[Intraosseous Tophaceous Gout of the Hand: Case Report and Literature Review]

We report on an intraosseous gout manifestation in the middle phalanx of the left index finger of a 54-year-old patient.

Carl von Reyhers Studien zur Wundtherapie

Carl von Reyher (1846-1890), a young Russian army surgeon of the late nineteenth century, established the principle of repeated debridements on a scientific basis. After a visit to Lister's clinic, acquainting himself with antiseptic wound management, von Reyher was the first to present a controlled study of debridement in contaminated gunshot wounds. He was able to show that the combination of primary debridement and antiseptic treatment decreased the mortality rate of gunshot injuries from 66% to 23%. Although published in more than 16 papers and presented at international congresses, Reyher's contribution was completely negated. Finally more than 30 years later in World War I, the Inter-allied Surgical Conference officially endorsed primary excision with delayed wound closure as the rule for treatment of gunshot wounds.

[Wound healing complications in smokers, non-smokers and after abstinence from smoking]

BACKGROUND

The pulmonary and cardiovascular ramifications of smoking are well documented and this also applies to increased wound healing complications in smokers. The aim of this study was to ascertain whether preoperatively refraining from smoking would affect the incidence of wound healing disorders.

MATERIAL AND METHODS

Between 2006 and 2008 a total of 295 patients underwent aesthetic (n = 167) or reconstructive surgery (n = 128). They were divided into three groups: A (n = 98) non-smokers for at least 2 years, B (n = 99) patients who refrained from smoking 6 weeks prior to surgery and C (n = 98) smokers. Smoking abstinence was verified by cotinine tests. Wound healing complications were defined as dehiscent wounds, wound infections, atypical scar formation and adiponecrosis.

RESULTS

Smokers developed wound healing complications in 48.2% of cases, non-smokers in 21.0% and patients who had stopped smoking for 6 weeks in 30.8% of cases (p = 0.006).

CONCLUSION

Elective surgery should only be performed on non-smokers and smokers who had refrained from smoking for at least 6 weeks to reduce wound healing complications as far as possible.

[Three case reports of frostbite. Management and literature]

Due to social and demographic changes as well as new leisure activities, the number of frostbite injuries in the general population is on the increase. Because the injuries are primarily located on the hands and feet the consequences for those concerned are devastating. We provide help in grading and introduce concrete therapeutic regimes for frostbite which are illustrated by three case reports from our clinical experience with varying risk profiles.

[Local therapy of grade IIa burns: efficacy and tolerability of a new hydrosome wound gel for the local treatment of grade IIa burns as compared with silver sulfadiazine ointment]

BACKGROUND

A new hydrosome wound gel is based on a new mechanism of action. It contains hydrosomes that penetrate to the wound bed and supply the wound with phospholipids, which are identical to membrane phospholipids of human cells. In this manner it supports the proliferative processes during wound healing.

PATIENTS AND METHODS

In a randomized, controlled, intraindividual comparative study of 47 patients with grade IIa burns, the hydrosome wound gel was tested against silver sulfadiazine cream. Digital pictures of the burn wounds were taken daily, and the wounds were analyzed in terms of their reepithelization rate.

RESULTS

Wounds receiving the hydrosome wound gel healed 1.5-2 days faster than wounds treated with sulfadiazine cream (9.9+/-4.5 days vs. 11.3+/-4.9 days, p=0.015). In 66% of the patients, faster epithelization was observed with the hydrosome wound gel treatment. The hydrosome gel guaranteed secure prophylaxis against infection, and it was well tolerated and easy to apply.

CONCLUSION

In this study, the treatment of grade IIa burn wounds with hydrosome wound gel led to faster wound closure compared with treatment with sulfadiazine cream. Therefore, hydrosome gel represents a good alternative to sulfadiazine cream.

[Crossover extremity transfers. Limb salvage in amputations with segmental defects]

Clinical conditions in which crossover extremity transfer should be considered are rare. In the case of bilateral amputation associated with extensive proximal segmental injury, ectopic implantation could be an additional concept for two-stage limb salvage. If replantation is impossible due to segmental damage of the amputated part, at least uninvolved tissue should be harvested for stump lengthening or improving soft-tissue at the ends. The case of a 34-year-old man with segmental amputation of the left forearm and left lower leg and mutilated amputation of the right hand caused by a train accident is presented. Limb salvage was performed by cross-hand replantation and modified rotationplasty of the left foot as a stump lengthening procedure.

Weichteiltumor unklarer Dignität

Cystic necrotization with liquefaction and calcification of muscle tissue is a rare late sequel of compartmental syndrome. Diagnosis and treatment of this clinical picture is still a problem. In the literature, various therapeutic approaches are described such as incision, needle decompression, and complete compartmental debridement. We report a case in which cystic degradation and liquefaction of three compartments developed 51 years after a complete fracture of the tibia. The patient was treated by radical compartmental resection. No postoperative complication was noted, and almost no functional loss occurred.

Polybrene improves transfection efficacy of recombinant replication-deficient adenovirus in cutaneous cells and burned skin

BACKGROUND

The hostile environment found in acute and chronic wounds decreases the physiological half-life of purified synthetic or recombinant peptides dramatically. Gene therapy, on the other hand, may be a viable option since it relies on the cellular machinery of the host to locally manufacture the proteins of interest. The aim of this study was to evaluate and optimize the local administration of transient cutaneous adenoviral gene delivery in wounds.

METHODS

Primary human keratinocytes (HKC) and HaCaT cells were transfected with replication-deficient adenovirus (Ad5) containing the reporter gene for beta-galactosidase (LacZ). The vector was used alone or precoated with either (1) Lipofectamine 2000, (2) FuGENE 6, or (3) Polybrene. For in vivo testing a rat burn model was used. Animals were randomized into three groups: (1) Ad5-LacZ alone; (2) Ad5-LacZ precoated with Polybrene, or (3) carrier control (phosphate-buffered saline (PBS)). Samples were harvested from burned and unburned tissue sections after either 48 h or 7 days. Transgene expression was quantified by bioluminometric assay and localized using immunohistochemistry. A BrdU assay was performed to determine the influence of the used transfection reagents on cell proliferation.

RESULTS

Transfection efficacy was significantly improved in vitro (p < 0.001) as well as in partial thickness burned (p = 0.015) and unburned skin (p > 0.001) after precoating Ad5 with Polybrene compared to Ad5 alone. Transgene expression was 10-fold higher in burned skin (9305 pg/mg protein) compared to unburned skin (859 pg/mg protein).

CONCLUSIONS

It is feasible to improve transfection efficacy in vitro and in vivo by precoating the adenovirus with Polybrene.

A qualitative and quantitative analysis of protein loss in human burn wounds

INTRODUCTION

It is well known that in patients suffering from major burn injuries of more than 15% of total body surface area (TBSA), capillary leak and loss of proteins including immunoglobulins (Ig) lead to cardiovascular failure and significantly elevated risk of infections. However, knowledge of the resulting protein profiles is limited. In order to elucidate quantitative and qualitative protein loss in human burn wounds we compared wound fluid (WF) protein content with serum protein levels.

MATERIAL AND METHODS

Eleven patients suffering from second degree burns of 18-68% TBSA were enrolled in the study. Immediately after admission burn wounds were enclosed in cutaneous vinyl wound chambers covering a 2.25 cm(2) wound surface area. WF and serum samples were harvested every 8 h with a follow up of 48 h and analyzed for total protein content, albumin and the immunoglobulins A, E, G and M.

RESULTS

Protein levels in serum were significantly lower as compared to physiological levels while WF protein levels were elevated and remained high. Total protein (TP) and albumin (AL) accumulated in high concentrations on the wound surface (average accumulation on 10% burnt TBSA within 8 h: TP=16.59+/-8.86 g; AL=12.39+/-5.87 g). The albumin fraction in WF showed increasing values (24 h: 69%; 32 h: 86%) although the serum albumin fraction remained nearly unchanged (55%). Peak values were initially found for all immunoglobulins both in serum and WF. IgA, E and M reached a steady state 32 h post-trauma, whereas IgG continuously decreased until 40 h. IgG values in serum were significantly below physiological levels at all time points.

CONCLUSIONS

This study qualifies and quantifies a significant protein loss in second degree burn wounds. Protein concentrations in wound fluid correlate highly with serum concentrations until 48 h post-burn. A patient's entire amount of serum proteins accumulates in wound fluid in a 20% TBSA burn within approximately 24h. In contrast to capillary leak theory proteins and immunoglobulins extravasate to wound fluid even after 48 h post-trauma.

New model for in vivo investigation after microvascular breakdown in burns: use of intravital fluorescent microscopy

BACKGROUND

The breakdown of skin microcirculation is assumed to play a key role in the pathophysiology after burn injury. The aim of the present study was to develop a burn model, which allows repetitive quantitative in vivo analysis of the microcirculation after a burn injury, focusing on the interaction between leukocytes and the endothelium.

MATERIALS AND METHODS

Experiments were carried out on male hairless mice. Deep partial thickness burns were inflicted with a no-touch-technique to the ears. Intravital fluorescent microscopy in combination with FITC-dextran as a plasma marker was used to assess microcirculatory parameters. Leukocytes were stained with rhodamine 6G. Preburn baseline data was obtained before as well as 1, 3, 7 and 14 days subsequent to the burn injury.

RESULTS

The non-perfused area decreased significantly over the observed period and perfusion was almost completely restored at day 14. The functional vessel density was characterized by reduction of perfused vessels immediately after burn and an increase after 24h. Leukocyte endothelium interaction significantly increased immediately after injury; baseline values were reached 1 day later. The extravasation of the plasma marker into the surrounding tissue increased immediately after burn, decreased at day 1 and remained at this level during the following observation time. The venular as well as the arterial blood flow increased immediately subsequent to the burn injury, decreased after 1 day and reached baseline values at day 3.

CONCLUSION

The presented burn model allows quantitative assessment of the dynamics of microcirculatory disturbances after thermal trauma by high quality visualization of both plasma stained microvessels and leukocyte-endothelium interaction.

[Importance of microcirculation in plastic surgery]

The article summarizes distinct microcirculatory models for use in surgical research with a special interest to plastic surgery. Methods for the quantitative analysis of the microcirculation in burns, flaps and wounds are presented. Vascularization of biomaterials can be observed by means of the dorsal skinfold chamber model in hamsters and mice. Developing capillary sprouts can be assessed by means of videomicroscopy and angiogenetic drugs can be tested using this model. Hairless mice allow for direct, long-term observation of the microcirculation in burns as well as during healing of dermal wounds. The pathophysiology of diabetic wound healing can also be studied. A mouse model to assess flap microcirculation during ischemia/reperfusion injury with special emphasis on platelet/endothelium interaction in vivo is described. Platelets adherent to the inner vessel wall are known to trigger compromised perfusion in flaps. The model allows us to test anti-thrombotic drugs. The use of a special microscopic device (OPS imaging) allows us to study the microcirculation at sites of burn injury and chronic wounds in humans. Microcirculatory research in plastic surgery has increased the understanding of the pathophysiology of vascularization of biomaterials, wound healing and ischemia/reperfusion.

[Gorham-Stout disease: report of a case affecting the right hand with a follow-up of 24 years]

Gorham-Stout disease is a rare idiopathic syndrome with distinctive clinical, pathologic and radiologic features. It is a variant form of osseus angiomatosis associated with massive osteolysis of bone. Usually appearing after trauma, the disease is described to occur at any age. Especially in case of thoracic involvement (chylothorax), lethal outcomes are reported. In Medline, about 200 cases have been described. A patient with osteolysis of the right hand following contusion at the age of two years is reported. Despite radiotherapy and repeated bone grafting, the osteolysis progressed until today (24 years). The pathologic features and various treatment methods for hand involvement are discussed.

The impact of topical antiseptics on skin microcirculation

AIM

Antiseptics are commonly used in clinical practice to disinfect tissue and to avoid infections. However, topical antiseptics are assumed to have an influence on skin microcirculation, per se. Thus, the aim of the study was to analyse the influence of topically applied antiseptics on the microcirculation of intact skin in vivo.

MATERIALS AND METHODS

The investigation was carried out on ears of male hairless mice (SKH-1hr, n = 25). The influence of four antiseptics was examined. Sodium chloride 0.9% served as control. An alcohol-based solution with a mixture of ethanol, 2-propanol and purified water (Softasept), an antiseptic with octenidine dihydrochloride and phenoxyethanol as the main active agents (Octenisept), as well as hexamethylenbiguanide (Lavasept) and 70% ethanol were tested. Intravital fluorescence microscopy in combination with intravenous injection of the fluorescence dyes FITC-Dextran as plasma marker and Rhodamine 6G (leukocyte staining) allowed a quantitative analysis of standard microcirculatory parameters (vessel diameter, functional capillary density, red blood cell velocity, FITC-leakage and leukocyte endothelium interaction). Recordings of the microcirculation in several regions of interest (ROI) were made prior to application and after 10 min exposure time and 60 min after the baseline data. Data were evaluated off-line with aid of computer assisted analysis.

RESULTS

The diameter of arterioles decreased after the treatment with the alcoholic solutions. The other two antiseptics (Octenisept and Lavasept) caused a significant increase. Functional capillary density (FCD) was significantly reduced after application of ethanol and Softasept. There was no reduction of FCD following application of Octenisept. After treatment with ethanol and Softasept there was a significant decrease in red blood cell velocity (RBCV). The use of Lavasept revealed a decrease of FCD and RBCV. In the Octenisept treated group RBCV shows a mild increase after 10 minutes. The application of ethanol, Softasept and Lavasept was characterized by a significant increase of leukocyte endothelium interaction (LEI). After treatment with saline and Octenisept LEI remained constant. All used antiseptics except of Octenisept caused a significant leakage of FITC-Dextran.

CONCLUSION

The antiseptics used in this study all showed an influence on skin microcirculation. As expected, our findings show that the alcoholic solutions are most aggressive to skin microcirculation.

[The interdisciplinary approach in reconstructive surgery of the extremities]

In cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits will inevitably produce new imperatives for interdisciplinary cooperation in the future.

Combined pollicization and toe transfer for thumb reconstruction

A 45-year-old orthopaedic surgeon sustained a complete thumb amputation and severe injuries to his index finger in a lawn mower accident. He was treated with a combined second toe transfer and an index finger pollicization.

Liposuktion?kein Problem?

Subcutaneous liposuction in tumescent technique is the most frequent aesthetic plastic procedure in the United States. In Germany, nearly 250,000 liposuctions are done per year by a variety of surgical and nonsurgical specialists including plastic surgeons, dermatologists, gynecologists, oral surgeons, and otolaryngologists in settings ranging from hospital operating rooms to physicians' offices. The method is applied and promoted as an easy-to-learn technique that is suited as an outpatient procedure. Although major complications seem to be rare, there are definite risks, including death at a rate of 1/5,000 procedures. Major risk factors are insufficient hygiene standards, multiliter wetting solution infiltration, megavolume aspiration, multiple cosmetic procedures in one setting, sedative and anesthetic drug hangover threatening ventilation, permissive postoperative discharge, and mistakes in patient selection. When major complications occur, office-based practitioners may refer patients to hospital emergency departments, where medical personnel unfamiliar with this procedure may underestimate the risk of major complications.

[Direct visualization of microcirculation in burn wounds with OPS imaging--is determination of depth of burns possible?]

Adjunct diagnostic techniques might help surgeons to accurately analyse the depth of a burn. However, despite all technical innovations an ideal device for such an application has not been established for routine use as yet. OPS imaging implemented into the CYTOSCAN A/R is a new, recently introduced technique which allows to obtain high contrast images of the microcirculation without the necessity for fluorescent dyes. The aim of the study was to validate OPS imaging as a tool to study microcirculation in skin after burn injury. OPS imaging was applied by no-touch technique and capillary blood flow was videotaped. Subsequent measurements of the microcirculation were performed at the identical site of the burn. Quantitative analysis of the microcirculation was performed off-line using CapImage. OPS imaging produces high quality images of the microcirculation in a burn wound. Data is given as the number of perfused capillaries per observation area (functional capillary density; FCD) [n/cm2]. OPS imaging allows for direct in vivo visualization and quantification of the microcirculation in burned skin. Our preliminary results of the use of OPS imaging in assessing the microcirculation in burns appear promising, and we hope that this novel technique will allow to improve the knowledge of the dynamics of the microcirculation in the pathophysiology of thermal injury.

[Joint infection caused by radiogenic defect: prevention and therapeutic options]

Exposed irradiated joints are characterized by bone and cartilage necrosis with a chronically infected joint space. The indication for treatment results from possible infection spreading and more often because of severe pain. The usual concept of sequential debridement, joint replacement and regional flap coverage, is often impossible due to the radiodermitis and bone necrosis in the neighbourhood of the joint. Even free flaps are associated with a higher failure rate, because of the irradiation of the recipient vessels long vein grafts are often needed. If regional flap coverage is desired, distant flaps with long, not irradiated pedicles must be chosen. Prevention due to special considerations during the first surgery is essential.

[Secondary reconstruction after burns of the anogenital area]

The incidence of burns of the genitalia and peri-anal region which may cause a reconstructive intervention is very low. In the most cases the use of split thickness skin grafts yields a sufficient permanent wound closure. Upcoming problems such as painful scare formation require a reconstructive intervention (Z-plasty, full thickness skin grafting, pedicled flaps etc.). In case that the anal sphincter is involved with the consequence of incontinence or major damage of the genitalia occurred, sophisticated operative solutions are necessary.

[Myofibroblastic sarcoma of the thoracic wall. Change in appearance in tumour recurrence]

The existence of malignant mesenchymal tumours with myofibroblastic differentiation (myofibroblastic sarcoma, myofibrosarcoma) is controversially discussed. In the present case report a low-grade myofibroblastic sarcoma of the thoracic wall with varying morphological appearance in numerous recurrences over a number of years is described. The varying immunophenotypes of tumour cells with myofibroblastic differentiation suggests that changing of morphological and immunohistochemical phenotypes may occur in tumour cells with myofibroblastic characteristics corresponding to the "plasticity" of the myofibroblast. The classification of soft tissue tumours is based on a discernible line of differentiation. If cells of a malignant mesenchymal tumour show characteristic features of myofibroblasts by light microscopy and immunohistochemistry, this neoplasm should be classified as a myofibroblastic sarcoma, even if the ultrastructural detection of "fibronexus" is not possible.

[Solitary plasmacytoma of the shoulder. Diagnosis and therapeutic methods]

5% of all multiple myelomas manifest as solitary plasmocytomas. The multiple myeloma is the most frequent malignant transformation of the haematopoetic system, with an incidence of 2:100,000 per year. 1% of all solitary plasmocytomas are found in the extremities, accounting for less than one case per year in Germany. In this article we present the case of a fifty year old patient with a solitary plasmocytoma of the shoulder region and discuss the diagnostic and therapeutic procedures involved.

[Intravital microscopic analysis of perfusion, leukocyte-endothelial cell interaction and neovascularization after burns: an in vivo study of SKH-1/hr hairless mice]]

Breakdown of skin microcirculation is supposed to play a key role in pathophysiology of burn injury. The aim of the study was to develop a burn model, which allows repetitive quantitative in vivo analysis of microcirculation after burn injury with special focus on leukocyte endothelium interaction over a longer period of time. Male hairless mice (SKH-1/hr) were used. Deep partial thickness burns were inflicted in no-touch-technique to the ears. Intravital fluorescent microscopy in combination with FITC-dextran as a plasma-marker was used to assess standard microcirculatory parameters. Leukocytes were stained with rhodamine-6-G to study their interaction with the endothelium.

The effect of wound ointments on tissue microcirculation and leucocyte behaviour

An intact microcirculation is essential for normal healing to occur. Wound repair may be impaired by various endogenous and exogenous factors, such as reduced microvascular perfusion, infection and debris. In the nonhealing wound, radical surgical debridement is critical. To supplement healing, various ointments are used in clinical practice. Little is known about their effects on tissue perfusion. We have therefore selected two substances widely used, the antiseptic Betadine and the enzyme combination Elase and investigated their impact on the microcirculation and on leucocyte activity, using the cremaster muscle as a model. We found that functional capillary density and arteriolar diameters were significantly reduced by Betadine, whereas leucocyte activity was not affected. In the Elase group, capillary flow and arteriolar diameters were significantly increased, and again leucocyte activity was not changed. The mechanism by which Betadine reduces microvascular flow is believed to be the same as in reperfusion injury. The positive effect of Elase on the microcirculation might be attributed to plasmin, which has been shown to dilate blood vessels.

Augustus V. Waller and plastic surgery

Augustus V. Waller's name is associated eponymously with the regressive changes in transected nerves. This article intends to present the many other aspects of Waller's scientific ventures. Apart from pioneering intravital microscopy, Waller made significant contributions to the understanding of the process of tissue inflammation. In addition to his observations of the degenerative changes in severed nerve fibers, he developed a concept of trophic dependence that is relevant for the management of the regeneration of peripheral nerves in plastic surgery.

[Propane-induced tissue damage: burn or freezing injury?]

Tissue damage due to direct contact of liquid propane with the integument is extremely rare. Only five such cases have been described in the literature. We report the case of a girl who sustained a full-thickness skin necrosis of 14.5 % of her body surface area. There is little agreement about the optimal treatment of these injuries in previous reports. The pathophysiological mechanism suggests a freezing injury. The treatment, however, should be analogous to that of third-degree burns.

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept. By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps). Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery. Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients. On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.

[Etiology, clinical aspects and therapy of penoscrotal lymphedema]

Penoscrotal lymphedema has serious functional, cosmetic, psychological and potentially malignant consequences. In contrast to the relatively common occurrence of this disease in areas with endemic filariasis, the incidence in the rest of the world is almost exclusively due to therapeutic sequelae of other illnesses or as congenital entities. As conservative forms of treatment have proved to be inefficient, we discuss different surgical options based on the treatment of 12 patients seen in our clinic. Only the complete excision of the edematous and fibrotic tissues, together with reconstructive methods using local flaps and skin grafts, can guarantee a definitive solution, irrespective of the etiology. A detailed anatomical knowledge of the regional lymphatic drainage pathways allows safe operative treatment. Despite the rarity of this disease, a number of different surgical procedures have been reported in the literature that are compared with the findings in our patients.

[Resection method and functional restoration in soft tissue sarcomas of the extremities]

In soft tissue sarcoma of the extremities wide tumor excision (R0) has become the most important factor for local control. The tactical and technical surgical parameters are defined, which allow for diminished complication rates during tumor biopsy and definite resection. Reconstructive plastic procedures play a key role in coverage of major defects and prevention of problems due to wound infection and irradiation. If localized within the periphery of limbs, the vast majority of cases will require sophisticated techniques to achieve limb salvage.

[Clinical application of growth factors and cytokines in wound healing]

The clinical value of growth factor treatment of chronic wounds has yet to be determined. Beneficial effects have been reported so far only from specialized wound care centers where growth factors supplemented the results achieved with good wound care. In general optimization of current methods of external wound care, adequate metabolic and nutritional control and surgical measures should be employed before any adjuvant growth factor therapy is attempted. Current use of exogenously applied growth factors and cytokines appears to be reasonable only in the setting of controlled clinical studies according to the rules of "good clinical practice". With more knowledge on the biology of chronic wounds and progress in wound pharmacology the best application for these peptides will have to be reevaluated.

[Reconstruction of an extensive anterior tracheal defect in a tetraplegic patient during long-term ventilation by autologous cartilage clasps within a pectoralis major flap]

Tetraplegic patients on permanent respirator therapy are likely to develop cuff related pressure ulceration of the trachea with subsequent tracheomalacia in the cuff level. Regional flaps for the reconstruction of anterior defects are insufficient due to the lack of rigidity and resulting intolerance of the cuff-pressure. Tracheal prostheses are not suitable in the inflammatory tissue in patients requiring continuous respirator therapy. A case report on a permanent reconstruction of an extensive anterior defect of the trachea employing a pedicled pectoralis--major flap incorporating autologous cartilage is presented. Due to "upside-down" rotation of the flap with the cartilage clasps implanted subcutaneously, an epithelialized reconstruction of the anterior tracheal wall was achieved in a length of 10 cm. Sufficient stability of this reconstruction is now given for 42 months.

Early postoperative enteral nutrition with arginine-omega-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact

OBJECTIVE

To evaluate the effect of early postoperative feeding with a nutritionally complete enteral diet supplemented with the nutrients arginine, ribonucleic acid (RNA), and omega-3 fatty acids on the immune function in patients undergoing surgery for upper gastrointestinal (GI) malignancies.

DESIGN

Prospective, randomized, placebo-controlled, double-blind study.

SETTING

Surgical intensive care unit (ICU) in a German university hospital.

PATIENTS

Forty-two consecutive patients receiving an enteral diet via needle catheter jejunostomy after GI surgery for cancer.

INTERVENTIONS

Patients were randomized to receive either the arginine, RNA, and omega-3 fatty acids supplemented diet or an isocaloric and isonitrogenous placebo diet. Early enteral nutrition was started on postoperative day 1 in the surgical ICU with 20 mL/hr and progressed to the optimal goal of 80 mL/hr by postoperative day 5.

MEASUREMENTS AND MAIN RESULTS

Clinical examination and adverse GI symptoms were recorded on a daily basis. Body weight was determined twice weekly. Immunoglobulin concentrations were determined by laser nephelometry. Interferon-gamma concentrations were measured with a modified enzyme-linked immunosorbent assay method. Fluorescence-activated cell scan flow cytometry was performed to analyze B cells, T lymphocytes and their subsets. Clinical patient characteristics and mean caloric intake were similar between the two groups and both formulas were well tolerated. The number of T lymphocytes and their subsets, helper T cells (CD4) and activated T cells (CD3, HLA-DR), were significantly higher in the supplemented diet group on postoperative days 10 and 16 (p < .05). Mean interferon-gamma concentration after phytohemagglutinin stimulation was higher in the supplemented diet group on postoperative day 16. In the supplemented diet group, mean immunoglobulin M concentrations were significantly higher on postoperative day 10 and mean immunoglobulin G concentrations were higher on postoperative day 16 (p < .05) compared with the results in the placebo group. B-lymphocyte indices were significantly higher in the supplemented vs. the placebo diet group on postoperative days 7 and 10 (p < .05).

CONCLUSIONS

Supplementation of enteral diet with arginine, RNA, and omega-3 fatty acids in the early postoperative time period improves postoperative immunologic responses and helps to overcome more rapidly the immunologic depression after surgical trauma.

[Follow-up of contralateral intratesticular oxygen pressure in unilateral testicular torsion]

The intratesticular tissue oxygen tension (= IT-pO2) depends on the testicular perfusion. Polarographic microcatheter probes have recently become available and are suitable for continuous measurements of the tissue oxygen tension. In 20 adult albino rats flexible Clark-type oxygen electrodes (1.5 F) were used for simultaneous monitoring of IT-pO2 of the ipsi- and contralateral testicle during unilateral torsion. A counterclockwise 720 degrees torsion caused a decrease of IT-pO2 from 21 mm Hg (+/- 5 mm Hg) to 5 mm Hg (+/- 1.5 mm Hg) in the twisted testicle within 5-7 min. After detorsion the IT-pO2 returned to normal level in the following 25 min. The IT-pO2 of the contralateral testicle showed no significant changes during torsion for 1 h or after detorsion. Thus, if the oxygen utilization is unchanged a unilateral acute torsion for 1 h does not cause a decrease in perfusion in the contralateral testicle. It will probably also prove possible to use oxygen tissue tension measurements to improve our understanding of testicular perfusion in humans.

Modulation of postoperative immune response by enteral nutrition with a diet enriched with arginine, RNA, and omega-3 fatty acids in patients with upper gastrointestinal cancer

OBJECTIVE

To find out whether an enteral diet supplemented with arginine, RNA, and omega-3 fatty acids modulated the production of interleukin-1 (IL-1), interleukin-2 (IL-2), IL-2 receptor, interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-alpha) after operations for upper gastrointestinal cancer.

DESIGN

Prospective double blind clinical study.

SETTING

University hospital, Germany.

SUBJECTS

42 patients randomised into two groups (n = 21 each), one of which was given an isocaloric and isonitrogenous placebo diet and one of which was fed the same diet supplemented with arginine, RNA, and omega-3 fatty acids.

INTERVENTIONS

The cytokines were measured before operation and on postoperative days 1, 3, 7, 10, and 16.

MAIN OUTCOME MEASURES

Comparison of concentrations of cytokines in the two groups.

RESULTS

Among those receiving the placebo diet (after spontaneous stimulation) IL-6 concentrations were significantly higher on days 3 and 7 (p < 0.05) and TNF-alpha concentrations on day 7. In contrast (after stimulation with phytohaemagglutinin) mean concentrations of IL-2 receptor were significantly higher on days 3 and 7, and of IL-1 beta and IL-2 on day 16 (p < 0.05) in the group receiving the supplemented diet.

CONCLUSION

Supplementation of an enteral diet with arginine, RNA and omega-3 fatty acids can modulate the acute phase reaction as indicated by the reduction in concentrations of TNF-alpha and IL-6 in the group fed the supplemented diet. Patients receiving the supplemented diet also showed accelerated recovery in the concentrations of IL-1 beta and IL-2 receptor.

Reduction in diarrhea incidence by soluble fiber in patients receiving total or supplemental enteral nutrition

BACKGROUND

Gastrointestinal side effects, particularly diarrhea, are still the main reasons for discontinuation of enteral nutrition. Although the causes of diarrhea are diverse, the enteral nutrition solution is frequently suspected of playing a leading role in causing diarrhea.

METHODS

Our randomized, prospective, double-blind trial with 100 patients assessed the effects of feeding a standard diet (Nutrodrip Standard) vs the same diet supplemented with 20 g of soluble fiber, containing partially hydrolyzed guar gum (Sunfiber), per 1000 mL. Thirty patients received total enteral nutrition postoperatively, and 70 patients received enteral supplementation.

RESULTS

The patients receiving total enteral nutrition with soluble fiber had decreased diarrhea but increased flatulence. In none of these patients did enteral feeding have to be discontinued because of gastrointestinal side effects, whereas in four patients who were on a standard diet, enteral feeding had to be interrupted because of diarrhea (p < .05). Similar observations were made in patients receiving enteral supplementation. In both groups, the incidence of diarrhea decreased significantly with the soluble fiber diet compared with the standard diet (6 vs 15, p < .05).

CONCLUSIONS

Enteral feeding with a formula supplemented with partially hydrolyzed guar gum reduces the incidence of diarrhea in patients receiving total enteral nutrition as well as in those receiving enteral supplementation, regardless of the cause of diarrhea. The increased hydrogen production and the significantly higher rate of flatulence are likely to result from fermentation of the soluble fiber in the colon, with concomitant production of short-chain fatty acids, which leads to increased absorption of short-chain fatty acids, sodium, and water by the colonocytes. This effect, together with the observed cholecystokinin-mediated decrease in colonic transit time with partially hydrolyzed guar gum, may explain the reduction in the incidence of diarrhea in this study.

[The temperature dependence of fibrinolysis with streptokinase]

In an in-vitro study standardized test thrombi were incubated at different temperatures between 25 degrees and 43 degrees C in a constant test mixture in which all reagents necessary for fibrinolysis including streptokinase were contained in excess. At each temperature step the dilution of the standard streptokinase solution (1:1000 IU/ml) was measured at which the test thrombus dissolved in exactly 15 min (clot lysis test). The highest fibrinolysis activity (dilution of 1:1140 of the standard) was obtained at 40 degrees C, lower activities having been recorded at both higher and lower temperatures (43 degrees C:1:1000; 37 degrees C:1:900; 34 degrees C:1:550; 30 degrees C:1:255; 25 degrees C:1:90). Related to the optimal temperature of 40 degrees C (100%), the fibrinolytic activity at 25 degrees C was only 7.9%. In view of the axial temperature gradients existing in the limbs, the internal temperature in their peripheral parts lies well below the optimal temperature for fibrinolysis. This situation should be taken into account during fibrinolysis procedures for thrombotic occlusions in the limbs.

[Postoperative small intestinal motility after abdominal surgery]

After abdominal surgery there is a postoperative small bowel ileus. We evaluate whether the duration of the small bowel ileus is depending on the kind of surgery or not. Over a needle catheter jejunostomy a 3-tip transducer was placed into the distal jejunum. At the end of the operations a pressure detector was connected to measure the intraluminal pressure continuously over five days. Group A consisted of three patients undergoing explorative laparotomy because of inoperable gastric cardia cancer, and group B of eight patients who underwent gastrectomy. In none of the patients a normal empty stomach motility pattern, determined by the activity of a migrating myoelectric complex (MMC) was detectable. In group A the normal MMC-activity returned after 24 +/- 4.5 h and in group B after 82 +/- 25 h. Therefore the duration of the loss of the interdigestive myoelectric complex appeared to be dependent upon the type of surgery.

[Monitoring of postoperative enteral feeding using the H2 breath test]

A group of 24 patients which underwent extensive abdominal surgery (gastrectomy and esophagus resection) were fed with a chemically defined diet by way of a needle catheter jejunostomy starting on day five postoperatively. On the fourth postoperative day the jejunocaecal transit time was measured by hydrogen breath test with a median of 97.5 min. Under enteral nutrition, hydrogen exhalation showed a significant rise in all patients. The 8 patients who developed diarrhea (33%) had significantly elevated hydrogen exhalation in relationship to the patients with no diarrhea. 6-12 h before diarrhea, patients had a significant increase in their hydrogen exhalation in correlation to the beginning of carbohydrate malabsorption. Therefore, the hydrogen breath test is a simple, non-invasive method to evaluate carbohydrate malabsorption and the risk of developing diarrhea under enteral nutrition.