Viability of five different pre- and intraoperative imaging methods for autologous breast reconstruction.

BACKGROUND: Autologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods' efficiency and informative value were analyzed. METHODS: We retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI). RESULTS: CTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information. CONCLUSION: Preoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.

Indocyanine green video angiography predicts outcome of extravasation injuries.

BACKGROUND: Extravasation of cytotoxic drugs is a serious complication of systemic cancer treatment. Still, a reliable method for early assessment of tissue damage and outcome prediction is missing. Here, we demonstrate that the evaluation of blood flow by indocyanine green (ICG) angiography in the extravasation area predicts for the need of surgical intervention. METHODS: Twenty-nine patients were evaluated by ICG angiography after extravasation of vesicant or highly irritant cytotoxic drugs administered by peripheral i.v. infusion. Tissue perfusion as assessed by this standardized method was correlated with clinical outcome. RESULTS: The perfusion index at the site of extravasation differed significantly between patients with reversible tissue damage and thus healing under conservative management (N = 22) versus those who needed surgical intervention due to the development of necrosis (N = 7; P = 0.0001). Furthermore, in patients benefiting from conservative management, the perfusion index was significantly higher in the central extravasation area denoting hyperemia, when compared with the peripheral area (P = 0.0001). CONCLUSIONS: In this patient cohort, ICG angiography as indicator of local perfusion within the extravasation area was of prognostic value for tissue damage. ICG angiography could thus be used for the early identification of patients at risk for irreversible tissue damage after extravasation of cytotoxic drugs.

[Squamous cell carcinoma in Dupuytren's disease--a case report]. / Höherdifferenziertes verhornendes Plattenepithelkarzinom in einer Palmarfibromatose (M. Dupuytren)--Fallbericht.

Squamous cell carcinoma in the palm is an extremely rare entity. In the following case report we describe the occurrence of a squamous cell carcinoma in the presence of Dupuytren's disease. A 49-year-old man was operated on the right hand for ulcerating Dupuytren's disease. A squamous cell carcinoma was diagnosed by performing obtaining a fast section intraoperatively. The patient had an invasive, highly differentiated keratinizing squamous cell carcinoma. The lesion was resected together with the Dupuytren lesion and the defect covered with a full-thickness graft. Postoperatively the patient was irradiated. He is free of recurrence for three years now. To our knowledge, this is the first published report of a squamous cell carcinoma in the presence of Dupuytren's disease.

Intra-individual comparison between open and 2-portal endoscopic release in clinically matched bilateral carpal syndrome.

Based upon bilateral carpal tunnel syndrome (CTS) we undertook a prospective randomised intra-individual comparison between open (OR) and 2-portal endoscopic release (2-PER) to establish if there is any demonstrable advantage in undertaking either technique in a 1 year follow-up. Ten patients with bilateral CTS were enrolled in this study and underwent a 2-PER on the one and an OR with two minimised incisions on the contralateral hand. Both hands were examined pre- and postoperatively after 2, 4, 6 and 12 weeks and after 6 and 12 months, respectively. Preoperatively both hands revealed statistically no significant differences in all the parameters recorded. Comparing both techniques no significant differences could be detected in the follow-up period. Nevertheless, both techniques showed significant improvements in the severity of symptoms and pain, in sensory nerve testing and in electro-diagnostic parameters, when comparing pre- with postoperative data after 1 year. The endoscopic approach revealed no distinct advantages over the open technique not only in the late but also in the early postoperative follow-up period when performing intra-individual comparison. Considering the higher complication rate and costs when performing 2-PER the OR with two minimised incisions seems to be a good alternative in order to keep the recovery period as short as possible.

Carpal tunnel syndrome: a question of hand and wrist configurations?

This study investigated whether there is an association between hand and wrist configurations and the occurrence of carpal tunnel syndrome. The external hand and wrist dimensions of 50 subjects with carpal tunnel syndrome and 50 healthy volunteers were measured and compared. In addition carpal tunnel depth and width were determined with ultrasound. Our results showed that the hand length was significantly higher in the control group (hand length, 19.0; SD, 1.0 cm: patients' hand length, 18.2; SD, 1.1cm) and the palm width was significantly greater in the patients' group (palm width, 9.1; SD, 0.7 cm: controls palm width, 8.6; SD, 0.6 cm). Carpal tunnel syndrome patients had a squarer wrist (wrist ratio, 0.72; SD, 0.1) and carpal tunnel (carpal tunnel ratio, 0.48; SD, 0.1) than the controls (wrist ratio, 0.68; SD, 0.1; carpal tunnel ratio, 0.42; SD, 0.1). These findings indicate that the anatomy of the hand, wrist and carpal tunnel may predispose to carpal tunnel syndrome.

[Continuous free-flap monitoring with tissue-oxygen measurements: experiences of the last years]. / Postoperatives Lappen-Monitoring mittels Messung des Sauerstoffpartialdruckes im Lappengewebe: Erfahrungen der letzten Jahre1.

Early recognition of flap failure is the prerequisite for flap salvage. Many methods are used to monitor free-flaps. The time interval for re-establishing vascular patency is the deciding factor for a successful revision. Prompt revision surgery and a quick and sufficient correction of the microvascular anastomosis are necessary to reestablish flap viability. The aim of this study was to evaluate the real impact of this probe as a continuous, precise and clinically relevant monitoring system in free-flap surgery. One of our main objectives was to create guidelines and "normal" ranges of p ti O 2 -values for the uncomplicated use of the Licox Probe in free-flap surgery for the first time. The Licox Catheter pO 2 Mikro-Probe instrument is used for continuous determination of oxygen partial pressure (pO 2 ) in body fluids and tissue (p ti O 2 ). Over a period of more than three years, 70 free tissue-transplantations to the head and neck, trunk, and upper and lower extremities were monitored by use of the implantable Licox Catheter Probe System. In all patients, a decrease of the p ti O 2 -levels was noted during the first minutes, until a more or less stable level was reached. At the time of weaning off, the p ti O 2 values decreased once again. After approximately 30 minutes, an almost stable but reduced p ti O 2 -level was reestablished (34,6 +/- 10,9 mm Hg). During the next days, we observed a more or less constant but reduced level. These values from the second day on were lower than the mean values of the first day. The mean value for all flaps was 23,1 +/- 6,5 mm Hg. Nevertheless, in all cases (10 of 70 flaps) where the p ti O 2 -level decreased more than 10 mm Hg within a half hour period, the flap showed vascular problems on re-exploration. Another clinically relevant value that was observed in all flaps with vascular problems was a drop of the p ti O 2 -value, below 10 mm Hg. In the cases of arterial thrombosis (2 of 10 flaps), a rapid decrease was noted. In the cases of venous complications (8 of 10 flaps), a more or less slow decrease of the p ti O 2 -value was observed. These observations may serve as precise indicators for vascular complications and flap failure. Based on our observations and data, it seems that the Licox-Probe is a sensitive and accurate monitoring system for a variety of free flaps.

The precision of ultrasound imaging and its relevance for carpal tunnel syndrome.

The carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy in human. The diagnosis is based on symptoms and on physical examination and is supported by nerve conduction tests. The aim of this study was to evaluate the precision and the valence of ultrasound (US) for CTS. An anatomic study was performed on 40 wrists of 20 unfixed human cadavers. The carpal tunnel and its important structures and contents were imaged and measured by ultrasound (7.5-MHz high resolution probe). The dorsopalmar diameter (DPD), the radioulnar diameter (RUD), the perimeter (P) and the cross-sectional area (A) were determined for the carpal canal and for the median nerve. These US images and measurements were directly compared with anatomic cross-sections gained from the same wrists at the same level. Our results showed that ultrasound is a very precise method to display the anatomy of the carpal tunnel and of the median nerve and thus the conditions of the median nerve. Significant differences could not be detected for each of these parameters either for the carpal tunnel or the median nerve. (Ultrasound: cross-sectional area of carpal tunnel: 162.4 +/- 29.3 mm2 and of the median nerve: 9.2 +/- 2.4 mm2; anatomy: cross-sectional area of carpal tunnel: 168.4 +/- 31.2 mm2 and of median nerve: 9.4 +/- 2.2 mm2).

[Value of several examination systems in patients with carpal tunnel syndrome. Comparison of Dellon computer-assisted sensation test with Mellesi hand status and Levine examination scheme]. / Wertigkeit verschiedener Untersuchungssysteme bei Patienten mit Karpaltunnelsyndrom. Vergleich des computerunterstützten Sensibilitätstestes nach Dellon mit dem Handstatus nach Millesi und dem Untersuchungsschema nach Levine.

The goal of the presented carpal tunnel syndrome (CTS) follow-up study was to compare the clinical value of the Millesi hand function score with the "Pressure Specifying Sensory Device" (PSSD) introduced by A. L. Dellon using self-administered patient questionnaires. 25 patients (10 male, 15 female) with an electrodiagnostically confirmed CTS were enrolled in this study, performing one preoperative and five postoperative examinations over 24 weeks. 12 of the 25 patients underwent an "open" two-portal carpal tunnel release with two minimal incisions (group OT); the other 13 patients were treated with a two-portal endoscopic carpal tunnel release (group ET). Additionally, in eleven out of the twelve patients of group OT, an epineuriotomy of the median nerve was performed during the same session. Concerning preoperative data of the Millesi score and the PSSD, no statistically significant differences were found between group OT and ET. However, preoperative comparison with the contralateral hand demonstrated a reduction in hand function of 15% and an increase in the pressure perception threshold of 41% compared to normative data could be measured with the PSSD. The subjective functional value of the hand was objectively evacuated using the Levine score. In the second postoperative week, a significant decrease in hand function could be obtained with the Millesi score in group OT. In group ET, the decrease in hand function representing the operative trauma was significantly lower than in group OT. Data of the static one- and two-point pressure perception threshold revealed a statistically significant improvement of the sensibility in both groups. The results of the Millesi score recorded at the last examination in the 24th postoperative week showed an improvement in hand function in both groups compared to preoperative data. Concerning static one- and two-point measurements with the PSSD, distinct improvements compared to the preoperative data could also be detected in both groups although significant differences between group OT and ET were evident: Data of group OT regarding the whole postoperative course demonstrate a continuous improvement in sensibility of the index finger. In contrast, the analysis of the PSSD measurements in group ET revealed an increase in all the parameters starting in the sixth postoperative week and ending with significantly worse static one- and two-point threshold measurements than in group OT. On the other hand, data of self-administered patient questionnaires using the Levine Score revealed significant improvements in hand function and reduction in pain intensity in both groups compared to preoperative results. Differences between both groups at the end of the examination course were not evident. In conclusion, the Millesi hand score with its emphasis on the motor function proved to be a reliable method to record the severity of CTS preoperatively, the severity of the surgical trauma and changes in the course of rehabilitation of the affected hand. A good correlation was found between data obtained with the Millesi Score and the self-administered patient questionnaires according to Levine. But when compared with the PSSD, both methods could not directly document the preoperative status and postoperative changes of the median nerve. Preoperative static two-point pressure threshold measurements with the PSSD confirmed their status as a screening parameter as published by A. L. Dellon. In the postoperative course of group ET, a distinct worsening in the sensibility of the index and little finger could only be detected with the PSSD before the patients noticed the onset of related symptoms.

Sister chromatid exchange in human lymphocytes exposed to isoflurane and nitrous oxide in vitro.

The question of whether or not inhalation anaesthetics are genotoxic remains controversial. Therefore, we have studied the in vitro genotoxic potential of isoflurane and nitrous oxide in human lymphocytes. Blood samples were obtained from eight healthy male, non-smoking volunteers, which were incubated and exposed to increasing concentrations of isoflurane (0.0, 0.3, 0.6 and 1.2 mmol litre-1) or 50% nitrous oxide in oxygen. Baseline sister chromatid exchange (SCE) rate per cell was mean 7.65 (SD 1.5) which increased to 9.15 (1.0), 9.55 (1.4) and 9.95 (1.8) SCE/cell during exposure to isoflurane 0.3, 0.6 and 1.2 mmol litre-1, respectively. During 50% nitrous oxide exposure, SCE rate was 9.26 (1.4). The difference between the control and exposed cells was statistically significant (P < or = 0.05). We conclude that exposure to nitrous oxide and subanaesthetic concentrations of isoflurane can produce genetic damage in peripheral lymphocytes in vitro.