Skin tube esophagus: present indications and late malignization

If there is no other possibility for the replacement of the whole esophagus, skin tube esophageal reconstruction gives a good result. Three successful cases treated with the antethoracal neoesophagus formed from musculocutaneous flaps are discussed. All patients recovered successfully. However, there exists the possibility of late malignization in the skin tube esophagus. Two such cases are also presented.

[Donor site digital subtraction angiography before mandible reconstruction with free fibula transplantation]

The use of fibula free flap has become established as a reliable and popular method for reconstruction of segmental mandibular defects. Vascular anomalies of the donor site may compromise the blood supply of the flap, may jeopardize perfusion of the foot or cause technical difficulties during the procedure. Clinical examination of the circulation in the lower extremities may have relatively normal results. Preoperative vascular imaging detects aberrant cases and thus may contraindicate the use of fibula free flap or may alter the surgical plan. Authors performed 64 preoperative lower-limb digital subtraction angiographies (DSA) in a series of 39 consecutive patients clinically judged to be satisfactory candidates for free fibula transfer. DSA detected vascular anomalies in 10 extremities (15.6%). Regarding the high potential for significant donor site morbidity authors consider vascular imaging essential part of preoperative evaluation.

Implant-prosthetic rehabilitation after segmental mandibulectomy and bone grafting

A free vascularized fibula (6 cases) and iliac bone (11 cases) graft were used to reconstruct a mandibular discontinuity defect resulting from cancer surgery in 17 patients. Fifty-two osseointegrated DenTi implants were secondarily placed into the grafted bone, and all the patients underwent prosthetic rehabilitation. (DenTi is an endosseous dental implant system invented and manufactured by Denti-System Ltd., Szentes, Hungary.) To date, the maximum follow-up time after prosthetic treatment is 5 years, the minimum is 2 years. During this time, only one of the 52 inserted implants was lost, and that occurred a few days after insertion. Clinical signs of peri-implantitis were observed in only 2 of the fixed prosthetic restorations. Long-term maintenance is essential if such patients are to achieve successful prosthetic restorations and, thus, enhanced lives.

[Extensive intraoral cicatrization treated by microsurgery]

Extensive intra-oral burns are very rare injuries. The microstomia resulting from the advanced cicatrization of the mucosa makes it difficult for the patient to eat and impossible to take care of his teeth. The traditional operation for widening the oral orifice was not sufficient because of the extensive scarring of the bucca. In the first operation the authors substituted the mucosa of the lip and the bucca of one side with splitted jejunum. Because of the advancing scarring another operation was performed and the mucosa of the other side of the bucca and the angle of mouth was substituted with a forearm graft.

The replacement of the esophagus by musculocutaneous flaps

If there is no other possibility for the replacement of the whole esophagus, the antethoracal neo-esophagus from musculocutaneous flaps gives the best result compared with the skin tube reconstruction. Two successful cases are discussed.

[Mandibular reconstruction using a microvascular method in the transplantation of a fibular flap]

The best results in mandibular reconstruction are achieved by transplantation of vascularised bone. This transplant has an own blood supply therefore its surviving is not influenced by the non-sterile environment of the oral cavity and the insufficient blood supply of the operated area (caused by scar or radiation). A new promising method for reconstruction of a wide segmented defect of the mandible is vascularised fibular flap transplantation. Eight consecutive patients treated with fibular flap transplantation in 1993 and 1994 were reviewed. Osteo- and osteo-cutan flaps were used for reconstruction of the composite tissue defects. The authors report on the surgical technique and their first experiences. The authors consider the application of the fibular flap the most successful procedure of all types of reconstruction of segmented mandibular defect.

[Rehabilitation of patients with head and neck tumors, with special attention to psychotherapy]

Few people are more severely handicapped than patient with facial deformities. The face forms a centre point of attention in human relationships with particular emphasis placed on cosmetic acceptance. Surgical ablation of head and neck cancer often creates significant functional and aesthetic problems. In addition to the numerous physiologic problems that can befall the patient, devastating changes in appearance may occur with serious psychologic sequel. Our purpose here is to discuss the numerous physiologic and psychological problems occurring after major ablative surgery of the head and neck. A team effort is essential to the effective treatment of those patients, including: surgeon, oncologist, radiotherapist, prosthodontist and last but not least psychologist, who has a main role in strengthening the patients and helping them to lead an acceptable quality of life.

[Up-to-date reconstruction of gunshot wounds of the face]

The extensive damage after gunshot injuries needs excellent primary closure, secondary reconstruction and functional rehabilitation. The huge bone defect can best be reconstructed with vascularized iliac bone graft. An additional advantage of vital bone transplant is the possibility of its support with endosseal implants, which leads to a very good chance for longtime restauration of the masticatory function with a low rate of complications.

[Use of an osteo-musculo-cutaneous flap from the trapezius muscle for the immediate restoration of a mandibular defect following surgery for cancer of the oral cavity]

The authors state their experiences using trapezius osteomusculocutaneous flaps in 22 clinical patients for primary reconstruction of mandibular defects. The additional investigative study examines the anatomy of 100 osteomusculocutaneous flaps in 50 fresh cadavers. 78 percent of the major vascular pedicle arose form the thyreocervical trunk. The advantages of this method are as follows: 1. This flap provides a well-vascularized bone graft; 2. The operation comparing to other bone grafting methods is simple; 3. After radical neck dissection the trapeziu muscle protects the carotid artery; 4. The vascularized bone graft can be used after irradiation; 5 Good functional and esthetic results can be obtained.

[Cancer of the skin tube--late complication of the ante-thoracic substitution for the esophagus]

The authors report on two patients suffering from benign oesophageal stricture reconstructed by a skin tube. In both skin tube there are developed a malignancy which infiltrated the skin of the chest wall. During one session they performed the removal of the skin tube and the antethoracic reconstruction with ileocolon. The large defect on the thorax was covered in both cases with a latissimus dorsi myocutaneous flap. This provided satisfactory functional and cosmetic result. They point out the effectiveness of the cytostatic combination they administered. Attention should be drawn to the use of the myocutaneous flaps and the regular checking of patients with skin tubes.

[Reconstruction of the maxilla by a microsurgical method and bone transplantation using bone from the scapula]

For replacing partial lack of the upper jaw bone shoulder-blade transplanted by microsurgical method is used. The anatomy of the veins supplying the transplant and the surgical method are described. In connection with describing two cases good functional and cosmetic successes are reported on and the great importance of living bone replacement is emphasized.

[Reconstruction of the oral and pharyngeal mucosa by a microsurgical method using a jejunal graft]

The microsurgery is a new, modern method of the reconstructive surgery which has made the free transplantation of the jejunal graft possible. The jejunum transplanted with microvascular anastomosis lends itself mainly to replacing the segmental and concentrical defect of the initial part of the alimentary tract, but the splitted jejunal graft cut along the antimesenterical side, because of its favourable biological nature, can be used for reconstruction of the oral and pharyngeal mucosus membrane. The authors applied the splitted jejunal graft in four cases for the reconstruction of oropharyngeal defects due to excision of malignant tumours. In harmony with literary data good result is reported on.

[The medical school and its training center at the District Institute of National Health in Nové Zámky from the viewpoint of medical students engaged in professional and social medicine summer practice]

Within the framework of professional and social practice of medical students in the district institute of national health in Nové Zámky a questionnaire survey was made concerned with the attitudes and views of students as regards training at the medical faculties and as regards summer practice. The authors consider the information obtained from 37 students of different medical faculties in the SSR and CSR, ensuing from their first empirical experience in the field, a valuable feedback as regards the standard of training and shaping of the profile of the qualified doctor for practice. On the whole the students are satisfied with the conditions of practical work in Nové Zámky but have also some concrete concructive comments and suggestions for optimation and intensification of undergraduate training and therapeutic and preventive care. The participation of medical students in the above activities is a significant factor shaping their professional identity.

Individual differences in the antidiuretic response induced by single doses of 1-deamino-8-D-arginine-vasopressin (DDAVP) in patients with pituitary diabetes insipidus

Marked interindividual differences were found in the height and duration of the antidiuretic action induced by increasing single intravenous doses (0.5 mug and 8 mug) of DDAVP in patients with pituitary diabetes insipidus. It was assumed that differences in the duration of action reflected individual variations in the rate of removal of vasopressin.

The antidiuretic action of 1-deamino-8-D-arginine vasopressin (DDAVP) in man

1. After administration of a new vasopressin analogue (DDAVP), a marked and prolonged antidiuresis occurred in 10 patients with pituitary diabetes insipidus. 2. The antidiuretic effects of single intravenous doses of 0.04--24 mug DDAVP and single intranasal doses of 5--320 mug DDAVP were investigated. Time curves of the antidiuretic responses expressed in changes of urine osmolality (Uosm) and free water clearance per 100 ml GFR (CH2O X 100/GFR) are described. 3. Maximal "peak" response was obtained after an intravenous dose of 1 mug within the first 12 hrs (Uosm was 7--800 mOsm/KgH2O). Further increase of dosage resulted only in prolongation of duration of action (up to 48 hrs) and peak ("plateau") effect (up to 24 hrs). 4. There was a linear relationship between the log dose and log osmolality of urine collected in the second 12 hours after administration of single intravenous and intranasal doses of DDAVP. 5. Comparison of the effects of 1 mug lysine-vasopressin and 1 mug DDAVP revealed only slight differences in peak effects, but extreme differences in duration of action. 6. It is concluded that in the evaluation of a synthetic vasopressin analogue the maximal antidiuretic ability and the prolongation of action have to be analysed separately.

Inhibition of the antidiuretic effect of 1-deamino-8d-arginine vasopressin (DDAVP) by glibenclamide in water-loaded healthy subjects

The diuretic effect of a three-day glibenclamide treatment was studied in 8 healthy subjects during maximal sustained water diuresis before and after administration of 0.04 mug l-deamino-8d-arginine vasopression (DDAVP). The antidiuretic response (decrease in free water clearance per 100 ml GFR and increase in urine osmolality) induced by DDAVP was significantly reduced by glibenclamide. In addition, changes in urine osmolality indicated a shorter duration of DDAVP -antidiuresis. These findings are consistent with the hypothesis that glibenclamide competitively inhibits the peripheral action of vasopressin.

Different effects of frusemide administered during hypertonic saline infusion in healthy subjects and hypertensive patients

1. The effects of hypertonic saline and frusemide administered during hypertonic saline infusion were studied during antidiuresis and infusion of lysine-vasopressin in fifteen healthy subjects and seventeen patients with hypertension.

2. Rates of excretion of water and sodium were higher during salt loading in the hypertensive patients as compared to the healthy persons. On the other hand, frusemide administered during saline infusion had a greater effect in the normal subjects.

3. Free water reabsorption increased markedly in the first 10-min clearance period after frusemide injection in the healthy subjects, while in the hypertensive group there was no significant change. This suggested that the diuretic may have a more marked proximal tubular effect in the healthy persons and/or a more intensive Henle's loop action in the hypertensives. However, the latter possibility was not supported by data concerning the correlation between solute excretion and free water reabsorption.

4. It is suggested that sodium transport is competitively inhibited in the same segment(s) of the nephron by frusemide and hypertonic saline and that this may explain the decreased effect of frusemide in the hypertensives.