Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches

BACKGROUND

Endoscopic expanded endonasal approaches (EEAs) for the resection of lesions of the anterior and ventral skull base can create large defects that present a significant risk of postoperative cerebrospinal fluid (CSF) leak. These defects, especially in patients who received preoperative radiotherapy, are best reconstructed with vascularized tissue. The Hadad-Bassagasteguy flap, a pedicled nasoseptal flap, is our preferred method for reconstruction. This option is not available, however, in patients who underwent a previous posterior septectomy or in those with tumors that invade the pterygopalatine fossa (PPF) or sphenoid sinus rostrum. In this scenario, we have used a temporoparietal fascial flap (TPFF) for the reconstruction of large surgical defects.

METHODS

We developed a new technique for the transposition of the TPFF into the nasal cavity to reconstruct skull base defects after EEA. The flap is harvested using a conventional hemicoronal incision but is then advanced to the defect using a temporal-infratemporal tunnel and an endonasal transpterygoid approach. The latter is created using an endoscopic endonasal approach that involves the resection of the posterior wall of the antrum, dissection of the PPF, and partial resection of the pterygoid plates. These maneuvers open a bone window to accommodate the flap. The soft tissue tunnel, extending from the temporal to the infratemporal and then to the PPF, is opened with percutaneous tracheostomy dilators. We present a detailed description of the surgical technique and a retrospective review of two cases in which we used this technique.

RESULTS

Two patients with large CSF fistulas who had undergone preoperative radiotherapy were reconstructed transposing the TPFF through a transpterygoid tunnel. We obtained an adequate exposure for placing the flap endonasally, and the flap provided complete coverage of the skull base defect. Both CSF leaks were resolved without any additional morbidity from the flap or the access technique.

CONCLUSION

The TPFF is a reliable and versatile method for the reconstruction of the anterior, middle, clival, and parasellar skull base after EEAs. Its harvesting requires an external incision; thus, it is not our preferred method of reconstruction. It is recommended for large dural defects in patients with previous posterior septectomy and previous radiation treatment.

Management of acute full-thickness losses of the abdominal wall

Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.

Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis

BACKGROUND AND STUDY AIMS

Open pancreatic necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Percutaneous or endoscopic necrosectomy are alternative techniques. We evaluated the use of endoscopic necrosectomy for treatment of patients with necrosis that could be accessed through the posterior wall of the stomach.

PATIENTS AND METHODS

We retrospectively analyzed the indication, patient status according to acute physiology and chronic health evaluation (APACHE) 2 severity score, and success of endoscopic necrosectomy as primary treatment, in selected patients with localized infected pancreatic necrosis, who presented between May 2002 and October 2004. After the necrosis cavity had been accessed, with the assistance of endoscopic ultrasound, a large orifice was created and necrotic debris was removed using endoscopic accessories under radiological control. Follow-up was clinical and radiological.

RESULTS

13 patients (nine men, four women, mean age 53 years), 11 with positive bacteriology, underwent attempted endoscopic necrosectomy. Median APACHE 2 score on presentation was 8 (range 1-18). Four patients needed intensive therapy unit care and one other patient required (nonventilatory) high-dependency unit care only. Necrosis was successfully treated endoscopically in 12 patients, requiring a mean of 4 endoscopic interventions (range 1-10); one patient required open surgery; two underwent additional percutaneous necrosectomy and one required laparoscopic drainage. Two patients died of complications unrelated to the procedure. The 11 survivors have a median (range) follow-up of 16 (6-38) months.

CONCLUSION

Endoscopic necrosectomy is a safe method for treatment of infected pancreatic necrosis. Multiple procedures are usually needed. It may be combined with other methods of surgical intervention. Larger prospective studies will more precisely define its role.

Treatment of anthracycline extravasation with Savene (dexrazoxane): results from two prospective clinical multicentre studies

BACKGROUND

The purpose of this study was to assess the efficacy and tolerability of i.v. dexrazoxane [Savene (EU), Totect (US)] as acute antidote in biopsy-verified anthracycline extravasation.

PATIENTS AND METHODS

Two prospective, open-label, single-arm, multicentre studies in patients with anthracycline extravasation were carried out. Patients with fluorescence-positive tissue biopsies were treated with a 3-day schedule of i.v. dexrazoxane (1000, 1000, and 500 mg/m(2)) starting no later than 6 h after the incident. Patients were assessed for efficacy (the possible need for surgical resection) and toxicity during the treatment period and regularly for the next 3 months.

RESULTS

In 53 of 54 (98.2%) patients assessable for efficacy, the treatment prevented surgery-requiring necrosis. One patient (1.8%) required surgical debridement. Thirty-eight patients (71%) were able to continue their scheduled chemotherapy without postponement. Twenty-two patients (41%) experienced hospitalisation due to the extravasation. Mild pain (10 patients; 19%) and mild sensory disturbances (nine patients; 17%) were the most frequent sequelae. Haematologic toxicity was common as expected from the fact that the extravasation occurred during a chemotherapy course. Other toxic effects were transient elevation of alanine aminotransferases, nausea, and local pain at the dexrazoxane injection site.

CONCLUSION

Dexrazoxane proved to be an effective and well-tolerated acute treatment with only one out of 54 assessable patients requiring surgical resection (1.8%).

Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos)

BACKGROUND

Surgical management of pancreatic necrosis is associated with significant morbidity and mortality. Several weeks after an episode of a necrotizing pancreatitis, necrosis can become organized. By the time necrosis becomes organized, endoscopic therapy has the potential to offer an alternative treatment to surgery.

OBJECTIVE

To evaluate the safety and efficacy of endoscopic debridement of organized pancreatic necrosis and to identify procedural aspects that may improve outcome.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

All consecutive patients who underwent this novel endoscopic approach were included.

INTERVENTIONS

Treatment started with a cystoenterostomy or a cystogastrostomy. The next steps consisted of balloon dilation, up to 18 mm; advancement of an endoscope into the retroperitoneal cavity; and endoscopic debridement of the collection under direct endoscopic vision. Debridement was repeated every 2 days until most necrotic material was evacuated. In addition, nasocystic catheter irrigation was performed manually with saline solution 6 to 8 times a day.

MAIN OUTCOME MEASUREMENTS

Clinical success, number of endoscopic procedures, and complications.

RESULTS

Twenty-five patients were identified, who had undergone debridement of 27 collections. In 11, 13, 2, and 1 collections, 1, 2, 3, and 4 endoscopic debridement procedures, respectively, were performed. There was no mortality. Severe complications that required surgery occurred in 2 patients: hemorrhage in 1 case and perforation of cyst wall in the other. During a median follow-up of 16 months (range 3-38 months), the overall clinical success rate with resolution of the collection and related symptoms was 93%.

LIMITATIONS

Retrospective study.

CONCLUSIONS

In this study, we showed that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies are warranted to define its definitive role in the management of these patients.

Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection

Forty-two patients with necrotizing soft tissue infection are reviewed. Bacterial culture revealed between two and seven types of micro-organism in each patient. All patients were treated with radical surgical debridement and a combination of antibiotics. In 30 patients, early diagnosis and treatment resulted in only two deaths. Delayed surgical intervention in 12 patients transferred from outside hospitals was followed by nine deaths. Predisposing factors and site of infection did not affect outcome. Of 26 patients with systemic manifestations of sepsis, 16 survivors responded well to initial surgical debridement.

A novel use of amniotic membrane in the management of tube exposure following glaucoma tube shunt surgery

AIM

To report a novel technique using amniotic membrane to cover exposed glaucoma tube shunts.

METHODS

A consecutive series of three cases that underwent drainage tube shunt surgery with the Ahmed valve for intractable glaucoma. All three patients developed exposure of the tube secondary to necrosis of the overlying bovine pericardial patch and conjunctiva. Repair of the defect was carried out with a double layer of amniotic membrane, the inner one acting as a graft and the outer as a patch. Autologous serum was used to promote epithelial growth.

RESULTS

Successful lasting closure of the conjunctival defect was achieved in all cases.

CONCLUSION

Erosion of the drainage tube following shunt surgery is a potentially serious problem. It can be successfully managed using a double layer of amniotic membrane.

Surgical treatment of acute necrotizing pancreatitis

Images

Peripheral intravenous infiltration necrosis

Peripheral extravasation of intravenous solutions containing calcium salts and/or 10% dextrose has caused significant local tissue necrosis in 8 patients, including 6 infants. These incidents prolonged hospitalization and in 5 cases caused severe disfigurement or imperiled limb function. Treatment followed established principles of debridement, early skin grafting and secondary reconstruction as needed. While intravenous alimentation or the administration of calcium salts if often indicated by the clinical situation, the physician administering these drugs must realize that extravasation may cause serious sequelae.

The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients

Huge sacral defects can be closed reliably with sliding gluteus maximus myocutaneous flaps. In ambulatory patients, this flap is designed to maintain innervation, vascularity, and functional integrity of the muscle.

Ten Years of Descending Necrotizing Mediastinitis: Management of 23 Cases

PURPOSE

Through a 10-year retrospective study, we report our experience in the management of descending necrotizing mediastinitis (DNM), a rare and often lethal complication of odontogenic and oropharyngeal infections.

PATIENTS AND METHODS

We reassessed 23 patients between the ages of 16 and 69 years (mean, 49 years) seen between 1996 and 2005, with DNM secondary to odontogenic abscess or phlegmon in 9 cases or secondary to peritonsillar abscess in 14 cases. In this study, 48% of the patients had immune system disorders, mainly diabetes mellitus (6 patients). The diagnosis of DNM was confirmed by cervicothoracic computed tomography.

RESULTS

Eight patients underwent a bilateral collar cervicotomy, and 15 underwent a combined cervicothoracic approach. Five, 2, 1, and 1 patients underwent surgery 2, 3, 4, and 5 times, respectively. Seven patients died as a result of septic shock and multiorgan failure, for a mortality rate of 30.4%. Four of those who died had a compromised immune system.

CONCLUSION

The relatively high mortality rate seen in this study shows that, in addition to early diagnosis and aggressive treatment, it is important to give greater attention to and be more medically and surgically aggressive in the management of patients whose immune system is compromised in any way.

Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study

BACKGROUND

The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).

METHODS

This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist's discretion.

RESULTS

A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %; P = 0.04). Bleeding was the most frequent adverse event observed.

CONCLUSIONS

The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.

Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization

BACKGROUND

Transcatheter arterial embolization (TAE) can cause gluteal skin and muscle necrosis. However, the ultimate and typical signs of gluteal necrosis resulting from TAE have not yet thoroughly been investigated.

METHODS

From January 1995 to December 2003, 165 pelvic fractures were managed with TAE to control retroperitoneal bleeding at our level 1 trauma center. From these, 12 patients suffered gluteal muscle and skin necrosis. We reviewed the medical records of these 12 patients for age, gender, fracture type, embolic sites, computed tomography (CT) findings, serum creatine kinase level, site of skin necrosis, time from injury to skin necrosis, treatment, and outcome.

RESULTS

All 12 patients underwent TAE of the bilateral internal iliac arteries with gelatin sponge slurries. One patient suffered from an infection of the gluteal muscle from an open fracture site. Five patients presented with signs of gluteal soft tissue injuries on admission. Of these, four had skin abrasions and three revealed fluid or air collection under the gluteal skin on CT. The remaining six patients showed no evidence of soft tissue injuries on admission, and the lesions appeared between 2 days and 7 days after their admission. In these six patients, low-density areas (LDAs) of gluteal muscle with a clear border on the CT were observed following the appearance of skin lesion. The skin necrosis was located in the center of either or both buttocks, and signs of ischemia were clearly demarcated from the adjacent normal tissue. Four of 12 patients died from sepsis, three of whom suffered from uncontrollable gluteal infections that had been pointed out as LDAs on the CT.

CONCLUSIONS

In every patient with gluteal necrosis associated with pelvic fracture following TAE, initial traumatic contusion cannot be ruled out as contributing to the development of the necrosis. However, for patients who undergo TAE of the bilateral internal iliac artery and who show clear-border LDAs on CT, skin necrosis centered on the buttock, and the delayed appearance of a skin lesion, careful attention must be given in the event of an arterial obstruction due to TAE.

Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis

BACKGROUND AND AIMS

EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON.

METHODS

A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established.

RESULTS

LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results.

CONCLUSION

LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

Development of post-traumatic cysts in the spinal cord of rats-subjected to severe spinal cord contusion

To study the development of post-traumatic spinal cord (SC) cysts, and their fine anatomic characteristics, rats were subjected to severe SC contusion. Specimens were analyzed from day 1 to 1 year post-injury. Using conventional light, and transmission and scanning electron microscopy, three stages were typified, namely: necrosis, repair, and stability. The final cell composition and thickness of the cyst walls were not uniform. Astrocytes, fibroblasts, ependymal cells, and collagen fibers were the main constituents. Chronic inflammatory cells were also observed. The neuropathologic characterization of posttraumatic SC cysts could be useful in planning strategies for SC reconstruction at different times post-injury.

Surgical strategy and management of infected pancreatic necrosis

Infected pancreatic necrosis and sepsis are the leading causes of death in patients with necrotizing pancreatitis. Between 1986 and 1993, 123 patients with infected pancreatic necrosis were treated; in all cases the infected necrosis extended to the retroperitoneal area. Surgical treatment was performed a mean of 18.5 days after the onset of acute pancreatitis. Operative management consisted of wide-ranging necrosectomy through all the affected area, combined with continuous widespread lavage and suction drainage applied for a mean of 39.5 days, with a median of 6.5 litres of normal saline per day. In 56 cases (46 per cent), another surgical intervention (distal pancreatic resection, splenectomy, cholecystectomy, sphincteroplasty or colonic resection) was also performed. Bacteriological findings revealed mainly enteric bacteria, but Candida infection was detected in 21 per cent of patients. The overall hospital mortality rate was 7 per cent (nine patients died). Infected pancreatic necrosis responds well to aggressive surgical treatment, continuous, long-standing lavage and suction drainage, together with supportive therapy combined with adequate antibiotic and antifungal medication.

Acute pancreatitis

The exocrine pancreas secretes into the gut on demand more than 20 proteins that are indispensable for digestion. In-vivo autodigestion is prevented by an array of natural safeguards. In acute pancreatitis, inappropriate intrapancreatic activation and release of pancreatic hydrolases occur, but the pathogenetic mechanism of autodigestion is unclear. The release of proteases, lipase and colipase, phospholipase A, vasoactive peptides, and other agents probably accounts for the edema, tissue destruction, fat necrosis, metabolic abnormalities, and complications. Ethyl alcohol abuse, gallstones, trauma, and other common and rare conditions can induce pancreatitis. The patient's outcome can be predicted by certain prognostic signs. Ultrasonography and computerized tomography are invaluable diagnostic tools and magnetic resonance imaging appears promising. Hemodynamic monitoring, intensive care with colloid and crystalloid infusions, correction of electrolyte abnormalities, judicious use of antibiotics, peritoneal lavage, drainage of pancreatic exudation fluids, and surgical intervention require a team approach, especially in patients with multiple complications. Additional research is needed into the pathogenetic mechanism of autodigestion and the design of specific therapies.

Grading of medullary thyroid carcinoma on the basis of tumor necrosis and high mitotic rate is an independent predictor of poor outcome

Medullary thyroid carcinoma (MTC) is a rare nonfollicular cell-derived tumor. A robust grading system may help better stratify patients at risk for recurrence and death from disease. In total, 144 MTC between 1988 and 2018 were subjected to a detailed histopathologic evaluation. Clinical and pathologic data were correlated with disease specific survival (DSS), local recurrence free survival (LRFS)  and distant metastasis free survival (DMFS). Median age was 53 years (range: 3-88). Median tumor size was 1.8 cm (range: 0.2-11). Lymph node metastases were present in 84 (58%) cases while distant metastases at presentation were found in 9 (6%) patients. Seven (5%) had ≥5 mitoses/10 HPFs. Tumor necrosis was present in 30 cases (20%) while lymphovascular invasion occurred in 41 (28%) of tumors. Extra-thyroidal extension was found in 44 (31%) and positive margins were seen in 19 (14%). There was a strong correlation between increasing tumor size and tumor necrosis (p < 0.001). Median follow up was 39 months. In univariate analysis, male gender, higher American Joint Committee on Cancer (AJCC) stage group, larger tumor size, tumor necrosis, high mitotic index (≥5/10 HPF), nodal status, size of largest nodal metastasis, and elevated postoperative serum calcitonin predicted worse DSS, LRFS, and DMFS (p < 0.05). Extra-thyroidal extension correlated with DSS and DMFS while positive margins and distant metastasis at presentation imparted worse DSS (p < 0.05). In multivariate analysis, tumor necrosis and mitotic activity (5 mitosis/10 HPFs as the cutoff) were the only independent predictors for DSS (p = 0.008 and 0.026, respectively). Tumor necrosis was the sole independent prognostic factor for LRFS and DMFS (p = 0.001 and 0.003, respectively). The presence of tumor necrosis and high mitotic rate are powerful independent prognostic factors in MTC and outperform serum calcitonin and stage. We propose a grading system based on tumor necrosis and mitotic activity to better stratify MTC patients for counseling, post-resection surveillance, and therapy.

Penile Strangulation: Two Case Reports and Review of the Literature

INTRODUCTION

Entrapment or strangulation of the penis is a rare emergency situation that can lead to a wide range of vascular and mechanical injuries.

AIM

The aim of this article is to present our experience dealing with penile strangulation. A review of the literature is also summarized in this report. Current treatment options and outcomes are also evaluated.

METHODS

We performed a computerized MEDLINE search followed by a manual bibliographic review of cross-references. These reports were analyzed and the important findings summarized.

RESULTS

Penile strangulation has been first time reported in 1755. Since that time, sporadic reports have appeared in the literature describing a variety of foreign bodies on the penis that have in common only the property of circularity. We noted motives, types of objects, types of strangulation, symptomatology, trauma grades, diagnoses, including psychological involvement, as well as possible treatment options. Furthermore, two cases of penile strangulation from our clinical practice are presented involving different degrees of vascular insult leading to different pathogenesis, clinical presentation, and surgical approach.

CONCLUSION

Penile strangulation is an unusual clinical condition and the consequences can be severe. Penile strangulation could lead to different degrees of vascular obstruction. Consequently, several clinical syndromes can occur: from mild nonsignificant vascular obstruction that resolves after decompression to severe gangrene of the penis accompanied with impaired renal function. The most common motive associated with foreign bodies on the penis is sexual or erotic in nature. The choice of method for removal depends upon type, size, incarceration time, trauma grade, and availability of the equipment. Prompt diagnosis and early treatment are essential to avoid the potential complications of ischemic necrosis and autoamputation.

Medial gastrocnemius flap coverage for treatment of skin necrosis after total knee arthroplasty

Skin necrosis after total knee arthroplasty is a rare complication that can rapidly lead to deep infection of the prosthetic components. The medial gastrocnemius transposition flap usually provides adequate soft tissue coverage to salvage the total knee arthroplasty. However, variations in defect location and excursion of the muscle flap can affect results. Twelve patients were treated with a medial gastrocnemius transposition flap after total knee arthroplasty. The skin defect that required flap coverage was located over the tibial tubercle or patellar tendon in eight patients (Group 1). The defect extended proximally to the patella or quadriceps tendon in four patients (Group 2). A functioning total knee arthroplasty was salvaged in 11 patients (92%). The medial gastrocnemius flap healed primarily in all patients in Group 1. Three patients in Group 2 required additional fasciocutaneous, lateral gastrocnemius, or free flap coverage, and one patient underwent above knee amputation. The medial gastrocnemius flap is most effective for coverage of distal defects over the tibial tubercle or patellar tendon. Defects that extend more proximally over the patella or quadriceps tendon are more likely to require additional procedures to achieve adequate soft tissue coverage.

LEVEL OF EVIDENCE

Therapeutic study, level IV (case series). See Author Guidelines for a complete description of levels of evidence.