Rational flap selection and timing for coverage of complex upper extremity trauma.

Reconstruction of complex extremity trauma continues to be a challenging task for plastic surgeons. Characteristics of such injuries include destruction of functional structures, often due to high energy trauma that causes significant invalidity. Before the era of free flaps, pedicled fasciocutaneous and muscle flaps were the only option for reconstruction of the severely injured upper extremity. The management of complex injuries of the upper extremity has changed with the development of reconstructive microsurgery. Nowadays, we have a great variety of different free flaps to cover defects of the upper extremity and restore function by innervated free flaps. Sensibility, skin thickness, texture, colour, durability, binding of the flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration for choosing the optimal reconstructive procedure. Not only the reconstructive und functional requirements but the timing of reconstruction is extremely important for final result. The purpose of this paper is to define the principles of flap selection and timing of flap reconstruction, according to the assessment of trauma in the upper limb.

[The treatment of carpal collapse: proximal row carpectomy or limited midcarpal arthrodesis? A comparative study]. / Der fortgeschrittene karpale Kollaps: Resektion der proximalen Handwurzelreihe (PRC) oder mediokarpale Teilarthrodese? Eine vergleichende Studie.

Between July 2000 and February 2002, 26 wrists were treated because of SLAC, SNAC and radiocarpal arthrosis after fracture of the distal radius. In 14 cases proximal row carpectomy (PRC) and in twelve cases limited midcarpal arthrodesis (LWF) was performed. Follow-up was after a mean time of 16.8 (PRC) and 13.7 months (LWF) on ten wrists each. There was one complication in the PRC group and two in the LWF group. In all cases significant reduction of extension/flexion was observed with a mean range of motion of 69 degrees (PRC) and 71 degrees (LWF). The reduction of pain postoperatively was almost identical in both groups. Comparing grip-strength to the unoperated hand, we measured 26 compared to 39 kg in the PRC group and 28 compared to 46 kg in the LWF group, respectively. The DASH-score for the LWF group was 30 points and therefore better than the 36 points for the PRC group.

Seasonal and diurnal changes of prostatic androgen receptor and circulating testosterone in young mature rats.

Low- and high-salt (600 mM KCl) extractable androgen receptors were measured in the ventral prostate lobes of 70-day-old rats which were housed in constant environmental conditions (22 +/- 2 degrees C, 65 +/- 5% air humidity, light 6.00h-18.00h). Seasonal variations were observed during 2 years, exhibiting elevations in late summer and autumn and depressions in late winter and spring time. These fluctuations were superposed by steep changes from month to month. The maximum and minimum values of the low- and high-salt extractable receptors differed within 1 year by a factor 8.5 and 2.4, respectively. Both receptor fractions showed a diurnal rhythm as measured during 1 day in January with maximal concentrations at 9.00 h (low-salt: median = 1308 fmol/mg DNA) and minimal values at 18.00 (424) and 24.00 (230). The electrophoretic mobility in agar gel of pH 8.2 also showed a diurnal variation with maximal values at 18.00 h in either receptor fraction. Neither the seasonal nor the diurnal variations were correlated to the corresponding rhythms of serum testosterone concentrations. As steroid receptors may be regulated by neural transmission, in a final experiment the parasympathic innervation of the prostate was blocked by infiltrating the plexus pelvicus with a local anesthetic drug. One hour later, the total receptor concentration was not changed, while the ratio of low- to high-salt extractable receptors and the electrophoretic mobility of both fractions were elevated as compared to the control animals. This finding indicates that peripheral neural transmission rather than circulating testosterone may be involved in the regulation of androgen receptors in rat ventral prostate.

Surgical experience with pancreatic and periampullary cancer.

Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively. It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.

Extramammary Paget's disease.

Extramammary Paget's disease is an in situ skin and mucosal carcinoma frequently associated with and probably arising in a subjacent or regionally proximate carcinoma. Microscopic spread of tumor cells almost always extends beyond clinically apparent disease. Surgical treatment requires carefully planned, systematic excision under precise histologic control. An ideal treatment method remains to be developed. Inadequate excision usually results in recurrences that can be successfully treated by reexcision. Associated invasive carcinomas occur frequently, and mortality is high in these patients.

Pancreatoduodenal resection and total pnacreatectomy--an institutional review.

Between 1940 and 1978, 150 major pancreatic resections--92 pancreatoduodenal resections (PDRs) and 58 total pancreatectomies (TPs)--were performed for benign and malignant disease. The majority of resections were for pancreatic cancer (70 patients) and ampullary cancer (40 patients). The overall operative mortality rate for PDR was 14%; it was 26% for TP. After resection for adenocarcinoma of the head of the pancreas, the operative mortality rate was 28% for TP and 15% for PDR. The number of 5-year survivors after resection for cancer of the head of the pancreas was four (5.7%). Three survived after PDR and one after TP. Of the 42 adenocarcinomas resected by TP, one of the patients had multicentric cancer and two others had carcinoma in situ. TP appears to have no advantage over PDR for cancers of the head of the pancreas from a theoretical or practical standpoint.

Colorectal carcinoma 15 years after the diagnosis of perianal Paget disease.

We report a patient with perianal Paget disease who developed a colorectal carcinoma fifteen years later, complicated by pseudomyxoma peritoneal. While perianal Paget disease is often associated with underlying carcinomas noted at the time of the diagnosis, we suggest that perianal Paget disease may also predispose to the future development of colorectal cancer.

Impaired cytotoxicity of lymphocytes from patients with cancer.

We have investigated the ability of peripheral blood lymphocytes from 57 cancer patients and from 54 normal controls to exert cytotoxic activity in vitro on allogeneic target cells by using a residual tritiated proline assay. Phytohemagglutin was added to the cultures for potentiating the reaction. The cytotoxic potential of lymphocytes from cancer patients was significantly lower than that of healthy controls. Increased survival of target cells was found in numerous reactions with patients' lymphocytes, probably reflecting a "feeder" effect. The source of plasma used for testing, i.e., autologous or pooled normal homologous plasma, did not affect the strength of cytotoxicity reactions displayed by lymphocytes from either normal or cancer patients. A lower reactivity was generally seen in patients with metastatic disease than in patients with no evidence of distant spread.

Comparison of lymphocyte reactivity in patients with cancer, systemic lupus erythematosus and renal allografts.

The PHA and MLC reactivity of lymphocytes from patients with cancer, SLE or renal allografts was comparatively tested in the presence of autologous and of normal homologous serum. Sera from patients with advanced cancer, active SLE or chronic allograft rejection strongly inhibited the MLC reactivity of autologous lymphocytes. It is suggested that serum inhibitory factors might be antibodies which are directed against modified antigenic determinants of the major histocompatibility complex, and are capable of blocking T lymphocyte receptors.

Carcinoembryonic antigen and prognosis in patients with colon cancer.

One-hundred and fifty patients with non-metastatic colo-rectal cancer were followed for a period of 24 to 36 months postoperatively. Preoperative CEA values have been shown to correlate with the extent of the disease and the patient's prognosis. The prognosis for recurrences is greater in patients with elevated pre-operative CEA values regardless of the stage of their disease. This tendency to have recurrences is 1.8 times higher in individuals with increased pre-operative CEA levels. This same relationship occurs to a greater or lesser extent at each stage of the disease.