Reconstruction of large defect of lower lip and commissure using Karapandzic flap: case report.

Xeroderma Pigmentosum (XP) is a photosensitive skin disease with a high risk for developing skin malignancy. We present an 18-years-old boy with XP and recurrent basal and squamous cell carcinoma of lower lip. Because of scars from earlier resections Karapandzic circumoral advancement-rotation flap was performed. The method is suitable for defects covering 1/3 to 4/5 of the lower lip with possible involvement of commisura. 70% of the lip was resected and reconstruction was made with bilateral flaps. This reconstruction resulted in good oral muscular and sensory function. The scars followed natural folds of the face and despite a slight microstomia gave an acceptable esthetic appearance. The Karapandzic flap is simple and safe method for reconstruction of large defects of lower lip.

Capsular contracture around saline-filled fine textured and smooth mammary implants: a prospective 7.5-year follow-up.

In a previous prospective randomized clinical study comparing in the same patient textured and smooth saline-filled mammary implants (Biocell) with large pore size (300 to 600 microm), we saw no difference in capsular contracture. This study was undertaken in a similar way to compare capsular contracture around smooth and textured saline-filled prostheses with pores of small size. During a period of 7.5 years, the breast hardness was followed up, and at the end of the study patient satisfaction was evaluated. Twenty healthy women with a mean age of 30 years were operated on for breast augmentation. Two surgeons performed all operations in a standardized way. Each patient received subglandularly a Siltex textured saline-filled prosthesis with a pore size of 30 to 70 microm in one breast, and a smooth saline-filled prosthesis in the other. The hardness of the breasts was evaluated after 0.5, 1, and 7.5 years using Baker grading and applanation tonometry. Eighteen patients completed 1-year and 7.5-year follow-up. Two breasts with smooth prostheses were contracted after 6 months (Baker III or IV). After 1 year, four patients with smooth prostheses and one with a textured prosthesis had capsular contracture (p = 0.34). Seven and one-half years after surgery, six patents with smooth and four with textured implants had contracture (p = 0.66). On two patients with smooth prostheses and one patient with a textured prosthesis, the capsule around the implant hardened between 6 and 12 months. Between 1 year and 7.5 years, three breasts with smooth and textured implants contracted and one with a textured implant softened.The patients reported on a Visual Analogue Scale (1 to 10) the impact of the augmentation on their quality of life to be 9 +/- 1. Four patients preferred the breast with the smooth prosthesis, three preferred the breast with the textured prosthesis, and the others found both breasts equal. This study showed no significant difference of contracture with smooth versus fine textured implants. The majority of the patients preferred the smooth implants. The patients reported that the breast augmentation had had an extremely high impact on their quality of life.

Changing pattern of histological type, location, stage and outcome of surgical treatment of gastric carcinoma.

BACKGROUND: There are indications that some features of gastric carcinoma are changing, with a possible impact on prognosis. The aim of this study was to examine any changes in type, location, stage, resection rate, postoperative mortality rate or prognosis for patients with gastric carcinoma in a well defined population. METHODS: During 1974-1991, 1161 new cases of gastric adenocarcinoma were diagnosed in Ostergötland County, Sweden. Tumour location, Laurén histological type, tumour node metastasis (TNM) stage, radicality of tumour resection and postoperative complications were recorded after histological re-evaluation of tissue specimens and examination of all patient records. Dates of death were obtained from the Swedish Central Bureau of Statistics. Time trends were studied by comparing the intervals 1974-1982 (period 1) and 1983-1991 (period 2). RESULTS: The proportion of diffuse type of adenocarcinoma increased (from 27 to 35 per cent), while that of mixed type decreased (from 16 to 9 per cent) and that of intestinal type was unchanged. The proportion of tumours located in the proximal two-thirds of the stomach increased (from 32 to 42 per cent) and the proportion of patients with tumours in TNM stage IV decreased (from 32 to 25 per cent). Overall tumour resection rates were unchanged, although the proportion of radical total gastrectomies increased (from 36 to 50 per cent). Excluding tumours of the cardia or gastric remnant after previous ulcer surgery, the 5-year relative survival rate after radical resection increased from 25 to 36 per cent and the postoperative mortality rate decreased for both radical (from 11 to 4 per cent) and palliative (from 18 to 6 per cent) resection. CONCLUSION: The patterns of tumour histology, location and stage of gastric carcinoma have changed in the authors' region. These changes were paralleled by a significant improvement in survival and postoperative mortality rates.

Treatment of leg ulcers with split skin grafts: early and late results.

Sixty patients (mean age 73.5 years) with 88 leg ulcers that had not responded to conservative treatment had split skin grafts applied at the Department of Plastic Surgery, Linköping, Sweden. Of 51 venous leg ulcers 45 (88%) healed after a mean of 15 days (range 5-30); and 13 (62%) of the 21 arterial ulcers healed after a mean of 18 days (range 8-30). Additional skin grafting was done on nine of the venous and on three of the arterial ulcers. Twenty-two (49%) of the healed venous ulcers recurred after a mean of four months while only two (15%) of the healed arterial ulcers recurred after a mean of 10 months. At late follow up after a mean of four years 18 of the patients were dead and 10 had had the leg in question amputated. Of the 34 patients still alive who had not had amputations, 31 were investigated at open ward or interviewed by telephone and 23 patients were examined with colour duplex scan. Seven of these patients had open leg ulcers. At duplex scan six patients had no venous or arterial insufficiency that could cause a leg ulcer. Of 16 patients with venous insufficiency 10 patients had only an inadequate superficial system. The mean cost for treating one leg ulcer by skin grafting is estimated at SEK 89000 (US$11125). We conclude that leg ulcers often heal with skin grafting but that venous ulcers often recur. To reduce the recurrence rate we suggest a better preoperative aetiological evaluation and improved postoperative treatment with a compression bandage.

Fibroblast movements during contraction of collagen lattices--a quantitative study using a new three-dimensional time-lapse technique with phase-contrast laser scanning microscopy.

In this study we assessed the behavior of fibroblasts during contraction of collagen lattices. We applied a new technique for three-dimensional time-lapse studies of movements of living cells using phase-contrast laser scanning microscopy. Five anchored and five floating collagen lattices were studied regarding the activity of cells during a 7-h period of active contraction. Three-dimensional reconstructions of the fibroblasts and their extensions were made from datasets of 16-26 "optical sections" 5 microm apart recorded hourly during the period of measurements. The distance between fibroblast nuclei in the floating lattices decreased by a mean of 6.8 microm, but remained constant in the anchored group. Only minor variations were found in the angle between a line connecting any two nuclei and the tangent of the lattice margin. The lengths of the cellular extensions continuously changed by shortening and extending, and an increasing number of intercellular contacts were established with time. The angle between the extensions and the periphery of the lattice varied continually, and no distinct pattern of arrangement of the extensions was seen. In conclusion, we have shown in living cells in vitro that fibroblasts do not appear to move around within lattices during contraction but rather send out and withdraw cellular extensions continuously. This speaks against cellular locomotion or movement as a main feature of contraction. Time-lapse scanning laser microscopy has also been shown to be a suitable method to study cellular behavior quantitatively in three dimensions during lattice contraction.

Expression of alpha-smooth muscle actin, TGF-beta 1 and TGF-beta type II receptor during connective tissue contraction.

Closure of rat mesenteric perforation is considered to occur by connective tissue contraction, a process that has been shown to be stimulated by transforming growth factor-beta 1. In the present study, we assessed the expression of alpha-smooth muscle actin during closure by quantitative-reverse transcription-polymerase chain reaction and in situ hybridization. The expression of transforming growth factor-beta 1 and transforming growth factor-beta type II receptor was also estimated in mesenteric membranes and free peritoneal cells after wounding. A larger expression of alpha-smooth muscle actin was seen around the wound edges compared to unwounded tissue. Both alpha-smooth muscle actin and transforming growth factor-beta type II receptor were expressed during Days 0, 3, 5, 7, and 10. The expression of alpha-smooth muscle actin on Day 5 was > 100 times higher than on Day 0. Transforming growth factor-beta 1 was expressed in both membranes and free peritoneal cells of unoperated control animals but down-regulated after wounding, a finding that has not been reported previously. It reappeared on Days 7 and 10 in free peritoneal cells but not in perforated membranes. The enhanced expression of alpha-smooth muscle actin and down-regulation of transforming growth factor-beta 1 expression after wounding appears to be important phenomena in tissue contraction and repair.

Capsular contracture with textured versus smooth saline-filled implants for breast augmentation: a prospective clinical study.

Texturization of silicone-filled breast implants has been shown to reduce the incidence of capsular contracture. A double-blind clinical study was undertaken to compare this incidence in saline-filled implants with textured or with smooth surfaces. Twenty-one women underwent mammary augmentation with a textured implant in one breast and a smooth implant in the other. The implants were placed subglandularly. All operations were performed by the same surgeon and all follow-up examinations by another. Breast hardness was evaluated 6 months postoperatively with applanation tonometry, using Baker's grading, and after 12 months, now also with a questionnaire concerning the patient's evaluation. Capsular contracture (Baker 3) had occurred in 33 percent of the breasts at the end of the study, and was bilateral in five cases. The incidence of contracture and the patients' views on the results did not differ between textured and smooth prostheses or between right and left breasts. Five patients requested reoperation, two of them because of breast hardness. Texturization of saline-filled implants thus did not reduce the incidence of capsular contracture.

The effect of diclofenac (Voltaren) on the contraction of collagen lattices.

The inhibition of prostaglandin synthesis by diclofenac was studied with regard to effects on connective-tissue contraction and on the chemotaxis of fibroblasts stimulated by platelet-derived growth factor type BB (PDGF-BB). Collagen lattices populated with human fibroblasts responded to diclofenac with significantly increased contraction; the peak effect occurred at a dose of 5 micrograms/ml. Using a two-chamber system, PDGF-BB significantly increased the chemotactic activity of fibroblasts, and addition of diclofenac further increased this activity. Higher doses of diclofenac resulted in cell death, which was also reflected in lessened contraction of lattices with 50 micrograms/ml diclofenac, half of the cells were dead. The study showed that inhibition of prostaglandin synthesis by diclofenac increases the contraction of collagen lattices populated with human fibroblasts and increases the chemotactic activity of fibroblasts stimulated with PDGF-BB.

Stimulation of protracted connective tissue repair in normal mice by transforming growth factor beta 1.

The repair and contraction during connective tissue repair of mesenteric perforations is prolonged in mice compared with rats. In the present study the stimulating effect of transforming growth factor beta 1 (TGF-beta 1) on different aspects of such repair of the mouse mesentery was assessed. The number of closed mesenteric perforations were counted on different days after operation and the free peritoneal cells were counted, the mitotic index was assessed, and actin distribution of fibroblasts around the perforation was studied with laser scanning confocal microscopy. TGF-beta 1 significantly increased the speed of closure and seemed to induce more actin in fibroblasts at the wound margin. It did not significantly influence the mitotic index, but fewer free peritoneal cells were obtained in mice treated with TGF-beta 1. We conclude that TGF-beta 1 is a potent stimulator of connective tissue repair and contraction in mice. The different methods of closure in rats and mice implicate different molecular responses in wounds and further studies on the stimulating effect of TGF-beta 1 may indicate basic fibroblastic cellular mechanisms that are active during contraction in connective tissue repair.

Contraction of collagen lattices by cells from Dupuytren's nodules.

The aim of this study was to see if nodular cells in Dupuytren's disease differed from dermal cells in their contractile capacity and motility. Ten surgical specimens from patients with Dupuytren's disease and contracture of the finger of more than 45 degrees were harvested and the nodular cells were explanted and cultured. Dermal fibroblasts from the forearm were used as control cells. Both types of cell had the same growth pattern. The morphology on confocal laser scanning microscopy was also similar in both types of cell. Dermal control cells caused significantly more contraction of collagen lattices compared with fibroblasts from nodules of Dupuytren's contracture. The F-actin content was equal in both groups. Platelet derived growth factor, PDGF-BB (but not PDGF-AA), increased the chemotactic activity of both cell types, but there were no differences between them. The results indicate that at a late state of the disease cells from Dupuytren's nodules lose their contractile capacity and regain a phenotype resembling that of dermal fibroblasts.

Actin fiber orientation in connective tissue contraction: a quantitative study with the perforated rat mesentery model.

Numerous fibroblasts with long cytoplasmic protrusions containing F-actin appear during closure by contraction of rat mesenteric perforations. These protrusions are predominantly arranged parallel to the wound margin. In the present study, the spatial and temporal organization of such protrusions was quantitated during normal and retarded healing in zinc-deficient animals. An orientation index, which gives the global orientation of the F-actin fibers, was calculated after Fourier transformation of images generated in a laser confocal microscope. Actin-rich fibroblasts began to accumulate at the wound margin on the first postoperative day, and the amount of actin gradually increased with time. The orientation index of the F-actin in unperforated mesenteric membranes was low, whereas the orientation index around perforations increased significantly (p < 0.001) with time and reached a maximum level on postoperative days 5 to 7. The orientation index was significantly lower (p < 0.02) in membranes with retarded healing in zinc-deficient animals than in controls. The findings show that image analysis can give valuable information about fibroblast organization during tissue repair and indicate that the spatial organization of the fibroblasts is an important factor in connective tissue contraction.

Bacterial peritonitis with hyperamylasemia in the absence of ultrastructural changes of pancreas. A light and electron microscopic study in the rat.

Bacterial peritonitis was induced in rats by injecting two concentrations of E. coli (10(6) cfu/mL or 10(8) cfu/mL) and B. fragilis (10(8) cfu/mL or 5 x 10(8) cfu/mL) ip. Twenty-four hours later the serum amylase activity was significantly increased in both groups. At light microscopy scattered polymorphonuclear leukocytes were observed in the pancreatic glands of both controls and rats receiving bacteria. In the peripancreatic fat microabscesses were seen in 5 of 10 animals receiving the higher dose of bacteria. There were no fat necroses. Morphometric analysis of the pancreatic ultrastructure revealed a marginal but statistically nonsignificant increase of the volume density of connective tissue stroma indicating slight edema. There were no apparent changes seen within the acinar cells. Morphometrically the granule volume density, numerical density of granule profiles, numerical granule density, nuclear volume density, and numerical condensing vacuole density were similar between controls and animals receiving bacteria. We conclude that, although bacterial peritonitis caused hyperamylasemia, no obvious morphologic damage was found in the exocrine pancreas.

Bacterial translocation during acute pancreatitis in rats.

OBJECTIVE: To see if bile-induced pancreatitis could cause bacterial translocation to mesenteric lymph nodes, and therefore pancreatic necrosis, in rats. DESIGN: Controlled experiment. MATERIAL: 18 Male Wistar rats. INTERVENTIONS: Pancreatitis was induced in the experimental group (n = 12) by infusion of 0.2 ml of a solution containing 4 mumol (20 mumol/ml) sodium taurodeoxycholate into the pancreatic duct over one minute. The controls had sham operations (no infusion). Two days later repeat laparotomy was done on all surviving animals and samples taken for microbiological analysis. All animals were weighed at the beginning and end of the experiment. RESULTS: Bacteria were isolated from the mesenteric lymph nodes in all survivors in the experimental group (9/12), and from the pancreas in all but one. Blood and peritoneal fluid were colonised in 5 and 7 rats, respectively. Escherichia coli was the most common organism isolated. Positive anaerobic cultures were obtained from mesenteric lymph nodes in 5, and from the pancreas in one. Rats with pancreatitis developed overgrowth of both aerobic and anaerobic bacteria in the caecum and the ileum, but on light microscopic examination the proximal and distal intestinal mucosa did not differ between control and experimental rats. Bacterial translocation increased as the condition of the animals worsened. CONCLUSION: Acute pancreatitis in rats causes systemic bacterial colonisation, probably as a result of bacterial translocation, which may therefore be a mechanism of pancreatic infection.

The resorption of FITC-dextran 10,000 from the peritoneum in different modifications of bile-induced acute pancreatitis and in bacterial peritonitis.

The resorption from the peritoneum of fluorescein-isothiocyanate-conjugated (FITC) dextran with a mol wt of 10,000 was studied after 6, 15, and 24 h in rats with (1) only laparotomy (LC), (2) bacterial peritonitis (BP), (3) bile-induced acute pancreatitis (AP), (4) acute pancreatitis induced with contaminated bile (AIP), and (5) cerulein administration during acute pancreatitis (CAP). Animals in the AIP and CAP groups had a significantly higher mortality rate at 24 h and higher hematocrit at 6 h, indicating severe disease in these animals. At 6 and 15 h, all groups displayed similar peritoneal resorption. After 24 h, all groups with active inflammation showed significantly higher resorption than laparotomy controls. We conclude that peritoneal resorption as defined is independent of the severity and mode of induction of acute experimental pancreatitis and that it is the same as in bacterial peritonitis.

Acute experimental suppurative pancreatitis in the rat.

Acute pancreatitis was induced in rats by infusing sodium taurodeoxycholate with or without Escherichia coli and Bacteroides fragilis into the bile-pancreatic duct. Survival did not differ between the 'noninfected bile group' (NIB) and the 'infected bile group' (IB). At standardized macroscopic evaluation, pancreatitis was more severe in the IB group (p less than 0.05). Histologic examination on day 7 showed suppuration of pancreatic tissue in 6/7 IB and 3/14 NIB rats (p less than 0.05). Bacteriologic culture of pancreatic tissue was positive in 6/8 IB and 3/17 NIB rats (p less than 0.01). Bacterial culture of blood, peritoneal fluid of pulmonary tissue was seldom positive. Concordance between microscopically observed suppuration and positive bacterial culture was almost total. Recall antigen skin testing indicated anergy in the IB group, while the NIB group showed moderately diminished reaction (p less than 0.001). Similar increase of S-fibrinogen was found on day 3 in both groups, but complement factor C3 was reduced only in the IB group. This experimental model, with suppurative pancreatitis induced by intraductal infusion of an infected bile salt, may be useful for studies of systemic complications in acute pancreatitis.

Proglumide treatment in bile-induced acute experimental pancreatitis.

Rats with acute experimental pancreatitis were treated with the cholecystokinin (CCK)-receptor antagonist proglumide. S-amylase was not affected by proglumide during the initial 4 h but was reduced after 72 h as compared to pre-pancreatitis values. The amylase levels in peritoneal fluid were lower in proglumide treated animals at 1, 2, 4 and 72 h after the induction of the pancreatitis, and amylase in pancreatic tissue was increased by proglumide after six but not 72 h. In spite of these biochemical changes, suggesting beneficial therapeutic effects by proglumide, survival rate was not improved when using a dose of 100 mg/kg every 8 h for 48 h and significantly reduced at a dose of 500 mg/kg every 8 h for 48 h. The results do not support proglumide as the sole treatment in acute pancreatitis.

Gallbladder cancer: current status in clinical practice.

A total series of 68 unselected patients with gallbladder cancer, diagnosed during 1972 to 1981, was studied retrospectively. In 61 cases (90%), the diagnosis was histologically verified. The cardinal symptoms were local pain (87%), loss of weight (53%), and jaundice (59%). The diagnosis was established after autopsy in 22 patients (32%), and exploratory laparotomy in 22 patients (32%). Palliative surgery was carried out in 26 patients of whom seven (27%) died postoperatively. Only one patient, with an incidentally detected cancer at routine cholecystectomy, was treated radically. Four out of nine patients died within one month after PTC-drainage. The mean survival time for the whole series was 2.9 months. The longest survival was 21 months. Considering the increasing incidence of gallbladder cancer in Sweden, as well as of other cancers of the biliary system, these findings emphasize the need for intensified research. An epidemiological approach studying the correlation of gallbladder cancer with the changing trend of gallstone disease and its treatment would perhaps be fruitful.

Pancreatic cancer.

During 1972-1981, a total of 177 individuals were diagnosed as having pancreatic cancer at the Central Hospital of Eskilstuna, Sweden. The mean crude incidence rate was 15.0 X 10(-5) year-1. Only 56% of the patients had the diagnosis made prior to death. 63% of the cancers had advanced beyond therapeutic range. Symptoms compatible with upper abdominal disease for more than six months prior to diagnosis occurred in 27% of the cases, and 15% had sought medical advice more than 6 months prior to diagnosis. Radical surgery was performed on 5 patients of whom one died postoperatively, and 61 patients (34%) underwent palliative treatment. The postoperative mortality rate after palliative treatment was 28%. The mean survival time for the whole series was 2.6 months, and 13% survived for one year. One patient survived for 2 years after palliative treatment. It is concluded that the only means by which the prognosis for patients with pancreatic cancer may be improved is to define populations at high risk and to develop more specific and sensitive diagnostic methods.

Endoscopic sphincterotomy in the treatment of choledocholithiasis and ampullar stenosis. Experience with 202 patients.

Endoscopic sphincterotomy (EST) was performed on 202 patients (265 EST) in the 5-year period 1978-1983 because of choledocholithiasis or benign stenosis of the ampulla of Vater. The indications for EST in choledocholithiasis included residual or recurrent stone(s) in 80 cholecystectomized patients, and 96 had choledocholithiasis with the gallbladder in situ. Ductal calculi passed spontaneously after EST in 87 cases (50%) and were actively extracted in 73 (41%). Ductal clearance failed in 16 patients. The overall success rate thus was 91%. Ampullar stenosis was successfully treated in 26 patients. Sphincter stenosis after EST was diagnosed in one patient. Immediate complications of EST arose in 31 patients (11.7%), one of whom died. Emergency laparotomy was required in three cases (1.1%). EST with or without stone extraction is a relatively safe procedure for managing choledocholithiasis in high-risk patients before cholecystectomy is considered, and also for stones retained or reformed after cholecystectomy. Endoscopic treatment may offer appreciable clinical and financial benefits by reducing morbidity and mortality rates and shortening hospitalization and convalescence time.