Mesenteric ischemia secondary to toxic epidermal necrolysis: case report and review of the literature.

A 28-year-old otherwise healthy man was admitted to the burn center for treatment of toxic epidermal necrolysis (TEN) involving 90% of the TBSA and oropharynx. On hospital day 8, his cutaneous lesions were healing well, but he developed respiratory distress, fever, and abdominal distension. Computerized tomography demonstrated distended bowel, pneumatosis intestinalis, and portal venous gas. He underwent emergent celiotomy. Patchy areas of nonperforated necrosis along the jejunum and ileum were present. No mechanical or embolic source of ischemia could be identified. A 120-cm segment of ischemic small bowel was resected and the abdomen was closed temporarily. On planned "second look" the following day, no further disease was encountered and intestinal continuity was restored. Tube feeds were then initiated and the patient's recovery was uneventful thereafter. Although traditionally considered a skin disorder, TEN may be more accurately described as a disorder affecting the junction of an epithelium and its supporting tissue. It is most prominently manifested at the epidermal-dermal junction, but epithelial-submucosal junctions are also affected. The ocular, respiratory, genitourinary, and gastrointestinal manifestations of TEN are variable and incompletely understood. This disease is rooted in immunological dysfunction and the small bowel is rich in immunologically active tissue; Peyer patches and lymph nodes abound. Clinicians should be vigilant for gastrointestinal tract involvement, which is potentially treatable with resection of the ischemic bowel. The authors suspect that, given the critical condition of many TEN patients, bowel symptoms may be incorrectly attributed to global hypoperfusion and sepsis.

Pylephlebitis and acute mesenteric ischemia in a young man with inherited thrombophilia and suspected foodborne illness.

We report on a young man who developed complicated pylephlebitis after foodborne illness. Despite antibiotics and resection of the focus of infectious colitis, he developed extensive small bowel infarction. He was treated with anticoagulation, local thrombolytic infusion, and resection of irreversibly ischemic small bowel. Thrombophilia workup demonstrated heterozygosity for factor V Leiden and the prothrombin G20210A mutation. The complications of pylephlebitis can be minimized by using systemic anticoagulation, thrombectomy, and/or local thrombolytic infusion along with antibiotics and surgical management of the infection. Evaluation for thrombophilic states should be considered, particularly if a patient does not respond to initial therapy.

Durability of saphenous vein grafts: 44-year follow-up of a saphenous vein interposition graft in a pediatric patient.

We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft.

Plastic surgery within the Veterans Affairs Medical System: proposed modified indications for operative procedures.

Many plastic surgery procedures span the divide between aesthetic ("cosmetic") and reconstructive surgery. However, definitions and guidelines may be inconsistent, which may decrease patients' access to legitimate procedures. The article aims to assist Veterans' Health Administration-affiliated plastic surgeons in continuing to provide optimal care to the Nation's Veterans and family members, and should be regarded as an open discussion.

Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation.

BACKGROUND: Traditionally, management of exposed hardware has included irrigation and débridement, intravenous antibiotics, and likely removal of the hardware. Increasingly, the goal of wound closure without hardware removal using plastic surgical techniques of soft-tissue reconstruction has been emphasized. Identification of parameters for retaining exposed hardware may assist surgeons with management decisions and outcomes. METHODS: A current literature review was performed to identify parameters with prognostic relevance for management of exposed hardware before soft-tissue reconstruction. RESULTS: The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: hardware location, infection, duration of exposure, and presence of hardware loosening. CONCLUSIONS: Management of exposed hardware has included the removal of the hardware. However, if certain criteria are met--specifically, stable hardware, time of exposure less than 2 weeks, lack of infection, and location of hardware--salvage of the hardware with plastic surgical soft-tissue coverage may be a therapeutic option.