Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata.

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

Barber-Say syndrome in a father and daughter.

We report on a father to daughter transmission of Barber-Say syndrome (BSS), a rare, congenital disorder characterized by severe generalized hypertrichosis, macrostomia, ocular telecanthus, bulbous nose and atrophic skin. These two cases further support the autosomal dominant inheritance. Both presented with the typical BSS symptoms but the phenotypic expression in the father was milder. Treatment is challenging for both patients and doctors, requiring a multidisciplinary approach.

Titration efficacy of two auto-adjustable continuous positive airway pressure devices using different flow limitation-based algorithms.

BACKGROUND: Auto-adjustable continuous positive airway pressure devices are widely used in titration procedures to determine therapeutic pressure levels in obstructive sleep apnea patients. However, differences in operational characteristics may influence the effect on the apnea-hypopnea index (AHI). OBJECTIVES: We compared the titration performance of two devices based on detection of inspiratory flow limitation, i.e. the Respironics REMstar Auto (RR) and the ResMed Spirit (RS). METHODS: Fifty obstructive sleep apnea patients were recruited for a double-blind randomized crossover trial. Both devices were employed overnight by means of split-night polysomnography. The primary outcome was the AHI. Secondary outcome measures were the snoring index, pressure profiles and subjective appraisal of sleep quality assessed the morning after the sleep study. The Wilcoxon signed rank test for matched pairs was applied to assess differences between treatment conditions. RESULTS: No significant differences were found in sleep parameters, subjective sleep quality and snoring index. The use of the RR was associated with a significantly lower AHI in comparison with the RS [mean (SD) 6.9 (11.6)/h vs. 9.4 (9.2)/h, p = 0.004]. This result was obtained at significantly lower pressure levels [P95 9.2 (2.3) cm H(2)O vs. 10.2 (1.5) cm H(2)O, p = 0.001]. CONCLUSION: While the RR provided a lower AHI than the RS at lower pressure levels, it could not be assessed whether this difference was relevant for clinical outcomes. However, this face-to-face comparison of Auto-adjustable continuous positive airway pressure devices seems useful for the assessment of titration efficacy.

Safety and efficacy of hyperthermic intraperitoneal chemoperfusion with high-dose oxaliplatin in patients with peritoneal carcinomatosis.

BACKGROUND: Cytoreduction with hyperthermic intraperitoneal chemoperfusion (HIPEC) has an established role in selected patients with peritoneal carcinomatosis (PC). We analyzed the safety and efficacy of HIPEC using high-dose oxaliplatin, a cytotoxic agent commonly used in metastatic colorectal cancer and showing promising activity in ovarian cancer and mesothelioma. METHODS: Following complete cytoreduction, HIPEC was performed using 460 mg/m(2 )oxaliplatin in 5% dextrose for 30 min at a temperature of 41-42 degrees C. Open perfusion (coliseum technique) was performed in all patients. Metabolic, electrolyte, and hemodynamic changes were recorded during chemoperfusion as well as postoperative morbidity, mortality, late toxicity, and survival. RESULTS: From July 2005 to January 2007, 52 patients were treated. Chemoperfusion with 5% dextrose resulted in temporary significant hyperglycemia, hyponatremia, and metabolic acidosis. Major morbidity developed in 24% of patients, while 30-day mortality did not occur. One patient developed unexplained repeated episodes of hemoperitoneum. Chemoperfusion with oxaliplatin resulted in mild hepatic toxicity evidenced by persistent elevation of glutamyl transferase and alkaline phosphatase 1 month after surgery. After a mean follow-up time of 14.5 months, nine patients died from disease progression. In colorectal cancer patients, actuarial overall survival was 80% at 1 year. CONCLUSION: Cytoreduction with HIPEC using high-dose oxaliplatin leads to manageable metabolic and electrolyte disturbances and frequent mild hepatic toxicity without discernible impact on postoperative morbidity. Longer follow-up in a larger patient cohort will be required to assess the real risk of unexplained hemoperitoneum observed in one patient, and to establish the long-term effect on local relapse and survival.

Prospectively randomized trial using perioperative low-dose octreotide to prevent organ-related and general complications after pancreatic surgery and pancreatico-jejunostomy.

The aim of the present study was to evaluate the influence of low-dose perioperative octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreaticojejunostomy. A total of 105 patients were randomized to receive either octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no octreotide. The primary endpoints were the occurrence of a pancreatic fistula and or general complications, including extended length of hospital stay. There were 25 surgical draining procedures performed and 80 duodenopancreatectomies with or without preservation of the pylorus. In all, 25 (23.8%) of the patients were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease, and 72 (68.6%) for carcinoma. All patients underwent pancreaticojejunostomy.