Local flaps of the hand.

Hand injuries are common, and due to the complex functions of the hand, soft tissue defects present a surgical challenge in reconstruction. Hand defects exposing deeper structures warrant reconstruction with local flaps, but in Denmark, reconstruction surgery of the hand is routinely managed within the orthopaedic specialty alone with no plastic surgical involvement. This review aims at describing the most common local flaps of the hand and forearm and encourage to stronger collaboration between hand- and plastic surgeons in Denmark.

Case report: surgical management of massive scrotal lymphedema in a bariatric patient.

A morbidly obese male patient was referred to our department for joint-venture excision surgery of a massive genital lymphedema that had increased 10-fold in volume over a 3-year period. The patient underwent two-stage excision and reconstruction surgery including orchiectomy and was discharged with no major complications and reported improved outcome and urogenital function after surgery at 6-month follow-up. Genital lymphedema is a rare and surgically challenging disease that is related to obesity and causes functional and psychosocial impairment. The planning, performance and postoperative care of surgery on bariatric patients requires tailored surgical treatment and the involvement of several different medical professions and specialties. Surgical debulking can bring about satisfactory outcomes and profound improvements in quality of life.

Endothelial glycocalyx shedding in patients with burns.

Shedding of syndecan-1 from the endothelial glycocalyx layer (EGL), referred to as endotheliopathy of trauma (EoT), is associated with poorer outcomes. This study aims to determine if EoT is also present in the burn population. We enrolled 458 burn and non-burn trauma patients at a Level 1 trauma center and defined EoT by a syndecan-1 level of ≥40 ng/mL. Sixty-eight of the enrolled patients had burns with a median TBSA of 19%, with 27.9% also suffering inhalational injury (II). Mortality was similar between the burn and non-burn group, also for patients with EoT. The incidence of II was significantly greater in the EoT+ burn group compared to the EoT- group (p = 0.038). Patients with II received significantly larger amounts of i.v. fluids (p = 0.001). The incidence of EoT was significantly different between the II-groups, as was mortality (pEoT = 0.038, pmortality < 0.001). EoT is attributed to the shock rather than the mechanism of trauma and may in burns be associated to II rather than TBSA. Patients with burns and II had worse outcomes and higher mortality compared to patients with burns alone. Burn injury induces EGL shedding similar to that in non-burn patients with EoT, and results in similar higher rate of mortality.

Management of bleeding in major burn surgery.

Major burn surgery is often associated with excessive bleeding and massive transfusion, and the development of a coagulopathy during major burn surgery is associated with increased morbidity and mortality. The aim of this study was to review the literature on intraoperative haemostatic resuscitation of burn patients during necrectomy to reveal strategies applied for haemostatic monitoring and resuscitation. We searched PubMed, EMBASE, and CENTRAL for studies published in the period 2006-2017 concerning bleeding issues related to burn surgery i.e. coagulopathy, transfusion requirements and clinical outcomes. In a broad search, a total of 1375 papers were identified. 124 of these fulfilled the inclusion criteria, and six of these were included for review. The literature confirmed that transfusion requirements increases with burn injury severity and that haemostatic monitoring by TEG® (thrombelastography) or ROTEM® (rotational thromboelastometry) significantly decreased intraoperative transfusions and was useful in predicting and goal-directing haemostatic therapy during excision surgery. Resuscitation of bleeding during major burn surgery in many instances was neither standardized nor haemostatic. We suggest that resuscitation should aim for normal haemostasis during the bleeding phase through close haemostatic monitoring and resuscitation. Randomised controlled trials are highly warranted to confirm the benefit of this concept.