ABSTRACT
The technique of laparoscopic formation of loop ileostomies has been previously described for use in a variety of conditions. We present this as an option for faecal diversion in severe burns involving the back and buttock region and describe its use in two cases. Faecal diversion allows for easier wound care and nursing. Intra-abdominal assessment of these very sick patients can also be performed simultaneously. The technique is relatively simple, readily available and associated with minimal morbidity. Furthermore, this technique minimises interference with the abdominal wall as a donor site for skin grafts.
Subject(s)
Burns/surgery , Ileostomy/methods , Laparoscopy/methods , Adult , Burns/complications , Burns/diagnosis , Female , Follow-Up Studies , Humans , Injury Severity Score , Lumbosacral Region , Reoperation , Surgical Flaps , Treatment Outcome , Wound Healing/physiologyABSTRACT
The results of 132 consecutive endoscopically selected pharyngoplasties were assessed. Depending on the size and shape of the velopharyngeal defect on attempted closure, patients had been allocated to one of four pharyngoplasties: (1) a superiorly based pharyngeal flap combined with a V-Y pushback of the soft palate (Honig), (2) a modified Hynes approach, (3) a superiorly based pharyngeal flap, or (4) a fish flap. Patients were categorized according to etiology as having cleft palate, submucous cleft palate, disproportion, or neurologic origin. Acceptable nasal resonance was found after 81 percent of the Honig operations, 81 percent of the Hynes operations, and 63 percent of the superiorly based flap operations, vindicating the selection criteria based on palatal and pharyngeal wall movement. The fish flap operation was successful in only 50 percent and is not recommended. The cleft, submucous cleft, disproportion, and neurologic categories were equally well corrected by the Honig and Hynes operations. Side effects were common, with catarrh or snoring in 51 percent, difficulty breathing through the nose in 27 percent, and 9 percent requiring revision of their pharyngoplasty (6 of 53 Honig and 5 of 63 Hynes operations). The higher median age for those patients requiring pharyngoplasty revision (17 versus 10 years) suggests more cautious use in the older patient.
Subject(s)
Cleft Palate/surgery , Palate, Soft/surgery , Pharynx/surgery , Surgical Flaps/methods , Velopharyngeal Insufficiency/surgery , Endoscopy , Humans , Postoperative Complications , Respiration , Snoring/etiology , Speech Acoustics , Speech Disorders/etiology , Surgical Flaps/rehabilitation , Voice Disorders/etiologyABSTRACT
One-hundred and eighty patients undergoing limb-salvage surgery for soft-tissue sarcoma from 1986 to 1991 were assessed retrospectively for risk factors associated with major wound-healing complications. Twenty-three of 137 patients (16 percent) treated with primary direct wound closure sustained complications. In univariate analysis, the cross-sectional area of tumor resection, the use of preoperative irradiation, the width of the skin excision, a history of smoking, and a history of diabetes and/or vascular disease were associated with wound failure. Multivariate analysis revealed that preoperative irradiation (p = 0.04) and resection diameter (p = 0.017) accounted for the risk of complications. Eighteen additional patients were treated empirically with distant vascularized tissue transfer following preoperative irradiation because of concerns regarding potential wound complications. The lower complication rate in this group suggested that vascularized tissue transfer may be beneficial in lowering wound complication rates.
Subject(s)
Postoperative Complications/surgery , Sarcoma/surgery , Soft Tissue Neoplasms/surgery , Surgical Flaps/methods , Wound Healing , Adolescent , Adult , Aged , Aged, 80 and over , Combined Modality Therapy , Female , Humans , Male , Middle Aged , Multivariate Analysis , Preoperative Care , Retrospective Studies , Risk Factors , Sarcoma/radiotherapy , Skin/blood supply , Skin/radiation effects , Soft Tissue Neoplasms/radiotherapyABSTRACT
Massive pharyngocutaneous fistulae may be arbitrarily defined as those involving two-thirds or more of the circumference of the pharyngeal wall. Three such patients are presented, all after failed radiotherapy and surgery. The principles of management consist of salivary diversion, complete debridement, nutritional support, prophylactic antibiotics, and two-layer, well-vascularized overlapping closure. We currently recommend a radial forearm flap used in conjunction with a pectoralis muscle (or musculocutaneous) flap for rapid rehabilitation of these patients, particularly in the presence of obesity or an irradiated bed.
Subject(s)
Carcinoma, Squamous Cell/surgery , Fistula/surgery , Laryngeal Neoplasms/surgery , Neoplasm Recurrence, Local/surgery , Pharyngeal Diseases/surgery , Postoperative Complications/surgery , Surgical Flaps/methods , Aged , Female , Humans , Laryngectomy , Male , Middle Aged , Reoperation , Stents , Surgical Wound Dehiscence/surgeryABSTRACT
Forty-three patients underwent microvascular free flap reconstruction of severe acute compound tibial fractures between 1980 and 1987. Thirty-three patients with follow-up of one to three years were retrospectively reviewed. Time to bone union took an average of 37 weeks; 30% developed infection necessitating bone removal, and 2 patients required amputation for infected nonunion. Infection rates were lower for the free muscle flaps than for the free skin flaps. No correlation was drawn with the type of fracture, but a delay in wound closure was associated with a higher infection rate. All adult patients required bone grafting, with the least infection seen with the free vascularized bone flaps. Immediate fresh bone grafting at the time of free flap reconstruction, compared with delayed bone grafting, showed no added risk of infection.
