[Mesenteric ischemia: a severe complication in burn patient]

Gastrointestinal complications are a common problem in severe burned patients. Reported complications include paralytic ileus, gastrointestinal tract bleeding, gastric ulcers and acute necrotizing cholecystitis. Although there are no exact data concerning the frequency and outcome of acute intestinal necrotizing ischemia in severe burned patients, it is a well known complication in specialized burn centers. The most common reason for acute intestinal ischemia are arterial embolism, arterial thrombosis, venous thrombosis and non-occlusive disease. The overall survival differs between 81 % and 34 %. The therapy aims at arterial re-perfusion of life-threatening intestinal regions and resection of necrotic tissue. A 45-year-old male patient attempted suicide by inflaming himself with gasoline. He sustained partial and full thickness burn injury of the face and the throat. Additional burn injuries were found at the chest region, both arms and the abdominal wall. The total burn surface area (TBSA) was 42 % including an severe inhalation injury trauma. The ABSI-score (Abbreviated burn severity index) was 10. The combination of a thrombus at the aortic valve with an tachycardic dysrhythmia was the cause for an embolisation with acute intestinal ischemia. The necrotic part of the small intestine was resected, the further course was uncomplicated.

[Clinical impact of operative multidisciplinarity for severe defect injuries of the lower extremity]

BACKGROUND

The aim of this study was to examine the impact of our multidisciplinary therapeutical concept (MTC) on the clinical outcome in posttraumatic defect injuries of the lower extremity.

PATIENTS AND METHODS

Since 1999, we have performed a free tissue transfer in 37 patients. In group 1 (n = 21), our MTC was started more than two weeks (range: 17 to 83 days) after trauma and in group 2 (n = 16) within two weeks (range: four to twelve days) after trauma. Both groups were comparable with respect to trauma severity.

RESULTS

100 % patients of group 1 and 25 % patients of group 2 had clinical and microbiological manifestations of wound infection after admission in our clinic. Significantly more operations were necessary in group 1 compared to group 2 (7.3 +/- 2.6 versus 2.9 +/- 0.8; p < 0.05), until definitive wound closure could be achieved. The postoperative course was uneventful in 35 cases. All injured extremities could be salvaged. Multistaged bone reconstructions by means of spongious or tricortical bone from the iliac crest were successful in all cases. Hospital stay after admission to our clinic was significantly longer in group 1 compared to group 2 (57 +/- 12 days versus 31 +/- 7 days, p < 0.05).

CONCLUSIONS

In our study, the early start of MTC significantly reduced the risk for wound infection, the number of surgical revisions before definite wound closure and time until bone and wound healing was completed.

A technique to detect and to quantify fasciocutaneous blood vessels in small laboratory animals ex vivo

PURPOSE

A microangiographical technique is described, which allows visualization of small and capillary blood vessels and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals.

MATERIALS AND METHODS

The left carotid artery of 20 nu/nu mice was cannulated (26 gauge) and a mixture of gelatin, bariumsulfate, and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units [SU] by computer program.

RESULTS

With the described microangiography method, fasciocutaneous blood vessels down to capillary size level can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Comparable results may be obtained by calculating the microvascular area index (MAI) and the microvascular length index (MLI), related to the ROIs size. Identical ROIs showed a high reproducibility for measured [SU] < 0.01 +/- 0.0012%.

CONCLUSION

Combining microsurgical techniques, pharmacological knowledge, and modern digital image technology, we were able to visualize small and capillary blood vessels even in small laboratory animals. By using our own computer analytical program, quantification of vessels was reliable, highly reproducible, and fast.

Laparoscopic resection of perforated Meckel's diverticulum in a patient with clinical symptoms of acute appendicitis

We report the laparoscopic resection of a perforated Meckel's diverticulum (MD) found in a 14-year-old boy who presented with abdominal pain and nausea. There was rebound tenderness in the right lower quadrant of the abdomen, which appeared suspicious for acute appendicitis. The patient was referred to the operating room, and laparoscopic appendectomy was performed. With the appendix showing no macroscopic signs of inflammation, laparoscopy was continued and a perforated MD was identified 50 cm proximal to the ileocecal valve. The findings included pus and localized peritonitis between the ileal loops adjacent to the perforation site. The diverticulum was longitudinally resected with an Endo-Gia stapler. The histopathologic workup confirmed the diagnosis of a perforated MD. The patient completely recovered and was discharged 8 days after the procedures. At this writing, he is completely asymptomatic 6 months later. We conclude from our observation that laparoscopic resection of a perforated MD can be performed safely even when localized peritonitis is present. Inspection of the small intestine should be performed to exclude a symptomatic or perforated MD when the appendix does not show any signs of acute appendicitis.

Treatment of liver metastases in patients with neuroendocrine tumors

BACKGROUND

Hepatic metastases of neuroendocrine tumors demand differentiated therapeutic management due to the unique natural course and hormone secretion of the tumors.

AIM

The purpose of the prospective nonrandomized study was to review the institutional experience with surgical treatment of hepatic neuroendocrine metastases.

PATIENTS AND METHODS

From September 1992 until March 1996 29 consecutive patients with neuroendocrine tumors have been evaluated for surgical treatment of liver metastases. Of them, 11 (37.9%) fulfilled criteria for surgical treatment of hepatic secondary tumors. Extensive preoperative workup was carried out. Patients were divided in groups for curative or palliative resection. Liver transplantation was carried out in selected patients with disseminated liver metastases.

RESULTS

Of 29 patients 4 (13.7%) underwent curative resection and in 3 patients (10.3%) palliative resection was performed. The patients who underwent curative resection are all biochemically and clinically tumor free at a mean postoperative follow-up of 22.3 months. Two patients who underwent palliative resection are alive at 40 and 29 months, respectively. From 12 patients evaluated for liver transplantation 4 were considered as suitable candidates.

CONCLUSIONS

Liver resection can be recommended in patients with hepatic metastases of neuroendocrine tumors in terms of potential survival prolongation and palliation. Liver transplantation is generally acceptable treatment in highly selected group of these patients. Long-term results have to be awaited before definitive proof of the beneficial effect of surgical treatment.

[Somatic ret proto-oncogene mutations in sporadic C-cell carcinoma of the thyroid gland]

Germline mutations of the RET proto-oncogene localized on chromosome 10q11.2 are the underlying cause of hereditary medullary thyroid carcinoma. In MEN 2A and FMTC, mutations can be found in exons 10, 11, 13 or 14. MEN 2B is characterized by a specific mutation in exon 16. In a significant number of sporadic MTC somatic mutations in codon 918 (exon 16) are detectable. Some rare sporadic MTC present somatic mutations in codons 611, 634, 768 and 883. Recently, deletion-insertion of the RET proto-oncogene in exon 11 and a deletion in exon 10 has been found. RET proto-oncogene mutations are not only responsible for the development of the familial MTC, but may also play an important role in the pathogenesis of sporadic MTC. However, the prognostic relevance of these somatic events is still unclear.