Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula.

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

A new technique for the quantitative analysis of cranial suture biology.

OBJECTIVE: Our objective was to assess the ability of the microcomputed tomography scanner to correctly image normal and synostosed cranial sutures at the ultrastructural level. DESIGN AND METHODS: Two specimens of coronal sutures were collected from operative specimens. After appropriate preparation, histological sections were obtained and stained with toluene blue for evaluation. Representative histological sections were compared to microcomputed tomography slices. RESULTS AND CONCLUSIONS: With microcomputed tomography, we successfully imaged one normal and one synostosed human coronal suture and performed a quantitative analysis of these specimens. Microcomputed tomography scanning was found to be a highly accurate imaging device for the evaluation of cranial suture development. Microcomputed tomography offers three-dimensional imaging at the microscopic level and allows for rapid quantitative analysis of bone architecture, including several measurements unavailable through histologic analysis. We believe that microcomputed tomography can play an important role in imaging and in the quantitative analysis of the stereology of bone microarchitecture. Among its advantages, microcomputed tomography is able to image many more slices than are obtainable through histology, and the method is not prone to human error. Microcomputed tomography slices are generated without destruction of the specimen and without loss or corruption of reproducible data. Structure-oriented slices from microcomputed tomography together with cellular-oriented sections from histology are complementary in the overall quantitative analysis of cranial sutures.

Pediatric facial fractures: analysis of differences in subspecialty care.

At the University of Michigan, the pediatric facial fracture call schedule rotates through the plastic surgery, otolaryngology, and oral surgery services. This situation provides an opportunity to evaluate differences in the management of pediatric facial fractures between subspecialty groups. At this hospital, a retrospective review of all pediatric facial fracture cases within a 5-year period was undertaken. Sixty patients with 82 facial fractures were studied along subspecialty lines. Differences in patient groups, practice patterns, and treatment strategies based on subspecialty assignment were found. Overall treatment followed traditional lines, with plastic surgeons involved in all types of pediatric facial fractures, whereas otolaryngology and oral surgeons were more limited in their operative scope, despite equal call responsibilities. It is believed that the managed care arena is a competitive environment in which it will be important to know the strengths and weaknesses of the plastic surgery specialty, as well as those of competing specialties, as patient contracts are negotiated. The overlap of plastic surgery, otolaryngology, and oral surgery in the care of facial trauma could result in plastic surgeons being left off of managed care participant lists. This study highlights plastic surgeons as efficient deliverers of quality care for pediatric facial fractures. Although the treatment of these fractures has fallen into the duties shared by all three subspecialties, data such as those presented here should strengthen our ability to succeed in the evolving environment of managed care.

Use of microcomputed tomography scanning as a new technique for the evaluation of membranous bone.

Previous basic bone studies in cranial bone biology and bone grafting have used calipers, volume displacement, and cephalometric tracings to measure membranous bone and to infer fundamental properties of cranial bone. These tools have limited accuracy and reproducibility. Histomorphometry has also been used in the quantitative analysis of cranial bone; however, two-dimensional histology is unable to capture a precise representation of the three-dimensional structure of bone. For the first time, we have used the advanced technology of three-dimensional microcomputed tomographic (micro-CT) scanning as a highly accurate and automated tool to precisely measure changes in bone stereology, volume and projection, and microarchitecture in the evaluation of membranous bone. The advantages of this technology are numerous and include the rapid and nondestructive three-dimensional analysis of bone microstructure at resolutions between 10 and 75 microns. Measures of "connectivity" in three dimensions and the architectural parameter of "anisotropy" are available through micro-CT imaging but can only be inferred through two-dimensional histological series. We successfully imaged two full-thickness cranial bone specimens and one cancellous iliac bone graft. The images demonstrate a similarity between the two membranous specimens and a marked difference in comparison with the endochondral graft. These differences are borne out by mathematical analysis, and their significance is discussed. The utility of micro-CT in the evaluation of membranous bone was displayed by its ability to rapidly calculate differences in bone stereology and to quantitatively measure morphological changes at an ultrastructural level. We believe the benefits of this system will prove to be extremely useful for investigations into the basic biology of membranous bone, bone grafts, and craniofacial interfaces, and we encourage its use by other scientific investigators in the field of craniofacial surgery as they strive for more scientifically rigorous tools to understand the basic biology of membranous bone.

Pediatric facial fractures: a demographic analysis outside an urban environment.

This study reviews all pediatric facial fractures treated operatively at the C.S. Mott Children's Hospital of the University of Michigan over a 5-year period. Previous series of pediatric facial fractures have been collected at large urban centers and may not be representative of all practice environments. Our institution is a level 1 trauma center that serves a patient population primarily from suburban and rural regions throughout the state. Referral and practice patterns at our institution gave us an important opportunity to analyze differences in patient care and management secondary to venue, and challenge the assumptions made by studies collected at large urban centers. We reviewed 80 fractures in 62 patients. Patient age ranged from 2 to 18 years old with the majority of patients (58%) between 15 and 18 years old. Most fractures resulted from motor vehicle accidents (43%) and there were no firearm injuries. Fracture sites included the mandible (38%), the frontonasoethmoid region (35%), the midface (17%), and the orbit (10%). Only two operative complications were reported. There were no cervical spine injuries. Median patient age was higher and mechanism of injury differed in our study compared with urban studies. Rapid changes in the health care delivery system and the emergence of managed care demand accurate demographic updates for the efficient allocation of valuable resources. Our results showed important differences with previous studies and imply that assumptions and analysis of the care of pediatric facial fractures based solely on data collected at large urban centers may be too parochial, and therefore subsequent health care decisions of resource allocation arrived at without respect to practice environment could be erroneous.

Salpingocolonic fistula secondary to diverticulitis.

A rare diverticular fistula is reported in a 37-year-old woman. The case history and literature were reviewed for clinical presentation, radiologic investigations, and treatment options. Internal fistulas may complicate diverticular disease. The least common fistula is between the colon and the fallopian tube. Successful management of this complication is directed at removing the diseased colon. The woman had a salpingocolonic fistula secondary to diverticulitis. To our knowledge, she represents the youngest patient with this complication of diverticular disease in the literature. Diagnosis of a salpingocolonic fistula complicating diverticular disease requires clinical suspicion when genitourinary symptoms complicate the clinical presentation. Hysterosalpingography or contrast injection of percutaneous drainage tubes may contribute to the diagnosis.