[Closure of persisting rectourethral fistula after suprasymphyseal adenoma enucleation of the prostate by combining the Bressel-Naujox and gracilis flap procedure]. / Verschluss einer persistierenden urethrorektalen Fistel nach suprasymphysärer Adenomenukleation der Prostata durch kombiniertes Bressel-Naujox- mit einem Gracilisflapverfahren.

When taking into consideration the basic principles of fistula surgery, numerous options are available for the surgical repair of rectourethral fistulas. However, there is no standard regarding which surgical method should be used under which circumstances-due to the heterogeneity of this disease. This case report describes the individual adaptation of a surgical technique that is used for the treatment of vesicovaginal fistulas to treat a rectourethral fistula in a patient who had already undergone an unsuccessful fistula closure attempt. Successful closure of the fistula was achieved on the basis of an established method using tissue interposition.

The effects of reduction operation with genital lymphedema on the frequency of erysipelas and the quality of life.

Genital lymphedema represents a severe disability for patients particularly when complicated by erysipelas, the most frequent complication. The objectives of this study were: to investigate the frequency of erysipelas in patients with genital lymphedema and genital lymphatic cysts who underwent evaluation for surgical treatment, to observe the influence of resection operations on the frequency of erysipelas, and to measure changes in the quality of life due to the resection. A total of 93 patients with genital lymphedema were studied. All patients underwent integrated care treatment in the Földi Clinic, Hinterzarten and the Department of Plastic and Hand Surgery of the University Hospital Freiburg during the period between 1997 and 2007. 44 of these patients underwent surgical treatment of genital lymphedema. The results indicate that lymphatic cysts were the most important risk-aggravating factor for recurrent erysipelas with lymphorrhea in the genital region (p < 0.001). Following the resection operation, however, the number of erysipelas incidents significantly decreased (p < 0.001). In addition, the antibiotic dose could be reduced after surgery (p = 0.039) and an improved quality of life was achieved (p < 0.001).

3D-MSCT gastric pouch volumetry in bariatric surgery-preliminary clinical results.

BACKGROUND: Insufficient weight loss or persistent abdominal complaints are reasons for revisionary operations in bariatric surgery. The selection of the secondary procedure is influenced by clinical and by patho-anatomical factors like the size of the gastric pouch. The purpose of this study was to evaluate multi-slice computed tomography (MSCT)-based volumetric assessment of gastric pouches, gastric sleeves, and anastomoses in patients after bariatric surgery. METHODS: Twenty-six patients after bariatric surgery received abdominal MSCT immediately after oral administration of an ionic contrast agent solution and intravenous administration of buthylscopalamine. Indications were insufficient weight loss after primary operation, persistent upper abdominal complaints, and decline of bariatric analysis and reporting outcomes system (BAROS) score. The gastric volumes, diameter of the gastrojejunostomy, and the proximal part of the Roux limb were measured on volume rendering images and freely angulated reformations. RESULTS: Evaluation of gastric volumes was successful in 25 examinations (96%). The diameters of gastrojejunostomy as well as the dimensions of the Roux limb were evaluable in all cases. After gastric bypass surgery, a pouch volume >30 ml was found in ten, a widening of the gastrojejunostomy in eight, and a dilated Roux limb in six cases. Two patients presented a combination of a wide anastomosis and a strongly dilated Roux limb. Patients after biliopancreatic diversion had gastric volumes between 210 and 840 ml. Other findings were a fistula, an intragastral stenosis, and internal hernias. CONCLUSIONS: MSCT allows crucial patho-anatomical measurements and provides helpful information for selecting the appropriate revisionary operation after bariatric surgery.

A critical evaluation of the concomitant use of the implantable Doppler probe and the Vacuum Assisted Closure system in free tissue transfer.

Introduction of the Vacuum-Assisted Closure (V.A.C.) system has revolutionized the approach to a multitude of clinical settings. Yet, its use precludes adequate clinical monitoring of skin-grafted free flaps, thus, making a reliable monitoring system essential if broad clinical application is aspired. In a clinical study, the usefulness of the combination of the V.A.C. and implantable Doppler probe was critically evaluated in patients with microsurgical lower extremity reconstruction. We retrospectively analyzed the usefulness of the implantable Doppler probe in five consecutive patients treated in our department from January to July 2007. Inclusion criteria were lower extremity reconstruction by means of skin-grafted free tissue transfers with subsequent application of the V.A.C. device. Five consecutive patients (four males, one female) with a mean age of 37.8 years (range, 8-58 years) matched the criteria mentioned above. Of note, the two pediatric patients (8-year-old male and 12-year-old female) suffered from significant posttraumatic stress disorder necessitating concomitant psychological care by the Department of Psychiatry. All flaps healed uneventfully displaying no signs of vascular compromise. Interpretation of the Doppler signal was simple and well received by the nursing staff. The combination of V.A.C. and the implantable Doppler probe enhances patient comfort due to a reduction of the number of dressing changes while still allowing continuous free flap monitoring. Interpretation of the signal transmitted by the probe is simple and potentially reduces misinterpretations due to different levels of experience.

Management of defects in the groin, thigh, and pelvic region with modified contralateral TRAM/VRAM flaps.

In patients with sarcomas, or regional recurrence of the disease, radical resection and radiation therapy is indicated to achieve cure or palliation. As a result of radical surgery, extensive radiation, or infection in the pelvic, groin or thigh region, the development of large pelvic / groin / thigh defects present a difficult surgical problem. Musculocutaneous deep epigastric island-flaps, as a modification of the extended deep inferior epigastric flap, described by Taylor et al. in 1983, are an attractive option for a successful reconstruction for this defect localisation. Two technical modifications of the contralateral extended deep inferior epigastric island-flap permitted an adequate tailoring to a defect in the posterior lateral pelvic or groin-thigh region, and avoided the drawbacks of other loco-regional or microsurgical flaps in previously irradiated fields. The skin island reached the posterior lateral pelvic region, groin or thigh. The muscular portion of this flap was suited to fill the soft tissue defects in these critical areas. These so modified flaps represent an instrument, which in selected cases may be an interesting alternative tool for closure of complex defects. No significant functional impairment secondary to the flap procedures was noted in our patients.

The lymphatic system of the deep inferior epigastric artery perforator flap: an anatomical study.

The anatomical basis of the lymphatic system of the deep inferior epigastric perforator (DIEP) flap was studied in 24 abdominoplasty specimens and in three fresh cadavers. Methylene (n = 4), patent (n = 4) and Turnbull's (n = 8) blue were compared by injecting the dye intradermally. To facilitate staining, two different types of vacuum technique were used: a vacuum chamber (n = 4) and the vacuum-assisted method (n = 4). The lymphatic collectors were dissected, and embedded in paraffin for histological investigation. The most useful dye was Turnbull's blue. The vacuum had no effect on the distribution of the dye. Manual injection showed three parallel superficial collectors situated directly under the skin. Turnbull's blue was also injected into the rectus fascia to demonstrate the collectors of the deep abdominal structures. They run horizontally, and perforate the fascia to run with the inferior epigastric artery. Care should be taken when dissecting the pedicle, or removing the epithelium, to avoid destroying the lymphatic system of the flap.

Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap.

The anatomical basis of the blood supply to the deep inferior epigastric perforator (DIEP) flap and the circulation of the cutaneous territory zone IV have been studied in 40 anatomical dissections on fresh cadavers. The pedicle length, diameter and the number and distribution of the major perforator vessels were recorded. The cutaneous territories supplied by the perforator vessels were studied by injecting blue dye in the pedicle of ten specimens. In addition, intravital blue dye studies were performed by injecting the largest perforating vessel of five patients at abdominoplasty. The resulting cutaneous staining was recorded. The deep inferior epigastric artery was present in all cadaver dissections with an average length of 10.3 cm (range 9.0-13 cm) and an average diameter of 3.6 mm (range 2.8-5.0 mm). There were consistently one or two major perforator vessels for each pedicle, located within a radius of 8 cm below the umbilicus. The results of the injection study revealed cutaneous staining of zones I-III. Zone IV was stained weakly or not at all. The same findings were obtained in the clinical cases of abdominoplasty. Zone IV must be critically assessed in clinical cases of the DIEP flap.

Procalcitonin as a marker for the early diagnosis of severe infection after thermal injury.

High serum concentrations of procalcitonin (PCT), the 116 amino acid precursor protein of the hormone calcitonin, have been found in patients with various bacterial infections, particularly in those with sepsis. Because recent reports have shown that serum PCT constitutes a useful parameter for the diagnosis of sepsis in patients with several clinical conditions, a temporal analysis of the PCT concentrations in the plasma of 19 patients with severe burns (median body surface area burned, 32%) was conducted retrospectively. Nine patients were classified as septic on the basis of standardized clinical and laboratory parameters. Compared with the nonseptic group, these patients showed higher plasma PCT throughout the study period (median concentrations of septic vs nonseptic patient groups: 0.4 vs. 0.2 microg/L on postburn day 2; 1.0 vs. 0.3 microg/L on postburn day 4; 5.5 vs. 0.3 microg/L on postburn day 7; 10.8 vs. 0.5 microg/L on postburn day 9; 4.2 vs. 0.4 microg/L on postburn day 12; and 1.7 vs. 0.5 microg/L on postburn day 14), with differences considered to be significant (P<.05) from day 7 on. In contrast, differences in the plasma C-reactive protein concentrations were less pronounced and never reached statistical significance. PCT concentrations exceeding 15 microg/L were only observed in the 3 patients who died of sepsis-induced multiple organ failure. In addition to absolute PCT, individual time courses were also of diagnostic value. PCT is a highly efficient laboratory parameter for the diagnosis of severe infectious complications after a burn injury.