Clinical Analysis on Emergency Postpartum Hysterectomy / 대한주산의학회잡지

OBJECTIVE: To analyze incidence, indications, risk factors, complications, and neonatal outcomes of emergency postpartum hysterectomies performed at EulJi University Medical Center. METHODS: A retrospective study of all cases of postpartum hysterectomies between May. 1996 and Dec. 2000. was carried out. RESULTS: 37 cases of postpartum hysterectomies during this period were performed, for overall incidnce of 2.3 per 1000 deliveries. Incidence after vaginal delivery and cesarean section was 0.03% and 0.52% respectively. The rate of postpartum hysterectomy increased with increasing age and parity. The main indications were placental disorders(54.1%) including placenta previa and adherent placenta, uterine atony(37.8%), uterine myoma(5.4%) and uterine rupture(2.7%) in order. The relative risk of postpartum hysterectomy according to the risk factors was 97.6(95% confidence interval 52.17-184.06) for placental disorders, 16.3(95% confidence interval 4.94-52.31) for cesarean section and 2.4(95% confidence interval 1.21-4.76) for previous cesarean section. The mean amount of transfuion was 17.1 pints. Although no maternal mortality had occurred, 16 patients(43.2%) had complica-ions including respiratory complication(13.5%), hemorrhagic complication(10.8%), infection(8.1%) and urologic injury(8.1%). Regarding fetal outcome, 2 of 38 infants(1 case, twin) were stillborn (5.3%) and 10 infants(26.3%) were suffered from various illness including prematurity, sepsis, meningitis, and brain hemorrhage. CONCLUSION: The data identifies placental disorders are the leading cause of postpartum hysterectomy. Although postpartum hysterectomy is a necessary life-saving operation, maternal morbidity remained high.

Thanatophoric dysplasia in a dizygotic twins conceived by intrauterine insemination / 대한산부인과학회잡지

Twin gestations complicated by a single anomalus fetus present difficulties in obstetric management. It is unclear how the presence of a congenital anomaly in one twin affects its normal sibling. Parents may elect for obstetric management option such as expectant management or selective termination of the anomalous fetus in the hope maximizing the outcome for the normal co-twin. Thanatophoric dysplasia (TD) is the most common type of lethal skeletal dysplasia. Features of the disease are micromelic shortening of the limbs, relative macrocephaly with frontal bossing, flattened vertebrae, disorganized chondrocytes and trabeculae in the growth plates of the long bones, and shortened ribs resulting in a reduced thorax and a bell-shaped abdomen. We experienced a case of TD type I diagnosed in a dizygotic twins by ultrasound at 23 weeks' gestation and reported with concerned literatures.

Various Vein Conduit Modalities for Nerve Regeneration in Rats

Over the years, many surgeons have used various natural and synthetic materials to bridge the nerve defect. However, none of these materials has surpassed the effectiveness of the nerve autograft. Among natural materials, a vein graft has been used as conduit for nerve regeneration in both research protocols and clinical situations. Unfortunately, the comparison of various research reports is difficult, for each research has employed a different experimental model and method of evaluation for the study of the nerve regeneration. This study introduced various modifications of the vein graft technique, and investigated several vein graft models in an attempt to find the most effective formulation . Four vein graft models were employed: 1) the empty vein graft, 2) the inside-out pattern vein graft, 3) the vein graft filled with skeletal muscle strips, 4) the inside-out pattern vein graft filled with skeletal muscle strips. Regeneration was assessed with gross appearance, histologic examination and electromyography(EMG). In the vein graft filled with muscle strips, there was the increased axonal diameter, myelin sheath thickness, ratio of myelinated axon to unmyelinated axon, and conduction velocities. The result showed that any vein graft filled with muscle strips is superior to the empty vein graft and the inside-out pattern vein graft model which are not filled with muscle strips. It is concluded that the nerve repair using a vein graft filled with skeletal muscle strips can be effectively employed in the clinical field. Further study should be aimed at the regeneration of a longer distance nerve gap and its clinical application.

The Endoscopic Repair of Mandibular Subcondylar Fracture through Intraoral Approach

The Endoscopic Repair of Mandibular Subcondylar Fracture through Intraoral Approach. The treatment of the mandibular subcondylar fractures has been controversal. But, recently open reduction and rigid internal fixation was advocated as a reliable method of anatomically restoring condylar position, early restoration of T-M joint function without intermaxillary fixation or with short intermaxillary fixation period. The endoscopic repair of mandibular subcondylar fractures not only provides better visualization in the surgical field, but also makes rigid fixation, avoids facial scarring and facial nerve injury. From March of 1996 to November of 2001, the endoscope was used successfully to assist in the repair of mandibular subcondylar fractures in twelve patients. An intraoral incision was made in the anterior aspect of the mandibular ramus, and a 5.0mm, 30-degree telescope was introduced by means of this intraoral incision to aid in the dissection and to visualize the fracture site over the subcondylar area. After subcondylar reduction by lateral force of the preauricular trocar and inferior traction of the mandibular angle, a 2mm miniplate was used to stabilize the fracture site with the help of a percutaneous trocar. The proper alignment of the posterior border of the ramus could also be checked under direct endoscopic vision. Intermaxillary fixation was maintained for 5 days postoperatively in the first four patients. All the patients were followed up for minimum of 2 months, and there were no facial palsy. The mean of maximal mouth opening was 44 mm within 6 weeks and the stab incision wound in the preauricular and angle area were inconspicuous. All patients obtained normal range of motion of temporomandibular joint. Although requirement of endoscopic equipments and surgical skills is necessary, the use of endoscope may reduce the disadvantages of open reduction and should be considered in the treatment of mandibular subcondylar fractures.

Surgical Correction of Cryptotia using Hirose's Rotation Flap

Cryptotia is rare in Caucasians but more common in Orientals, particularly in Japanese people, where incidence has been reported as 1:400. The features of cryptotia are the invagination of the upper part of the auricle under the temporal skin and the deformation of the auricular cartilage itself. The principles of the surgical correction are the coverage of skin deficit and the correction of deformed cartilage if needed. For the correction of cryptotia, several methods have been tried. But, inadequate amounts of local tissue often result in undercorrection of the cephalo-auricular sulcus, with a tendency to recurrence of the buried ear. Incision scars, hair line distortion, poor color match of graft and multi-staged operation of tissue expansion are noted as the their shortcomings. Therefore, We have performed Hirose's rotation flap method in 15 cases of the 12 patients that available skin in the inferior part of the cephalo-auricular sulcus is transferred to the upper part where skin is deficient, and satisfactory results were achieved. This method has many advantages that the design is simple and the procedure easy, the required depth of the cephalo-auricular sulcus is achieved, the correction of the cartilage deformity can be carried out with unrestricted access, the hairline is not disturbed by the operation, the scar behind the auricle is not visible, and there is no need for additional skin grafting.

A Case Report of Bilateral Squamous Cell Carcinoma Arising in Endometriosis of the Ovary / 대한부인종양콜포스코피학회잡지

Primary ovarian squamous cell carcinoma is the one of the rarest of all ovarian malignancies. Most of them arise in mature cystic teratoma and a minority of them associated with endometriosis, arising in a Brenner tumor, or appearing in pure form. Due to its rarity, there is no agreement concerning the efficacy of postoperative treatment of primary squamous cell carcinoma of the ovary, although the prognosis of this type of tumor is much worse than that of other epithelial ovarian cancers. We describe a patient with squamous cell carcinoma of the ovary in association with ovarian endometriosis, who has undergone postoperative systemic chemotherapy.

Clinical Study of Peripartum Cardiomyopathy / 대한주산의학회잡지

No abstract available.

Reconstruction of Major Articular Osteochondral Defects with OP-1 Treated Allografts and Vascularized Tissue

The treatment of articular cartilage and bone defect has been challenging for many years. Autologous osteochondral grafting represents the most physiologic procedure for reconstructing joint defects but is severely limited by the availability of donor material. Allogenic osteochondral grafting differs from the other grafting method in obtaining almost unlimited amounts of material of exact size and form for complex joint reconstructions. An alternative approach that may improve allograft revascularization and incorporation was to combine an autologous muscle flap with an allograft and vascularized osteochondral allografts that have reported excellent long term results. The vascular characteristics of muscle flaps, with their capacity as a source for mesenchymal stem cells, provide the muscle flap with the ability to initiate bone formation and repair in transplanted allografts in response to osteogenic factors. Forty adult New Zealand White rabbits underwent complete resection of the proximal 2/3 of the humerus. The defects were immediately grafted following substance: (1) lyophilized osteochondral allografts (n=10); (2) lyophilized osteochondral allograft with a muscle flap filling the bone marrow cavity(n=10); (3) OP-1(Osteogenic protein-1) treated lyophilized osteochondral allografts (n=10); (4) OP-1 treated lyophilized osteochondral allograft with OP-1 injected muscle flap filling the bone marrow cavity(n=0). All the examinations were operated under aseptic conditions, and follow-up evaluations were performed in the 4th, 6th, 8th, 10th, 12th, and 24th week. Range of motion showed no difference between the groups, but more limited in OP-1 treated allograft groups. Under the histologic examination, the groups of lyophilized osteochondral allograft with a muscle filling the bone marrow cavity regenerated more articular cartilage than that of OP-1 treated allograft. These results suggest that using OP-1 treated lyophilized osteochondral allograft with OP-1 injected muscle flap filling the bone marrow cavity could get more organized articular cartilage and bone regeneration.

Regulation of Articular Cartilage Defects with OP-1 Treated Lyphilized Cartilage Allografts

Joint cartilage defects do nor heal and lead to post traumatic arthritis or degenerative joint diseases. The clinical problem is that so far, we have been unable to induce true cartilage healing and regeneration. Experimental attempts at repairing joint cartilage defects with various means have usually led to the formation of cartilage-like fibro-hyaline scars. We have recently shown that treatment of lyophilized allografts with recombinant osteoinductive protein-1 (OP-1 also known as BMP 7) induces the regeneration of articular cartilage over the head of lyophilized hemijoint allografts. A standardized 3 mm circular defect was created on the articular surface of the knee joint of 12 NZW rabbits. The defect was into carried as full thickness down to subchondral bone. In a blinded and randomized fashion, the rabbits were divided into four groups. In group l (n=4), the ulcer was left untreated; in group II (n=3), the ulcer was reconstructed with a 3 mm disk of lyophilized cartilage allograft; in group lll(n=2), the allograft used was pre-treated with low dose (20 pg) OP-1, and in group IV (n=3), the allograft used was pre-treated with high dose(100 pg) OP-1. The range of motion was normal in all groups. The gross appearance of the untreated defect was still depressed and appeared like a big crater. The lyophilized allograft has a level surface which was not smooth In high dose OP-1 group, the defect was healed much better than the lower dose treated OP-1 group. Under the histologic examination, untreated ulcer group never heals to the cartilage of around defect, a fissure always remains. Lyophilized allograft and low dose OP-1 treated lyophilized allograft groups seem to inhibit healing and there is fibrous scar in ulcer. In the high dose OP-1 treated lyophilized allograft group, new cartilage heals very well all around of the defect margin without fissure. The cartilage has a normal sequence of cellular maturation. In conclusion, in this study of full thickness joint cartilage defects, we confirmed finding in the literature that untreated defect heals with cartilage like tissue which does not fuse with the surrounding cartilage. We found that lyophilized allograft prevents healing of defect, while lyophilized allograft treated with high dose (100 pg) OP-1 seems to induce regeneration of articular cartilage that heals very well to the surrounding defect without any crack or fissure.

How Soon does Neovascularization Develop at Island Skin Flaps of Different Size ?

Island flaps or free flaps have been widely used for the management of soft tissue defect in reconstructive surgery. The successful transfer and survival of distal cutaneous flaps depends on the formation of a new nutrient blood supply from the recipient area (neovascularization), independent of the original vascular supply. The neovascularized time differs from size of flap, condition and site of recipient area, and general condition of patient. The author investigated time of neovascularization on island flap and effect of flap size on neovascularization in the rats. One hundred and twenty inferior epigastric island flaps were divided into three groups according to the size of flap (1.5 x 3.0 cm, 3,0x6.0 cm, and 5,0x 6.0 cm). In all group, vascular pedicles were ligated on the 2nd, 3rd, 4th and 5th days after flap elevation. Flap survival was assessed on the 3rd day after pedicle ligation. The results were as follow: 1. In all groups, flap survival was increased significantly in the flaps with pedicle ligation on the 3rd postoperative day compared to those at the 2nd postoperative day. 2. In all groups, flap survival was increased significantly in the flaps with pedicle ligation on the 4th postoperative day compared to those at the 3rd postoperative day. 3. From the 2nd and 3rd postoperative days, the larger flap was elevated, the greater flap survival was increased significantly. 4. Regardless of size of flap, pedicle ligation after 4th postoperative day was complete flap survival, indicating the establishment of adequate neovascularization for flap survival.

The effect of prostaglandin e1on the muscle flap in the rectus abdominis muscle of the rat

Flap survival is critical to the success in reconstructive surgery, there have been many investigations to increase the blood supply to the flaps such as surgical delay and pharmacologic delay. Prostaglandin(PG) is released from various tissues including blood vessel in response to physical stimulus. Among the Prostaglandins, PGE1 has been proven to be a vasodilatation property and many authors have demonstrated its effect to increase blood supply after random cutaneous flap surgery. Clinically, however, muscle flap or musculocutaneous flap is more significantly used in reconstructive surgery and hemodynamic effects of PGE1 of this type of flap are still not documented. The authors designed the random muscle flap to study the hemodynamic effects of PGE1 of the muscle flap. Superior based rectus muscle flap was elevated from rats and the superior epigastric artery, its major vascular pedicle, was ligated to create the random-type muscle flap. Twenty two rats were divided into two experimental groups and each group had 11 rats; Group I: No drugs Group II: PGE1 injection group for 7 postoperative days intraperitoneally The average muscle flap survival rate of group I was 46+/-3.0 precent and it had a higher survival rate than the control group(23+/-4.3%). The muscle flap survival rates showed significant differences between the two groups (p< 0.005) This study shows that the administration of the PGE1, in clinical usage of the rare random muscle flap with a pedicle injury or musculocutaneous flap with the risk of distal cutaneous flap necrosis, such as TRAM flap, which might be much safer and popular.

Reconstruction of median sternotomy dehiscence

Complications after a median sternotomy incision, which is used currently in most open heart surgery, are serious, although it is infrequent. Reconstruction of the sternal defect resulting from dehiscence of median sternotomy is still big challenge to the most plastic surgeons. Since vascularized greater omentum was transposed to eliminate mediastinal wound problems, many vascularized regional muscle flaps became mainstay in reconstruction of median sternotomy wound. We treated 13 patients with median sternotomy dehiscence between October of 1993 and March of 1998. In two patients, the wound problems were so confined to superficial tissue that debrided and closed primarily. Eleven patients with deep wound infection were managed with vigorous debridement of all necrotic tissues and resultant defects were covered with regional muscle flaps: rectus myocutaneous flap(3) and bilateral pectoralis advancement flap(8). We used the pectoralis major advancement flaps without counter incision at humeral insertion site and the dissections were limited only medial to the anterior axillary line to preserve the axillary fold. In five patients with larger defects, we elevated muscle and cutaneous flaps separately to make these flaps more mobile. Large portion of two rectus abdominis flaps could not survive, whereas pectoralis advancement flaps had mo special wound problems. Only one patient developed fistula due to remained wire, regardless to flap surgery.

CLINICAL EXPERIENCES OF MICROSURGICAL FINGERNAIL RECONSTRUCTION

No abstract available.

The management of costochondritis of the chest wall

No abstract available.

Microtia correction using autogenous rib cartilage grafts

No abstract available.