Differences between scar and dermal cultured fibroblasts derived from a patient with recurrent abdominal incision wound herniation.

Fibroblasts were derived from dermis and scar of a 47-year-old white man with a recurrent incisional hernia as a result of fractured ribs. The scar was thin and stretched, suggesting a defect in the maturation of granulation tissue. After surgical repair, biopsy specimens of discarded scar and skin were used to generate fibroblast cell lines. Fibroblasts maintained in medium containing 10% fetal bovine serum and antibiotic were studied between their third and eighth passage. By phase contrast microscopy, no structural differences were obvious, but it was noted that to pass scar fibroblasts, a more aggressive trypsin regimen was required. Immunohistologic and Western blot analysis of patient scar fibroblasts showed (1) more a smooth muscle actin within stress fibers, (2) increased expression of the vitronectin integrin receptor alpha(v) (CD 51), and (3) reduced expression of the collagen integrin receptor alpha2 (CD 49b). The expression of vinculin from focal adhesions or a tubulin from microtubules was the same among cell lines. Contractions of scar and dermal fibroblast-populated collagen lattice were compared. At 24 hours, contractions were 69 percent with newborn fibroblasts (normal); 68 percent for patient dermal fibroblasts; and only 48 percent for patient scar fibroblasts. The retarded contraction of scar fibroblast-populated collagen lattice was significant (p > or = 0.002). Myosin ATPase activity, critical for lattice contraction, and cell migration were equivalent among all cell lines. A plausible mechanism for the retardation of scar lattice contraction is disruption of fibroblasts and collagen interactions, for which the attachment of cells to collagen is altered. It is proposed that either the decrease in the expression of collagen integrin receptor alpha2 (CD 49b), an increase in the expression of the vitronectin receptor alpha(v) (CD 51), or a combination of both is responsible for disruption of collagen fibroblast interactions.

Correction of areolar depression in postsurgically treated gynecomastic patients.

Nipple-areolar depression after resection for gynecomastia can be avoided by preserving an ample amount of breast tissue and fat under the areola. If a marked depression of the areola occurs, correction can be difficult. Each patient requires an individual assessment, but the principle of rotation of soft tissue under the areolar complex is usually necessary. An effective way to accomplish this is by deepithelialization of a semilunar area inferior to the original subareolar scar, freeing it at its caudal boarder and advancing this deepithelialized flap under the areola and repairing the wound. The technique is simple in design and may be a useful tool in dealing with this difficult problem.

Negative-pressure dressings as a bolster for skin grafts.

Contoured wounds needing closure with skin grafts are often located in complex anatomic regions or are in unusual positions, which make conventional skin graft stabilization techniques cumbersome and ineffective. Often after 72 hours, a skin graft covered with a bolstered dressing has poor take secondary to shear stresses, as well as hematoma formation or serum collection, negating the effectiveness of the stabilizing dressing. The Food and Drug Administration has recently approved vacuum-assisted closure (V.A.C.), an innovative technique using negative pressure, for closure of chronic wounds. This reportedly leads to enhanced granulation tissue formation and consequently more rapid reepithelialization of wounds compared with conventional packing with saline-moistened gauze. Experimental studies have demonstrated increased oxygen tension, decreased bacterial counts, and increased granulation formation occurring under negative-pressure systems. Extending the use of this concept, we have coupled skin grafting with negative-pressure dressings for closure of large, complex open wounds. Our results indicate greater than 95% graft take in all patients in this study. This technique is extremely efficacious, with increased graft take due to total immobilization of the graft, thereby limiting shear forces, elimination of fluid collections, bridging of the graft, and decreased bacterial contamination. Moreover we have noted decreased edema in rotated muscle flaps, improved contour conformity, and shortened hospitalizations.

Techniques of rectal oncologic survey.

The possibility of constructing very low anastomoses using stapling devices led many surgeons to reduce the length of the distal clearance to 1-2 cm. This made it possible to perform a low anterior resection instead of an abdominoperineal resection of the rectum in a greater number of cases. Furthermore, the enthusiasm in preserving sphincteric function induced some Authors to perform a local excision for tumors of the distal portion of the rectum. On the other hand, in order to improve patients' survival after curative operations for cancer, either of the rectum or rectosigmoid junction, other surgeons have adopted a more aggressive approach, extending exeresis to the peri-aortocaval and pelvic nodes, and to the possible liver metastases as well. On the basis of our experience (374 cases from 1972 to March 1989) and a critical review of the literature, indications, techniques, and results of curative operations for both rectal and recto-sigmoid junction cancer are examined. The role of extended abdomino-pelvic lymphadenectomy is also discussed. The Authors believe that in the absence of a reliable evaluation of the potential of these tumors, an aggressive approach is required. Local excision is reserved to very selected cases, which should undergo an intensive follow-up in order to detect recurrences at a very early stage.

[Digestive reconstruction using mechanical staplers after total gastrectomy]. / La ricostruzione digestiva con suturatrici meccaniche dopo G.T.

From 1980 up to nowadays, after total gastrectomy for gastric cancer, the intestinal continuity was assured by oesophago-jejunostomy and oesophago-duodenoplasty using stapling devices. Two patients died for causes not related to the technique, and other two patients developed a stenosis of the oesophago-jejunostomy, which was easily managed by endoscopic dilatation. In one patient a partial dehiscence of the oesophago-jejuno-anastomosis was treated by total parenteral nutrition. The Authors have systematically adopted mechanical sutures after total gastrectomy. However, possible intraoperative accidents and complications should not be underestimated, although most of them may be due to the operator's inexperience or stapler misuse.

[Aneurysm of the popliteal artery: diagnostic and therapeutic considerations]. / In tema di aneurisma dell'arteria poplitea: considerazioni diagnostiche e terapeutiche.

The authors settle the roles of the most recent diagnostic methodologies useful to frame the popliteal aneurysm pathology namely digital arteriography, N.M.R., and doppler-flowmetry. They emphasize, in an observed case, the adopted therapeutic criteria, that is basically interventional. The thinness of saphenous veins draws toward the employing of "Goretex".

[Mesorectal resection in oncologic surgery]. / L'asportazione del mesoretto in chirurgia oncologica.

A surgical technique to "en bloc" resect the mesorectum while performing an anterior resection is here described. The procedure aims at preserving those nerves whose injury is responsible for a series of neurological sequalae, which affect the patient's quality of life. Fifteen dissections were carried out in order to demonstrate the possibility to perform an accurate mesorectal lymphadenectomy while preserving, in most cases, the nervi erigentes and, in some cases, the hypogastric plexus.

Stapled sutures in digestive tract surgery.

A six-year experience with mechanical sutures in digestive tract surgery is reported. Forty-nine esophageal resections during azygo-portal disconnection were performed since 1979 up to June 1986. Four patients died in the early postoperative course with no evidence of suture-related complication. One patient developed an anastomotic stricture (2.2%), which was successfully dilated. Fifty-three total gastrectomies with stapled reconstruction were performed between 1980 and June 1986. Two patients died soon after surgery for reasons unrelated to the suturing technique. Two strictures of the esophagojejunal anastomosis (3.9%) occurred two to three months after surgery and underwent successful dilation. One esophagojejunostomy (1.9%) leaked and one (1.9%) underwent uneventful remedial surgery (conversion of an omega-shaped loop to a Roux-en-Y procedure). Ten isoperistaltic jejunal interpositions, six Billroth I partial gastrectomies and 14 Roux-en-Y loops for hepatico- or pseudo-cystojejunostomy were performed since 1983 up to June 1986 in the absence of any operative morbidity or mortality. Twenty-three right colectomies were performed from 1983 to June 1986. The only complication reported was one leakage (4.3%) which spontaneously healed. Ninety-eight patients underwent formal colonic resections (anterior resection of the rectum, left hemicolectomy, subtotal and total colectomy) from 1981 to June 1986. Two patients (2%) died for reasons unrelated to the suturing technique. Three colorectal anastomoses (3%) developed a leak, one of which required surgical revision. One stricture (1%) was recorded in a recurrence-free patient three months after surgery. One patient (1%) complained of minor rectal bleeding. Two patients (2%) developed small anal fissures due to forced passage of the instrument.(ABSTRACT TRUNCATED AT 250 WORDS)