Surgical management of life-threatening epistaxis in Osler-Weber-Rendu disease.

Hereditary hemorrhagic telangiectasia is a systemic disorder of blood vessels. It often leads to severe epistaxis that is refractory to conventional therapy. Three patients with severe epistaxis caused by hereditary hemorrhagic telangiectasia unresponsive to laser coagulation and to septal dermoplasty and requiring multiple transfusions underwent extirpation of nasal mucosa through a rhinotomy approach, with a median forehead flap and split-thickness skin graft coverage of the mucosal defects over the floor and lateral walls of the nose. All patients had reduced frequency and severity of bleeding without any need for transfusions during follow-up periods of 6 months, 3 years, and 5 years, respectively. Forehead flaps resulted in minimal morbidity. Partial nasal obstruction and a forehead scar were the main complaints. Surgical technique, complications, and alternative therapy are discussed.

Nipple placement in simple mastectomy with free nipple grafting for severe gynecomastia.

Severe gynecomastia with excessive skin is difficult to treat by only periareolar excision or suction-assisted lipectomy or both. In these patients, total mastectomy and free nipple grafting may be the best option. Placement of the nipple, however, has been arbitrary. With use of 20 "aesthetically perfect" men as models, standard nipple distances were identified. The average sternal notch-to-nipple measurement was 21 cm. In addition, two consistent ratios were identified. The nipple plane was located 0.33 times the distance from the sternal notch to the pubis, and the internipple distance was 0.23 times the chest circumference. With use of preoperatively obtained measurements of the sternal notch to pubis and chest circumference, accurate nipple placement can be accomplished.

Common complications of wound healing. Prevention and management.

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.

Sensate palm of hand free flap for forearm length preservation in nonreplantable forearm amputation: long-term follow-up.

In traumatic proximal forearm amputation where replantation is not possible, "spare parts" from the amputated segment can be used to maintain adequate length for successful use of a below-elbow prosthesis. Two patients with long-term follow-up are presented in whom forearm length was preserved with the use of a sensate palmar skin free flap.

Free flaps to preserve below-knee amputation stumps: long-term evaluation.

Five patients with insufficient soft-tissue coverage on below-knee amputation stumps have been treated with free-tissue transfer surgery to preserve a functional below-knee prosthetic level. The flaps employed include one latissimus dorsi myocutaneous flap, two latissimus dorsi muscle-skin graft flaps, one groin flap, and one foot-fillet flap. All five flaps survived; one patient required early venous anastomosis reexploration and revision. The patients have been followed for a mean duration of 5.5 years (range 3 to 8 years). The mean duration to first ambulation with a prosthesis was 3.6 months (range 2 to 7 months). Four of the five patients developed ulcerations on or adjacent to their flaps which required surgical revision. The patients required a mean of 1.28 prosthesis changes annually since surgery. The functional motion (mean active knee motion is 100 degrees) and ligamentous stability of the knee joints were well preserved in all patients. Five patients wear patella tendon-bearing prostheses, with one requiring an additional thigh corset. In two of the patients, nerve anastomoses to their flaps were performed. Both patients developed true cutaneous sensibility, but nevertheless experienced flap ulceration. All the patients are fully ambulatory on their free flaps. Free-tissue transfer can assist in preserving traumatic below-knee amputations so that patients can benefit from the functional advantage of a below-knee prosthetic device.

The use of percutaneous nephrostomy in patients with ureteric obstruction undergoing renal transplantation.

The use of percutaneous nephrostomy with or without placement of a ureteric stent has been of increasing aid in treating both acute and chronic ureteral obstruction in recipients of renal allografts. Eight patients who underwent transplantation, had ureteric obstruction develop and were treated by this means are reported herein. The technique is standard and can be performed in an arteriography suite. Once a catheter is inserted into the allograft collecting system, a nephrostomy tube or a stent, or both, is easily inserted. Three of the patients had acute ureteric obstruction secondary to clot forming after needle biopsy of the transplant kidney. Percutaneous nephrostomy tubes were passed, the renal pelvis and ureter irrigated and the clots lysed. Operation was unnecessary. In five patients with declining renal function secondary to chronic obstruction, percutaneous nephrostomy placement allowed return of renal function to base line levels, while placement of a stent through the ureter into the bladder facilitated location of the ureter at operation for ureteral reimplantation. The technique of percutaneous nephrostomy is simple, convenient and allows patient recovery preoperatively. It has become part of our standard armamentarium in transplant recipients.

Computerized tomography and lymphangiography in staging testis tumors.

The usefulness of computerized tomography, lymphangiography and tumor markers has been examined in 20 consecutive patients with pathologic stage I or II nonseminomatous testicular tumors. Computerized tomography had a false negative rate of 40 per cent, a false positive rate of 50 per cent and an over-all accuracy of 69 per cent. Lymphangiography had a false negative rate of 42 per cent, a false positive rate of 0 and an over-all accuracy of 69 per cent. The combination of computerized tomography and lymphangiography did not significantly improve the diagnostic accuracy of either technique alone. Furthermore, because tumor markers usually were elevated in the presence of bulky metastatic disease that was detected easily by either computerized tomography or lymphangiography, they did not add measurably to the sensitivity of either computerized tomography or lymphangiography in the diagnosis of retroperitoneal lymph node metastases. Consequently, retroperitoneal lymphadenectomy remains the only reliable means for accurate staging of patients with nonseminomatous testicular tumors.

Superiority of perfluorocarbon cardioplegia over blood or crystalloid cardioplegia.

Oxygenated Fluosol-43 cardioplegia (CP), a perfluorocarbon with high oxygen solubility, was compared with crystalloid and oxygenated blood cardioplegia. Potassium in each CP was 25 mEq/l. Thirty perfused rabbit hearts in three groups of 10 hearts each underwent 100 minutes of global ischemia at 20 degrees C, followed by 45 minutes of reperfusion at 37 degrees C. During ischemia, CP was given every 20 minutes. With each CP injection, increases in myocardial oxygen tension were recorded using mass spectrometry and oxygen consumption (MVO2) was calculated. Left ventricular function was assessed before and after ischemia by measuring isovolumic developed pressure and dP/dt with an intraventricular balloon. Intramyocardial PO2 increased by 19.6 +/- 1.8 mm Hg in the Fluosol CP group, 0.4 +/- 0.1 mm Hg in the crystalloid CP group and 1.5 +/- 0.3 mm Hg in the blood CP group (p less than 0.001, Fluosol CP vs crystalloid CP and blood CP). MVO2 with each CP injection, expressed as ml O2/100 g dry weight, was 203.8 +/- 7.0 for Fluosol CP, 20.4 +/- 1.2 for crystalloid CP and 39.2 +/- 4.3 for blood CP (p less than 0.001 Fluosol CP vs crystalloid CP and blood CP). Recovery of maximal dP/dt after 45 minutes of reperfusion, expressed as a percentage of preischemic control, was 75.6 +/- 4.0% for Fluosol CP, 60.9 +/- 5.5% for crystalloid CP and 53.4 +/- 3.7% for blood CP (p less than 0.02 Fluosol CP vs blood CP and crystalloid CP). These data clearly show that the use of Fluosol cardioplegic solution enhanced oxygen delivery and use compared with blood and crystalloid cardioplegic solutions. The marked increase in intramyocardial oxygen and MVO2 with each injection of Fluosol CP shows that there is effective aerobic metabolic activity during ischemia, which may explain the improved functional recovery. The failure of blood CP to afford similar protection can be explained by a decreased oxygen release from hemoglobin due to the leftward shift of the oxygen-hemoglobin dissociation curve with hypothermia.

Differences in the effects of estradiol on dihydrotestosterone induced prostatic growth of the castrate dog and rat.

The treatment of castrate beagles with a combination of estradiol an dihydrotestosterone (DHT) results in the synergistic enhancement of prostatic growth and the experimental induction of benign prostatic hyperplasia. This estradiol synergism can be shown as a greater than 3 fold increase in both prostatic wet weight and total DNA content in castrate dogs treated with both steroids, as compared to those animals treated with DHT alone. In direct contrast to the situation in the dog, there was no evidence of estradiol synergism on prostatic growth when castrate rats were treated with combinations of estradiol and DHT, even if both the ratio and absolute amount of both steroids were experimentally varied over a wide range of values. Regardless of the ratio or absolute dose, estradiol was completely unable to synergize the DHT induced growth of the prostate as well as other sex accessory tissues of the castrate rat. This indicates a fundamental difference between the rat and dog in regard to prostatic growth response to combinations of estradiol and DHT treatment.