULTS

All implants survived adequately. No complications occurred following implantation. Operative time ranged from 50 to 60 minutes. No difficulty was encountered at excavation.

CONCLUSION

Ultrasound guidance can be a handy adjunct to any of the available techniques developed for excavating the fibrosed corpora cavernosa, with a possible decrease in difficulty and complication rate of the procedure. Utility of sheathed, sharp instruments guided by sonography is an alternative to the cavernotomes, allowing fast and efficient drilling into fibrous tissue.

Prise en charge chirurgicale des diplopies dysthyroïdiennes

INTRODUCTION

Forty percent of thyroid-related orbitopathies are associated with strabismus. In the healing phase of disease, fibrous hypertrophy of extraocular muscles may result in restrictive myopathy. We report our experience of surgical management in these cases.

PATIENTS AND METHODS

We present a retrospective case series conducted on 42 patients, operated between September 1998 and April 2003. All patients underwent complete oculoplastic and orthoptic examinations. Muscular recession was performed in all cases, with general anesthesia in cases of clinical muscular restriction; adjustable recession with topical anesthesia was performed in cases of moderate muscular restriction. Postoperative alignment and elimination of diplopia in the functional position of the gaze were evaluated.

RESULTS

The study included 42 patients (28 women, 14 men) with a mean age of 51 years. The mean follow-up was 48 months (range, 10 months to 6 years). Twenty-six patients presented vertical diplopia, 11 horizontal diplopia, and five mixed diplopia with a vertical and a horizontal component. These patients were operated on twice, beginning with vertical surgery. In cases of general anesthesia, muscular recession was adapted to an intraoperative forced duction test and a muscular elongation test. We obtained 94% good results for vertical diplopia and 81% for horizontal diplopia. Incomplete results were under correction. Adjustable muscular recession was adapted to intraoperative evaluation with patient participation. All patients had good results.

CONCLUSION

Successful surgical treatment depends on precise identification of the muscles that are restricting motility and producing misalignment. We insist on the importance of an intraoperative forced duction test and a muscular elongation test in case of clinical muscular restriction. Adjustable surgery is useful in cases of moderate muscular fibrosis.

Modification of Cysteinyl Leukotriene Receptor Expression in Capsular Contracture

The development of a fibrotic capsule around foreign material in the body is a physiologic reaction undertaken by the body to protect itself from a material it does not recognize. The periprosthetic capsule can pathologically contract, pressing on the implant; it can cause pain, firmness, and sometimes implant extrusion. The pathogenesis of capsular contracture is still unclear, but most reports indicate a multifactorial explanation. The aim of this study is to investigate the role of cysteinyl leukotriene receptors (cysLTR) on the inflammatory cells involved in the development of the capsular contracture. We recruited 20 patients affected by severe capsular contracture (Baker III-IV) and a control group composed of normal patients who had undergone implant substitution. In both groups, we performed a semiquantitative analysis of mRNA encoding for cysLTR1, cysLTR2, tumor necrosis factor-alpha (TNF-alpha) and interleukin 10 (IL-10) on myofibroblasts and macrophages of the periprosthetic capsular tissue. The molecular analysis showed an increase in the cysLTR2, TNF-alpha gene expression but no change in the cysLTR1 and IL-10 genes in patients affected by capsular contracture. These preliminary findings suggest a primary role for cysteinyl leukotrienes in the activation and up-regulation of capsular contraction mechanisms.

Surgical treatment of medial meatal fibrosis. Report of four cases

OBJECTIVE

We describe four cases of medial meatal fibrosis, a rare condition of the external auditory canal, in which hearing improved following surgery.

METHODS

Four patients with medial meatal fibrosis underwent surgical treatment and had been followed at the University of Tokyo during the last 5 years. We examined hearing improvement and recurrence. A patient had graft-versus-host disease (GVHD) with her urethra and vagina, and two patients had methicillin resistant Staphylococcus aureus (MRSA) infection with their affected ears.

RESULTS

All cases got hearing improvement without any major complications.

CONCLUSIONS

Medial meatal fibrosis may be treated satisfactory with surgical interventions.

Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement

The purpose of this study was to document the effect of arthroscopic management in patients with knee stiffness after total knee replacement. We present a case series study, in which 32 patients have been treated for moderate arthrofibrosis of the knee after total knee replacement, with the same regimen. We have excluded all cases of stiffness, because of infection, mechanical mal-alignment, loosening of the implants and other obvious reasons of stiffness of the knee, rather than pure arthrofibrosis. All patients first underwent a trial of conservative treatment before going for arthroscopic management. A pain catheter for femoral nerve block was inserted just before anesthesia for post-operative pain management. Arthroscopic arthrolysis of the intra-articular pathology was performed in a standardized technique with release of all fibrous bands in the suprapatellar pouch, reestablishing the medial and lateral gutter, release of the patella, resection of the remaining meniscal tissue or an anterior cyclops, if needed. Intensive physiotherapy and continuous passive motion were to start immediately post-operatively. All the patients were available for the follow up and they were evaluated using the knee society rating system. A total of 25 of the 32 procedures resulted in an improvement of the patients knee score. All the knees operated upon had intra-articular fibrous bands, hypertrophic synovitis and peri-patellar adhesions. A total of eight patients suffered from an anterior cyclops lesion and six patients showed pseudomenicus. In 19 cases a medial and lateral relapse of the patella was performed; only 5 patients got an isolated lateral release. The mean knee flexion was 119 degrees (100-130) at the end of arthroscopy and was 97 degrees (75-115) at the last follow up. The eight patients with extension lags decreased from 27 degrees (10 degrees-35 degrees) pre-operatively to 4 degrees (0-10) at time of follow up. The average knee society ratings increased from 70 points prior to the arthroscopy to 86 at time of follow up, which was found to be statistically significant (P < 0.01, student's t test). The average function score also showed improvement from 68 points pre-operatively to 85 at the time of final follow up. The average pain scores improved from 30 points pre-operatively to 41 at the time of final follow up. Our results showed that arthroscopic management of knee stiffness following total knee replacement is a safe and efficient method of treatment. Pain and functional knee scores can improve markedly.

MELD-XI: a rational approach to "sickest first" liver transplantation in cirrhotic patients requiring anticoagulant therapy

Priority for "sickest first" liver transplantation (LT) in the United States is determined by the model for end-stage liver disease (MELD). MELD is a good predictor of short-term mortality in cirrhosis, but it can overestimate risk when international normalized ratio (INR) is artificially elevated by anticoagulation. An alternate prognostic index omitting INR is needed in this situation. We retrospectively analyzed survival data for 554 cirrhotic veterans referred for consideration of LT prior to December 1, 2003 (training group). Using logistic regression we derived a predictive formula for 90-day pretransplant mortality incorporating bilirubin and creatinine but omitting INR. We normalized this formula to the same scale as MELD using linear regression. This yielded MELD-XI (for MELD excluding INR) = 5.11 Ln(bilirubin) + 11.76 Ln(creatinine) + 9.44. Accuracy of MELD-XI was validated in a holdout group of 278 cirrhotic veterans referred after December 1, 2003, and in an independent validation dataset of 7,203 cirrhotic adults listed for LT in the United States between May 1, 2001, and October 31, 2001. MELD-XI and MELD correlated well in training, holdout, and independent validation cohorts (r = 0.930, 0.954, and 0.902, respectively). In the holdout cohort, c-statistics of MELD vs. MELD-XI for mortality were, respectively, 0.939 vs. 0.906 at 30 days;0.860 vs. 0.841 at 60 days; 0.842 vs. 0.829 at 90 days; and 0.795 vs. 0.797 at 180 days. In the independent validation dataset, c-statistics for MELD vs. MELD-XI as predictors of 90-day survival were, respectively, 0.857 vs. 0.843 in noncholestatic liver diseases and 0.905 vs. 0.894 in cholestatic liver diseases. Comparable MELD and MELD-XI scores were associated with comparable prognosis. In conclusion, MELD-XI, despite omission of INR, is nearly as accurate as MELD in predicting short-term survival in cirrhosis. In patients treated with oral anticoagulants, substitution of MELD-XI for MELD may permit more accurate assessment of risk and more rational assignment of "sickest first" priority for LT.

The first two cases of living donor liver transplantation using dual grafts in Europe

The major limitation in adult-to-adult living donor liver transplantation (LDLT) is an adequate graft size with special regard to the safety of the donor. Only 20% of the evaluated donors are suitable to donate the right liver, depending mainly on the critical remnant liver volume. We report 2 cases of adult-to-adult LDLT using dual grafts. In the first case we implanted a left lateral lobe together with a left lobe; in the second case we used a left lateral and a right lobe. Dual graft LDLT solves the problem of graft-size insufficiency and avoids critical right lobectomy in the donor. This procedure can be safely performed and opens up the possibility of LDLT to even more families in the Western world.

Minimal tethered cord syndrome associated with thickening of the terminal filum

OBJECT

The authors investigated the occurrence of anatomical abnormalities of the terminal filum in children undergoing surgical filum lysis for minimal tethered cord syndrome (TCS).

METHODS

Five consecutive children (age range 6-12 years) with medically refractory voiding dysfunction but no magnetic resonance (MR) imaging-documented lumbosacral abnormality on 1.5-tesla sequences underwent preoperative urodynamic studies consisting of calibrated uroflowmetry, cystometrography, and voiding cystourethrography. Urodynamic bladder function was abnormal in each case. A sixth child (5 years of age) who had progressive lower-extremity weakness, gait abnormality, and voiding dysfunction, but in whom there was no MR imaging-documented lumbosacral abnormality, was also included. These six children experienced improved bladder function after terminal filum lysis. Histologically, the terminal filum in these patients was fattier, thicker, and more densely fibrous than that in three reference patients undergoing incidental terminal filum lysis during selective dorsal rhizotomy or resection of a lumbar dermal sinus tract. All four patients with voiding dysfunction who underwent postoperative urodynamic testing experienced corresponding improvement in bladder function.

CONCLUSIONS

Significant improvement of voiding dysfunction after surgical lysis of the terminal filum in children with MR imaging-documented normal lumbosacral spines was observed. In such children, in whom neurogenic dysfunction is identified by urodynamic testing, structural abnormalities of the terminal filum may exist. A prospective randomized controlled study of children undergoing surgical terminal filum lysis in cases of minimal TCS should be undertaken.

Resistance to activated protein C is a risk factor for fibrostenosis in Crohn’s disease

AIM: To evaluate the effect of resistance to activated protein C (aPCR), the most common known inherited thrombophilic disorder, on the risk of intestinal operation of fibrostenosis in patients with Crohn’s disease (CD).

METHODS: In a previous study, we assessed the prevalence of aPCR in CD. In a retrospective case-controlled study, 8 of these CD patients with aPCR were now compared with 24 CD patients without aPCR, matched by gender, age at diagnosis and duration of disease in a 1:3 fashion. The primary end point was the occurrence of an intestinal CD-related operation with evidence of fibrostenosis in the bowel resection specimen.

RESULTS: The Kaplan-Meier analysis revealed that patients with aPCR had a lower probability of remaining free of operation with fibrostenosis than patients without aPCR (P = 0.0372; exact log-rank test) resulting in a significantly shorter median time interval from diagnosis of CD to the first operation with fibrostenosis (32 vs 160 mo). At 10 years, the likelihood of remaining free of operation with fibrostenosis was 25% for patients with aPCR and 57.8% for patients without aPCR.

CONCLUSION: CD patients with aPCR are at higher risk to undergo intestinal operation of fibrostenosis than those without aPCR. This supports our hypothesis of aPCR being a possible risk factor for fibrostenosis in CD.

Histologische und immunhistochemische Untersuchungen bei Kapselkontraktur nach glatten Brustimplantaten

INTRODUCTION

A prospective study was performed to analyse the cellular and molecular composition of fibrous capsules around silicone breast implants. The necessity of an exact histological classification for comparing objectively the different findings of capsular contracture is shown.

PATIENTS AND METHODS

The prospective study (investigation time 1/2003 to 6/2005) included 24 female patients (average age: 40+/-12 years) with contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor). In each patient the baker score was determined preoperatively. Samples of capsular tissue from all patients were evaluated histologically and immunohistochemically and classified according to the histological classification introduced by Wilflingseder and co-workers.

RESULTS

All capsules showed the same basic histological structure with a three-layer composition. For the correlation analysis we had to exclude one patient with repeated implant change. There was no correlation between the patient's age, time of implantation, length of implant period, and capsular contracture. Greater amounts of silicone particles were associated with increased degrees of capsular contracture (Baker: r = 0.687, n = 23, p < or = 0.001; Wilflingseder: r = 0.784, n = 23, p < or = 0.001). High silicone amounts were associated with an increased local inflammation (r = 0.489, n = 23, p , 0.05). A moderate to severe local inflammation was found in 23 patients (95.8%). In summary, there was a positive correlation (r = 0.797, n = 23; p , or = 0.001) between the clinical classification (Baker score I to IV) and the histological classification (Wilflingseder score I to IV).

CONCLUSIONS

We demonstrated in our study, in spite of using implants with high gel cohesiveness (fourth generation), the presence of vacuolated macrophages with microcystic structures containing silicone and silicone particles in the capsular tissue. Greater capsular thickness was associated with an increased number of silicone particles ans silicone-loaded macrophages in the peri-implant capsule. The histological classification introduced by Wilflingseder and co-workers takes into consideration this pathogenetic mechanism of inflammatory reaction which seems to be one of the major key factors in the development of capsular contracture.

Kidney plays a major role in ammonia homeostasis after portasystemic shunting in patients with cirrhosis

The kidney plays an important role in ammonia metabolism. In this study the hypothesis was tested that the kidney can acutely diminish ammonia release after portacaval shunting. Thirteen patients with cirrhosis (6 female/7 male, age 54.4 +/- 3.3 yr) were studied. Blood was sampled prior to and 1 h after transjugular intrahepatic stent-shunt (TIPSS) insertion from the portal vein, a hepatic vein, the right renal vein, and the femoral vein, and renal and liver plasma flow were measured. Prior to TIPSS, renal ammonia release was significantly higher than ammonia release from the splanchnic region, which was not significantly different from zero. TIPSS insertion did not change arterial ammonia concentration or ammonia release from the splanchnic region but reduced renal ammonia release into the circulation (P < 0.05) to values that were not different from zero. TIPSS resulted in a tendency toward increased venous-arterial ammonia concentration differences across leg muscle. Post-TIPSS ammonia efflux via portasystemic shunts was estimated to be seven times higher than renal efflux. Kidneys have the ability to acutely diminish systemic ammonia release after portacaval shunting. Diminished renal ammonia release and enhanced muscle ammonia uptake are important mechanisms by which the cirrhotic patient maintains ammonia homeostasis after portasystemic shunting.

Calcifying fibrous pseudotumor of the soft palate--a case report

Calcifying fibrous pseudotumor has recently been described in the soft tissues. It is a rare benign lesion characterized by the presence of abundant hyalinized collagen with psammomatous or dystrophic calcification, and lymphoplasmacytic infiltrate. We report one such rare case in an 18 year old female with a nodular mass in the soft palate treated by complete resection. The mass had all the pathologic features of a calcifying fibrous pseudo-tumor.

ORIGINAL RESEARCH—SURGERY: Upsizing of Inflatable Penile Implant Cylinders in Patients with Corporal Fibrosis

INTRODUCTION

Placement of an inflatable penile prosthesis in a patient with scarred corporal bodies secondary to priapism or removal of a previously infected implant is a formidable surgical challenge; use of downsized implants has improved chances of successful reimplantation. Nevertheless, patients are frequently dissatisfied with the resulting short penises.

AIM

This study investigates the use of downsized inflatable penile prosthesis cylinders as tissue expanders in patients with corporal fibrosis.

MAIN OUTCOMES MEASURES

Corporal length and width were calibrated before implantation of downsized prostheses and after 1 year of their use as tissue expanders.

METHODS

Thirty-seven patients had insertion of Mentor Narrow Base (18), AMS CXM (9), or AMS CXR (10) into scarred corporal bodies. Etiology was previously infected and removed implant (29) or priapism (8). In each of these cases it was not possible to dilate to 12 mm in order to place standard-sized cylinders. Patients were encouraged to inflate their implant for up to 3 hours daily. After several months intracorporal stretching occurred. The patients were reoperated; corporal length and width were recalibrated.

RESULTS

Upon reoperation, it was possible to pass dilators of 12 mm width proximally allowing the substitution of standard-sized AMS 700 CX (23), Mentor Alpha 1 (10), or Mentor Titan (2). Additionally, corporal length measurements in the previously infected patients increased an average of 2.2 cm allowing placement of longer cylinders. Although priapism patients did not show this phenomenon of corporal lengthening, the implant space widened enough to permit replacement with standard-size cylinders improving girth, rigidity, and appearance.

CONCLUSIONS

Wider and sometimes longer cylinders can be substituted in patients with corporal fibrosis that required implantation with downsized cylinders because of fibrotic corpora. Prolonged inflation over an 8- to 12-month period results in expansion of the cylinder cavity, permitting standard-sized cylinders in all patients.

[Ulnar sesamoid bone of the small finger causing painful trigger finger]

We report on a 38-year-old woman suffering from painful trigger finger. Contrary to the expected intraoperative finding of a simple stenosing pulley and ganglion cyst on a thickened flexor tendon sheath, we found fibrotic cords between an abnormal ulnar sesamoid bone at the fifth finger and the A1-pulley to be responsible for distortion of the tendon sheath and a consecutive "klicking"-phenomenon. A coherence between sesamoid bones and trigger finger has repeatedly been found on the thumb but there is no such description regarding the long fingers.

[Idiopathic orbital inflammatory syndrome (orbital pseudotumors): diagnosis and therapy]

BACKGROUND

Pseudotumors of the orbit comprise a group of idiopathic inflammatory processes and are, except for endocrine orbitopathy, the most common reason for exophthalmos in adults. Orbital pseudotumors, also called idiopathic orbital inflammatory syndrome (IOIS), can be determined from orbital involvement in systemic fibrosing diseases. Finding the correct diagnosis can be challenging. Due to the topographic relations of the orbit to neighbouring structures, a multidisciplinary cooperation is highly recommended.

CASE REPORT

We report a case of a 42-year-old woman with unilateral exophthalmos. Additionally we found impaired motility of the affected bulbus, ptosis and reduction of visual acuity. Orbital MR imaging demonstrated dense fibrotic masses filling the whole orbita including the extraocular muscles as well as the optic nerve. Tissue specimens were extracted while performing orbital decompression via a lateral orbitotomy. Histological examination revealed a lymphatic infiltration and fibrotically destroyed tissue containing the lacrimal gland. After surgical decompression, oral steroid therapy and immunotherapy, a recovery of the visual loss could be seen.

CONCLUSIONS

Intraorbital fibrosclerosing pseudotumors often require a difficult long-term treatment. Therapeutic options are steroid therapy, immunotherapy, radiotherapy and surgery. The diagnostic steps include blood tests, ultrasound, CT and/or MRI as well as histological differentiation. Solid tumors and orbital involvement in diseases of the hematopoetic system have to be excluded. Since intraorbital fibrosis can be accompanied by manifestations in various other organs, a complete investigation of the body and thorough follow up are crucial.

[Urethral strictures--operative strategy]

Urethral strictures are very commonly encountered in urologists' day-to-day work. Many specific therapeutic and reconstructive procedures are available for treatment of the different types of urethral stricture, all of which can be recommended when the indications for each are carefully observed. This paper highlights operative concepts that allow a surgical therapy that is tailored to the localisation and length of the stricture and the severity of spongiofibrosis.

[Therapy of bony and fibrous contractures and buccal defects after noma using the temporalis muscle flap]

METHODS

A prospective pilot study was conducted on 12 patients to establish whether, under the difficult conditions prevailing in a developing country, the temporalis muscle flap is suitable as a safe and single-stage procedure for the repair of buccal defects combined with fibrous or osseous contractures of the temporomandibular joint.

RESULTS

The surgical procedures were performed from 1998 to 2000 in the Hôpital National du Niamey (Republic of Niger). Primary healing was achieved with all grafts. Local clinical and radiological follow-up (in Niger) was performed on seven patients after 12 and 24 months. Mouth opening of at least 1.5 cm was achieved in all cases, although there was virtually no use of physiotherapy to prevent scar contracture.

DISCUSSION

By contrast with expensive and surgically more complex reconstructions, our use of this procedure shows that even where medical conditions are less than ideal, a satisfactory functional and cosmetic result can be achieved in the long-term.

Faszienräume und Rezidiveingriffe beim Thoracic-outlet-Syndrom

We studied the passive motion of the brachial plexus in relation to movement of the upper extremity by observation during surgery and by measurements in cadavers. The spaces for these movement are defined. The passive motion is provided by gliding tissue. Pathologic changes of the gliding tissue may contribute to the development of the symptoms of the TOS. It is distinguished between reversible and irreversible changes. A recurrent fibrosis may develop in rare cases which may be best treated by microsurgical neurolysis and envelopment of the brachial plexus by a gliding tissue flap.