Clinical application of retrograde island flap carrying plantar metatarsal arteries as pedicle

As thyroid function has been documented to be of a higher prevalence in individuals with Down's syndrome, a study was set up to assess the thyroid status of these individuals. Thyroid function tests (T.F.T.s) were initially reviewed on 100 individuals with Down's syndrome in the community and on 36 individuals who were residentially based. Abnormal T.F.T.s were then reviewed 3 yr later. In total sample of 136, initially 13 percent [n = 18] of individuals with Down's syndrome had abnormal T.F.T.s, 5 percent [n = 7] were established cases of thyroid disease and 8 percent [n = 11] were newly identified cases who had abnormal T.F.T.s. Three yr later 6.5 percent [n = 9] of the group who had had abnormal T.F.T.s continued to have abnormal T.F.T.s, 5 percent [n = 7] had thyroid disease and 1.5 percent [n = 2] still had biochemical evidence of thyroid dysfunction. There was a statistically significant increase in abnormal T.F.T.s in the residential sample compared to the community sample on both occasions. The incidence of thyroid dysfunction has been found to increase with age, particularly over the age of 40, however in this study the majority were under the age of 40 with an age range between 28.3 yr and 33.8 yr. The results in this study, coupled with the variability of T.F.T.s over time, highlights the need for regular monitoring of the thyroid status of individuals with Down's syndrome.     

Cisplatin-based neoadjuvant chemotherapy and combined resection for ethmoid sinus adenocarcinoma reaching and/or invading the skull base

OBJECTIVE: To review our experience with cisplatin-based neoadjuvant chemotherapy before en bloc resection via a combined neurosurgical and transfacial approach for ethmoid sinus adenocarcinoma reaching and/or invading the skull base. DESIGN: Case series. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Twenty-two patients with primary untreated ethmoid sinus adenocarcinoma reaching and/or invading the skull base consecutively treated between 1984 and 1992 with cisplatin-based neoadjuvant chemotherapy and combined neurosurgical and transfacial approach. MAIN OUTCOME MEASURES: Statistical analysis of survival, local control, nodal recurrence, distant metastasis, and metachronous second primary tumor incidence based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors, survival, and local recurrence. Clinical response, histological response, toxic effects of chemotherapy, and postoperative course were also reported. RESULTS: The Kaplan-Meier 3-year survival, local control, nodal recurrence, and distant metastasis estimates were 68.1%, 65.7%, 5.3%, and 10%, respectively. Metachronous second primary tumor was not encountered in our series. Survival was statistically more likely to be reduced in patients with intrasphenoidal tumor extent (P = .04) and local recurrence (P = .01). Local recurrence was statistically more likely in patients with intrasphenoidal tumor extent (P = .002) and no response to cisplatin-based neoadjuvant chemotherapy (P = .03). CONCLUSIONS: The results achieved suggest that cisplatin-based neoadjuvant chemotherapy before combined neurosurgical and transfacial approach should be further investigated for the treatment of ethmoid sinus adenocarcinoma reaching and/or invading the skull base.     

Anterior approach for CT-guided biopsy of skull base and parapharyngeal space lesions

At our institution we use an anterior approach to biopsy of the parapharyngeal space or skull base lesions because it provides more direct access than the traditional lateral approach through the mandibular notch. The anterior approach follows a course lateral to the alveolar ridge of the maxilla and lateral pterygoid plate, and inferior to the zygomatic process of the maxilla. Biopsy was performed on 15 patients with either a skull base or a parapharyngeal space mass, none of which could be palpated externally or through the oral cavity by the ear, nose, and throat surgeon. In 12 patients the needle biopsy correlated with the surgical pathology. Three needle biopsies were nondiagnostic.     

Upper eyelid orbicularis oculi flap with tarsoconjunctival island for reconstruction of full-thickness lower lid defects

BACKGROUND: Various cryopreservation techniques have been investigated to elongate preservation time, however, most have failed to be clinically induced because of damage due to ice crystal formation. Subzero nonfreezing conditions could theoretically reduce organ metabolism without damage due to ice crystal formation. We evaluated the superiority of subzero nonfreezing storage compared with conventional hypothermic storage using isolated rat hepatocytes stored in University of Wisconsin (UW) solution without cryoprotectants. METHODS: Hepatocytes of Wistar rats isolated by collagenase digestion were suspended in UW solution and divided into the following three groups: subzero nonfreezing group (-4 degrees C), zero nonfreezing group (0 degrees C), and control group (4 degrees C). They were stored for 48 hr at the temperatures indicated. After 24 and 48 hr of storage, we carried out a trypan blue exclusion test and a 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay, and measured lactate dehydrogenase release, lactic acid, ATP content, and the ability of hepatocytes to synthesize urea. After 48 hr of storage, morphological differences between the control group and the subzero nonfreezing group were investigated by scanning and transmission electron microscopy. RESULTS: Significant improvements of the trypan blue exclusion test and ATP contents in the subzero nonfreezing group were observed. Lactic acid production was also significantly suppressed in the subzero nonfreezing group compared with that in the control group. The MTT assay value was significantly better at -4 degrees C than at 4 degrees C. The rate of urea synthesis at -4 degrees C was higher than that at 4 degrees C. Electron microscopy revealed that subzero nonfreezing delayed the lethal bleb-forming process of stored hepatocytes, which was followed by mitochondrial swelling, compared with the control group. CONCLUSIONS: Subzero nonfreezing storage (-4 degrees C) in UW solution could provide better preservability for isolated rat hepatocytes with protection against hypoxic cell injury compared with conventional hypothermic storage (4 degrees C).     

Microsurgical and prosthetic reconstruction of patient with recurrent ameloblastoma extending into the skull base

Pneumocystis carinii pneumonia is a common cause of death in patients with AIDS. Diagnosis is based on cytological examination of smears prepared from induced sputum samples and bronchoalveolar lavage (BAL) specimens which have been stained with methenamine silver. We have examined 46 BAL/induced sputum specimens from patients who had clinical symptoms and signs suggestive of P. carinii pneumonia and measured the diameter of a minimum 100 cysts in each specimen. We found that cyst size correlated with response to treatment with co-trimoxazole. This observation has implications for the therapeutic management of patients with this infection.     

Transverse glabellar flap for obliteration/isolation of the nasofrontal duct from the anterior cranial base

Management of fractures involving the nasofrontal duct region of the frontal sinus has focused on preserving function when possible or obliterating the sinus and duct when fracture patterns potentiate ductal obstruction and possible transcranial seeding of bacteria. When frontal sinus preservation is in doubt, controversy surrounds the use of cranialization versus obliteration, and the method of obliteration. Perioperative and late postoperative infections are uncommon, but their occurrence jeopardizes an often complex reconstruction and can be life threatening. This paper describes the design and indications for a pedicled transverse glabellar muscle flap for obliteration of the nasofrontal duct, thereby isolating the anterior cranial base from the aerodigestive system. This vascularized muscle flap utilizes the corrugator supercilii and procerus muscles, which are introduced into the sinus via a small, surgically created window in the superomedial orbital wall without disturbing the central facial aesthetic contours. Six patients with comminuted fractures at the nasofrontal duct level associated with displaced posterior frontal sinus fractures have been treated with the transverse glabellar flap. Follow-up ranges from 8 to 30 months. There have been no early or late postoperative complications. The transverse glabellar flap is a reliable and versatile method of partitioning the upper aerodigestive tract from the anterior cranial base with vascularized tissue, thus minimizing the risk of infectious complications. The resulting donor site deformity is more acceptable than that seen with the traditional pedicled galeal frontalis flap.     

Dexon and nylon-sutured wound reaction in conjunctival flap after trabeculectomy combined with or without topical application of mitomycin-C

In this study, rabbits were used to evaluate the sutured wound reaction with Dexon or nylon in the conjunctival flap 1, 4, 7, 14 and 28 days after trabeculectomy surgery with or without the use of mitomycin-C. Four major treated groups were used to compare their wound healing reaction; group 1--nylon-suture and non-mitomycin treatment; group 2--nylon-suture and mitomycin treatment; group 3--Dexon-suture and non-mitomycin treatment; group 4--Dexon-suture and mitomycin treatment. One day after surgery, the number of polymorphs was the greatest most in the nylon-sutured and non-mitomycin treated tissues (86 +/- 2). Four days after surgery, the number of polymorphs was the greatest most in Dexon-sutured and non-mitomycin treated tissues (109 +/- 87). The number of fibroblasts was the greatest most in nylon-sutured and non-mitomycin treated tissues (111 +/- 23). Seven days after surgery, the number of polymorphs was the greatest most in Dexon-sutured and mitomycin treated tissues (32 +/- 12). The number of fibroblasts was the greatest most in nylon-sutured and non-mitomycin treated tissues (126 +/- 15). Fourteen days after surgery, the number of fibroblasts was the greatest most in Dexon-sutured and non-mitomycin tissues (43 +/- 10). The number of goblet cells was the greatest most in nylon-sutured and non-mitomycin treated tissues (4 +/- 2). Twenty-eight days after surgery, the number of fibroblasts was the greatest most in Dexon-sutured and mitomycin treated tissues (40 +/- 15). The number of goblet cells was the greatest most in nylon-sutured and non-mitomycin treated tissues (4 +/- 2). Our conclusions are as follows: 1). The concentration of mitomycin in conjunctival wound edge should be maintained at as low a level as possible because the mitomycin will delay the wound healing process; 2). Nylon material is better than Dexon for conjunctival wound suture because nylon could induce a great quantity of fibroblasts before Dexon did.     

Clinical pharmacokinetics of carboplatin and MCNU in malignant brain tumor and normal brain tissues

We measured the concentrations of MCNU and CBDCA in the serum, brain tumor and normal brain tissue. Six patients with malignant glioma were treated with intravenous chemotherapy using 80mg/m2 MCNU and 300mg/m2 CBDCA during surgery. After drug administration, specimens of serum, tumor and normal brain tissue were collected every 30 min and then the drug concentration in each sample was measured. The highest MCNU levels in all samples were obtained immediately after administration which followed by gradual decrease. On the contrary, the mean CBDCA levels in the tumor and normal tissue remained almost at a constant level, although serum CBDCA level declined rapidly as MCNU. As expected, MCNU seemed to have advantages in the treatment of brain tumors as it distributed with higher concentration in the tumor tissue than in the serum and normal brain tissue. On the contrary, CBDCA in the tumor tissue did not exceed the concentration in the serum. Nevertheless, it remained longer in the tumor tissue with a constant level, suggesting that CBDCA can achieve an effective area under the concentration versus time curve (AUC) in the brain tumor tissue to kill tumor cells.     

Mutations in the SDHB gene are associated with extra-adrenal and/or malignant phaeochromocytomas

Germ-line mutations in the genes encoding succinate dehydrogenase complex subunits B (SDHB) and D (SDHD) have been reported in familial paragangliomas and apparently sporadic phaeochromocytomas (ASP), but the genotype-phenotype relationships of these mutations are unknown. Eighty-four patients (all but 2 followed up for 8.8 +/- 5.7 years) with ASP (57 with adrenal tumors, 27 with extra-adrenal, multiple, malignant, or recurrent tumors) were screened for the major susceptibility genes for phaeochromocytoma (RET, VHL, SDHD, and SDHB). Thirty-three tumors were available for molecular analysis, enzyme assays, and immunohistochemistry. No (0%) RET and 2 (2.4%) VHL mutations were detected. Only two coding single nucleotide polymorphisms in the SDHD gene (G12S and H50R) were found in 6 patients (7%). Conversely, six deleterious mutations in the SDHB gene were identified in 8 patients (9.5%). Ectopic site and recurrence or malignancy were strongly associated with SDHB mutations (7 of 8, 87%, versus 20 of 76, 26%; P = 0.001). Somatic DNA analysis indicated a loss of heterozygosity at chromosome 1p36 (SDHB locus) in 16 of 33 cases (48%). A loss of heterozygosity at the SDHB locus was found in all tumors with SDHB mutation, and assays of respiratory chain enzymes showed a complete loss of complex II catalytic activity. The vascular architecture of tumors with SDHB mutations displayed features typical of malignancy. These data strongly suggest that SDHB gene is a tumor suppressor gene and that the identification of germ-line mutations in SDHB gene in patients with ASPs should be considered as a high-risk factor for malignancy or recurrence.     

Evaluation of the skull base by SPECT. A comparison with planar scintigraphy and computed tomography

Computed tomography is currently the standard diagnostic tool for the evaluation of the skull base. The complex anatomy of this area is the primary reason why planar bone scintigraphy is often unsatisfactory; exact localization of abnormalities may be very difficult. These limitations may be overcome by SPECT. Seventeen patients with clinical features of basal skull involvement were assessed by CT, SPECT, and planar scintigraphy. Subsequent clinical diagnoses were malignancy in 15 patients, vasculitis in 1 patient, and osteomyelitis in 1 patient. Computed tomography with IV contrast was performed through the skull base at 5 mm intervals. Planar scintigraphy with Tc-99m MDP was followed by SPECT. Bony involvement compatible with the clinical findings was demonstrated by CT scans in 6 patients, by planar scintigraphy in 7 patients, and by SPECT in 9 patients. The abnormalities that were identified by CT were all identified by SPECT. This study suggests that, in imaging the skull base, SPECT is more sensitive and provides better anatomical localization than planar imaging and appears useful in patients with a negative CT study.     

Combination of an island advancement flap and a composite graft for reconstruction of the nasolabial defect

BACKGROUND: The alar region is one of the most difficult areas of the face to reconstruct. Up until now, various methods have been demonstrated for achieving the best possible results in terms of cosmetic appearance and function. This report deals with a combination of a random pattern flap and a free composite graft, carried out in two stages. OBJECTIVE: In order to reconstruct the alar region, an island advancement flap as well as a composite graft from the contralateral ear were used. METHODS: The defect in the cheek-upper lip region was closed using an island advancement flap. In a second operation 2 weeks later, the reconstruction of the alar region was attempted using a composite graft from the right ear. RESULTS: The reconstruction of the contour of the wing of the nose succeeded in a satisfactory manner. There are no functional restrictions on nose breathing. CONCLUSIONS: The combination of an island advancement flap with a composite graft from the ear for the reconstruction of the alar region is essentially a less invasive operation that can be carried out under local anaesthesia and that represents an addition to the previously stated methods.     

Clinical application of soft-tissue flap with an intercostal vascular pedicle from the chest wall in the trachea surgery

Between 1976 and 1995, 11 cases of side-wall defect repairment or circumferential reconstruction of trachea were performed using chest-wall tissue flap with an intercostal vascular pedicle. The indications were benign or malignant tumors of the tracheal side wall, lung cancers of the right upper lobe involving the side wall of the trachea and/or carina. The transverse diameter of the tracheal defect after removing the tumor was less than half of the tracheal circumference. Furthermore, we foun it feasible to reconstruct the trachea by using a tissue tube created by wrapping a chest-wall tissue flap over a temporary stent in case of long-segment tracheal resection of tracheal tumor or benign stenosis where. The defect was too long to be repaired by end-to-end anastomosis. The surgical technique & instructions were described.     

Occult tumor cells of malignant melanoma and consequences for surgical treatment

Immediate and complete surgical excision is the standard mode of treatment for primary malignant melanoma. There is still a controversy about the adequate resection margins. In this study we looked for microscopic satellites in order to estimate the extent of local therapy. METHOD: 19 patients with malignant melanoma of the trunk or extremities, treated by wide excision, were included. Clinical courses were documented. Postoperative follow-up was 1.4 years in the mean. In primary tumours and cutaneous excisions we looked for microscopic satellites with routine histology and immunohistochemistry (APAAP-technique, monoclonal antibody HMB-45). RESULTS: Using APAAP-technique in combination with routine histology, we could show that microscopic satellites only occurred in specimens of melanomas of more than 5 mm thickness. In the two cases where evident microscopic satellites were present a systemic dissemination obviously evolved already before the first surgical treatment. Therefore, in those cases wide resection margins do not provide an increasing chance of survival. CONCLUSION: The idea to remove microscopic satellites by wide surgical excisions and thus to reduce the risk for systemic dissemination and local recurrence cannot be supported.     

Relationship between grade and stage of renal pelvic and/or ureteral tumor and associated bladder tumor

The use of proxy respondents in surveys designed to provide population estimates of smoking prevalence offers an inexpensive way to obtain these data. The accuracy of this information is examined in analyzing data from tobacco use surveys of adults conducted in 22 North American communities as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. Proxy-reported smoking status was obtained in a cross-sectional telephone survey conducted from August 1993 to January 1994 (n = 99,682). Self-reported smoking status was obtained from an in-depth interview of a sample of the respondents aged 25-64 years enumerated from the telephone survey (n = 31,417). Discrepancy rates were calculated by comparing the proxy-reported and self-reported smoking statuses of a given individual (n = 10,226). In both surveys, respondents were categorized as current smokers (those who currently smoke and have smoked at least 100 cigarettes in their lifetime), recent quitters (< or = 8 years since cessation), long-term quitters (> 8 years since cessation), and never smokers. The overall discrepancy rate between the self-report and the proxy report was 5.4%. Self-respondents who were black, Hispanic, Asian, recent quitters, or aged 25-34 years were more likely to have inconsistent proxy reports. The authors estimate that the screener interview underestimated the true smoking prevalence by 0.1% when they corrected for smoking status discrepancies. These results confirm that proxy-reported smoking status is an accurate and effective means to monitor populationwide smoking prevalence of adults.     

Virilizing ovarian tumor of low malignant potential associated with antecedent tamoxifen use for breast cancer

OBJECTIVE: To assess the value and the associated morbidity of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic endoprosthesis insertion in the treatment of patients with Klatskin tumors. DESIGN: Retrospective study. SETTING: A tertiary referral center. PATIENTS: Fifty-five consecutive patients with Klatskin tumors diagnosed through typical cholangiographic and computed tomographic findings. INTERVENTION: Standard ERCP with endoscopic stenting technique was employed. Once the diagnosis of Klatskin tumor was confirmed on cholangiogram, endoscopic stenting was performed to bypass the stricture. Multiple stents were inserted if necessary to ensure adequate biliary drainage. MAIN OUTCOME MEASURES: The success rate of ERCP and endoscopic endoprosthesis insertion, successful drainage rate, early complications of endoscopic procedure, procedure-related mortality, and long-term outcome of endoprosthesis. RESULTS: Of the 55 patients, cholangiography was performed in 53 (96%). In the 49 patients in whom endoscopic stenting was attempted, the procedure was successful in 28 patients (57%) at the first attempt and 8 patients (16%) at the second attempt, resulting in a cumulative success rate of 73%. Only 20 of these patients had satisfactory biliary drainage, resulting in an overall successful drainage rate of 41%. Early complications, including acute cholangitis, acute pancreatitis, and postpapillotomy bleeding occurred in 14 patients (25%). Three patients (5%) died of procedure-related complications. The median patency of the first endoprosthesis inserted was 1 week (range, 0-8 wk). The 30-day mortality rate was 18%. CONCLUSIONS: In patients with Klatskin tumors, ERCP and endoscopic endoprosthesis insertion have a low successful drainage rate, are associated with high morbidity and procedure-related mortality, and have a limited effect on long-term palliation. Endoscopic retrograde cholangiopancreatography and endoscopic endoprosthesis insertion have a limited value in the management of patients with Klatskin tumors.     

Pseudomyxoma peritonei in association with primary malignant tumor of the ovary and colon

Pseudomyxoma peritonei (PMP) is a rare entity that is characterised by abundant intraperitoneal mucinous and gelatinous material associated with an intraperitoneal adenocarcinoma. We report the case of a patient who presented with PMP associated with a ruptured well-differentiated mucinous adenocarcinoma of the ovary and an infiltrating moderately-differentiated mucinous adenocarcinoma of the sigmoid. Diagnosis was made by ultrasonography and CT. Due to the presence of 2 mucinous tumors with different histological grade the most likely pathogenesis was that of multifocal metaplasia. The ovarian and colonic mucinous tumors were independent primary neoplasms and PMP probably was the result of rupture of one of these tumors with peritoneal seeding of viable mucus secreting tumor cells. Aggressive surgical debulking in addition to left hemicolectomy and radical hysterectomy were performed.     

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE: Reconstruction of soft tissue defects on the lower half of the leg. DESIGN: The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus. MATERIALS AND METHODS: Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years). MEASUREMENTS AND MAIN RESULTS: Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally. CONCLUSIONS: The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.