Successful local use of heparin calcium for congested fingertip replants.

BACKGROUND: Conventional methods of external bleeding for congested fingertip replants exhibit notable problems, including uncontrollable bleeding and unpredictable survival of the replant. We have added a local injection of heparin calcium to the routine use of systemic heparinization for inducing external bleeding. We retrospectively examined patients who underwent external bleeding using our method. METHODS: Local subcutaneous injections of heparin calcium were made in 15 congested replants in addition to systemic heparinization. Each injection ranged from 500 to 5,000 U. The average duration of the injections was 4.1 days. Surgical outcomes were analyzed and compared with a control group of patients who underwent external bleeding without heparin calcium. RESULTS: The overall survival rate was 93.3%, which was higher than that of the control group (83.3%), but the difference was not statistically significant (P=0.569). The survival rate for subzones I and II by the Ishikawa subzone classification was 100%, whereas it was 87.5% in subzones III and IV. No statistically significant difference was observed. The rate of partial necrosis was 0% in subzones I and II, whereas it was significantly higher (66.7%) in subzones III and IV (P=0.015). The mean total blood loss via external bleeding was 588 g in 10 fingers. No patients required blood transfusion. CONCLUSIONS: Congestion of a replanted fingertip can be successfully managed without blood transfusion by our method. Although complete relief from congestion in replants in subzones I and II is achievable, there is a higher risk of partial necrosis in subzones III and IV.

Successful treatment of a bowel fistula in the open abdomen by perforator flaps and an aponeurosis plug.

In this report, we present a case of successful treatment of a bowel fistula in the open abdomen by perforator flaps and an aponeurosis plug. A 70-year-old man underwent total gastrectomy and developed anastomotic leakage and dehiscence of the abdominal wound a week later. He was dependent upon extracorporeal membrane oxygenation, continuous hemodiafiltration, and a respirator. Bowel fluids contaminated the open abdomen. Two months after the gastric operation, a plastic surgery team, in consultation with general surgeons, performed perforator flaps on both sides and constructed, as it were, a bridge of skin sealing the orifice of the fistula. The aponeurosis of the external oblique muscle was elevated with the flap to be used as a plug. The perforators of the flaps were identified on preoperative and intraoperative ultrasonography. This modality allowed us to locate the perforators precisely and to evaluate the perforators by assessing their diameters and performing a waveform analysis. The contamination decreased dramatically afterwards. The bare areas were gradually covered by skin grafts. The fistula was closed completely 18 days after the perforator flap. An ultrasoundguided perforator flap with an aponeurosis plug can be an option for patients suffering from an open abdomen with a bowel fistula.

New chest tube management maintained with negative pressure therapy.

Management of a chest tube, especially when lasting for a long period, becomes difficult. The orifice of thoracostomy where a tube is inserted is maintained sterile usually with water-tight sutures. The longer and tighter the sutures are placed, the more severely skin becomes sore by pressure. Recently not only pressure sores but also other various open wounds were successfully treated by negative pressure therapy. This study presents two cases of intrathoracic abscess which were successfully treated by chest tube maintained with negative pressure therapy. One case was a bed-ridden cerebral palsy patient with empyema thoracis and the other was a premature baby with lung abscess. Both needed a chest tube longer than a month. Negative pressure was applied not only in the abscess cavity but also in the wound of tube insertion, thus simultaneously draining the abscess and accelerating the wound healing of the tube insertion. It was gradually elevated from 20 to 50 H2O (14.7 to 36.7 mmHg), which is below the level of the physiologic forced inspiration, with a 10 cm H2O (7.4 mmHg) increase every other day. Both abscesses disappeared without a complication.

Successful management of tracheoinnominate artery fistula using a split pectoralis muscle flap with anatomical reconstruction by a synthetic graft.

We report the successful repair for tracheoinnominate fistula, in which the innominate artery was interposed with a synthetic graft and the pectoralis muscle was used as a seal against infection. We know of 10 other reported cases.

Signet-ring cell carcinoma of the esophagus associated with Barrett's epithelium: report of a case.

We herein report a case of infiltrative esophageal signet-ring cell carcinoma resembling gastric signet-ring cell carcinoma. Grossly, the tumor was a diffusely infiltrative carcinoma involving the lower esophagus measuring 11 cm in diameter. The tumor extensively metastasized to the cervical, mediastinal, and abdominal lymph nodes, and the patient died of peritonitis and pleuritis carcinomatosa soon after undergoing a radical esophagectomy. Histologically, the tumor was signet-ring cell carcinoma covered with normal squamous epithelium. However, the most superficial part of the tumor center contained a region of Barrett's mucosa with incomplete-type intestinal metaplasia and a well-differentiated adenocarcinoma component with goblet cells. The expression of cytokeratins 7 and 20 also indicated that both the Barrett's mucosa and the signet-ring cell carcinoma had an esophageal origin. Esophageal signet-ring cell carcinoma with diffuse infiltrative growth is quite rare, and may need a special treatment strategy because of its highly aggressive behavior and poor treatment outcome.

Hepatocellular carcinoma in a patient with primary biliary cirrhosis and seronegativity for markers of hepatitis B virus and hepatitis C virus: report of a case.

We report a case of hepatocellular carcinoma (HCC) arising in a patient with primary biliary cirrhosis (PBC) in whom both hepatitis B virus (HBV) and hepatitis C virus (HCV) serological tests were negative. A 72-year-old woman was found to have HCC 10 years after a diagnosis of PBC. All serological tests for HBV and HCV were negative. Preoperative liver biopsy findings suggested moderately differentiated HCC. Dynamic computed tomography (CT) showed hypervascular tumors in segments IV and VII. At laparotomy, a 30-mm tumor was palpated in segment VII and a wedge resection was performed. The second tumor, which measured 10 mm in diameter, was detected in segment IV by abdominal ultrasound, and microwave coagulation therapy was done. HCC arising in hepatitis virus marker-negative PBC is rare and past reports do not clarify whether HBV or HCV infections are associated with HCC.