Reconstruction of the Scrotum With Bilateral Gracilis Muscle Rotational Flaps in a Patient With Acute Myeloid Leukemia Complicated by Fournier's Gangrene.

We describe the case of a 43-year-old male diagnosed with acute myeloid leukemia complicated by Fournier's gangrene. Multiple debridements led to the complete effacement of the scrotum, with 360 degrees of exposed testes and a narrow base of suspension. It was decided to reconstruct the scrotum using bilateral gracilis muscle rotational flaps, followed by split-thickness skin grafting from the thigh. The gracilis muscle as a donor flap allowed for the protection and support of the testes and suspensory tissue while achieving an aesthetically pleasing result that resembled the normal scrotum. We hope providers will consider this reconstructive method in future patients who present with similar extensive effacement of the scrotal tissue.

Laparoscopic treatment of gastroparesis: a single center experience.

BACKGROUND: Gastroparesis (GP) is a chronic disorder of gastric motility with delayed gastric emptying. Gastric electrical stimulator (GES) implantation and Roux-en-Y gastric bypass (RYGB) are surgical options for medically refractory GP. OBJECTIVE: Evaluate operational outcomes and symptom improvement of patients with diabetic (DM) and idiopathic (IP) GP. SETTING: University Hospital, United States. METHODS: A retrospective chart review was performed of all patients who underwent surgical treatment of GP from February 2003 to December 2014. Subgroup analysis was performed based on etiology of GP (DM versus IP) and procedure received (GES versus RYGB). Postoperative outcomes and postoperative symptom improvements were compared between groups. RESULTS: Of 93 patients, 47 (50.5%) had IP and 46 (49.5%) had DM. The majority underwent GES implantation (83.8%, n = 78), and 15 patients (16%) underwent RYGB. There were significant differences in hospital stay (2 versus 3 days) and reoperation rate (30% versus 7%) between IP and DM. Operation time, complication rate, and 30-day readmission rate were similar in both groups. DM patients significantly improved GP-related complaints compared with preoperatively. IP patients also improved nausea and vomiting and had no change in abdominal pain between pre- and postoperative period. GES showed significant improvement of nausea, vomiting, and abdominal pain. RYGB showed improvement of nausea, but not vomiting or abdominal pain. CONCLUSIONS: Surgery is a feasible intervention for GP for both DM and IP patients; however, based on the data presented in this manuscript and the current literature, the use of gastric bypass as an effective treatment modality for patients with intractable GP remains highly controversial. Care must be taken for IP patients in the postoperative period due to high incidence of reoperation. Although both procedures offer some degree of symptomatic improvement, GES seems to provide improvement of more GP symptoms. However, there is no significant difference in the need for postoperative medications regardless of the procedure used.

Reduction of Framingham BMI score after rapid weight loss in severely obese subjects undergoing sleeve gastrectomy: a single institution experience.

BACKGROUND: There is vast evidence that supports the importance of obesity in the pathogenesis and progression of cardiovascular disease. Rapid weight loss induced by laparoscopic Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB) has proven beneficial. The aim of this study is to evaluate laparoscopic sleeve gastrectomy (LSG) as an alternative treatment modality and its impact on the Framingham-BMI 10-year risk score. METHODS: We retrospectively reviewed all patients that underwent bariatric surgery at our institution between 2010 and 2014. Patients who met the criteria for calculating the Framingham BMI 10-year risk score were included. Data collected included baseline demographics, perioperative parameters such as tobacco use, diagnosis of diabetes, treatment for hypertension, BMI and postoperative outcomes at 3 and 12 months. RESULTS: From our 1129 bariatric patients, 358 (31.7%) met criteria for the Framingham BMI 10-year risk score calculation. LSG was the most prevalent surgery 61.45% (N = 220) followed by LRYGB 22.06% (N = 79). Females composed 69% (N = 248) of our population. The average age for females was 52.3 ± 10.8 years and for males 54.07 ± 11.2 years. The initial Framingham 10-year score risk was significantly higher in males compared with females (36.16% ± 22.3 vs. 16.97% ± 15.6 (p < 0.001)). After 12-month follow-up, the absolute risk reduction in males was 11.58% (p < 0.001) and 6.17% in females (p < 0.001). The preoperative heart age was high in females and males (69.23 ± 15.72 years and 73.55 ± 13.55 years, respectively (p = 0.012)), and after 12 months it was reduced 7.19 years in females (p < 0.001) and 7.04 years in males (p < 0.001). The percentage of estimated BMI loss at 1 year was 64.43% in females and 60.69% in males. CONCLUSION: Sleeve gastrectomy has demonstrated to be an effective method of treatment for obesity. Our results suggest that rapid weight loss after LSG has a positive impact in the reduction of the 10-year cardiovascular disease risk. Further prospective studies may be needed to better assess these findings.

The FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower extremities.

BACKGROUND: The aim of this study is to assess the accuracy of a Fast Doppler protocol for the examination of an injured lower limb, namely 2-Point Fast Doppler (2PFD), in order to rapidly triage arterial lesions after penetrating trauma. METHODS: The presence of flow and the aspects of the Doppler waveform of the dorsalis pedis artery (DPA) and posterior tibial artery (PTA) of the injured lower limb (2PFD) were evaluated immediately before the execution of a standardized Color Duplex Doppler (SD) evaluation in 149 limbs of 140 patients with gunshot penetrating injuries. We considered 2PFD normal exams as the ones with triphasic patterns in both the DPA and PTA, and 2PFD pathologic exams as the ones with absent, biphasic, or monophasic flow patterns in the DPA and/or PTA. 2PFD data were then analyzed to assess accuracy variables, using SD results as matching test reference. According to the trauma center standard protocols, SD positive cases underwent also angiography and surgical exploration, whose findings were used to further match the 2PFD specificity. RESULTS: The 2PFD protocol showed a sensitivity of 100%, and a specificity of 100% compared with the SD, in the diagnostic workup of arterial injuries of the lower limbs after penetrating trauma. Furthermore, all the pathologic cases that resulted in all true positives (TP), compared with SD, were confirmed as TP also when matched with the angiography evaluation results. CONCLUSIONS: The 2PFD protocol can rapidly identify arterial flow and differentiate between normal and pathologic spectral Doppler analyses in distal arteries. The presence of the normal triphasic flows in DPA and PTA is as sensitive as the standardized Color Doppler Duplex assessment of the entire limb in ruling out arterial lesions in lower-limb penetrating trauma. The absence of flow or the presence of a biphasic or monophasic pathologic flow in DPA and PTA is pathologic and should be always followed by further investigation. 2PFD is faster and easier to perform compared with the SD approach. It could become a new first-line screening technique, both in pre-hospital and hospital critical scenarios, particularly in contexts where advanced diagnostic performance is limited by time concerns or scarce resources.