Adverse metabolic consequences of nutritional support: micronutrients.

The role of total parenteral nutrition in cancer patients is still a matter of controversy. Over the last decade there has been a heightened interest in the interaction of micronutrients with tumor cells. A review of the literature reveals that the question of feeding or suppressing the tumor by supplementing micronutrients remains unanswered. Prospective studies are needed to define the requirements of vitamins and trace elements in the cancer patient.

Pressure ulcer accelerated healing with local injections of granulocyte macrophage-colony stimulating factor.

This is the first report of granulocyte macrophage-colony stimulating factor (GM-CSF) inducing accelerated healing of a sacral pressure ulcer in a bedridden patient with bilateral hemiplegia. GM-CSF was diluted and injected locally around and into the ulcer bed every 2-3 days for 2 weeks, then weekly for 4 weeks until complete healing occurred. A new firm granulation tissue was noted within a few days. The ulcer showed 85% healing within 2 weeks and 100% by 2 months. Healing started from the periphery and from within the ulcer bed at sites of GM-CSF injections. It was slower at areas where there was complete necrosis and detachment of skin from underlying tissue. The ulcer remained closed until the patient's sudden death 9 months later. A biopsy of granulation tissue showed inflammatory cells and reactive fibroblasts. The potential role of GM-CSF and growth factors in pressure ulcer therapy and wound healing are discussed.

Nonfunctioning adrenal tumors. Dilemmas in management.

A retrospective study conducted from 1975-1987 at Vanderbilt University Medical Center and affiliated hospitals identified 28 patients, ranging in age from 22 to 74 years, who were noted to have "nonfunctioning" adrenocortical tumors. Eighteen (64%) were men, and ten (36%) were women. A left adrenal mass was present in 16 (57%) patients, a right in 11 (39%) patients, and one (4%) patient had bilateral adrenal enlargements. Nineteen patients underwent an adrenalectomy. Ten were found to have adrenocortical adenomas, ranging is size from 2.5-4.0 cm in greatest diameter. Three were adrenocortical carcinomas (3.0, 5.5, and 8.0 cm). A necrotic mass (14.0 cm) was found in one patient. Two patients had myelolipoma, one had ganglioneuroma, and one had a suspected primary melanoma. Five patients were not operated upon and were followed by serial computed tomographic scans for variable periods; two died of unrelated cardiac problems, and one was lost to follow-up. Three patients underwent biopsy with benign pathology. The data indicate a high incidence of adenoma and carcinoma in patients with nonfunctioning adrenal tumors that measure more than 3.0 cm in diameter. These tumors have the potential to progress to malignant degeneration without any recognizable clinical or endocrine abnormalities. The authors thus conclude that all patients with "nonfunctioning" adrenal tumors that are larger than 3.0 cm in diameter should undergo surgical exploration and excision.

Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot.

We present our experience at the American University of Beirut Medical Center with two diabetic patients suffering from large necrotic and infected foot ulcers. Both patients were ambulatory at the time of presentation despite their extensive wounds and were believed to have a useful limb with adequate protective sensation worth saving. Below-knee amputation was prevented in both cases by successful soft-tissue coverage of the ulcers using microvascular composite-tissue transfer a few days after performing a preliminary arteriovenous fistula with a long vein graft loop. The flap vessels were anastomosed end-to-end to the arterial and venous limbs of the divided arteriovenous loop. This reconstructive technique of difficult diabetic wounds of the lower extremity, though in two stages, may be safer than one long procedure in a high-risk patient. It is technically easier than long interpositional vein grafts at the same time as free-flap transfer or microvascular anastomoses with small and diseased vessels. It definitely provides more chance of success as larger vessels are used to supply the flap. It permits distension of the vein graft at normotensive physiologic pressures and allows testing the arterial anastomosis as well as the venous flow before final flap transfer. Above all, it allows extreme freedom in performing tension-free anastomoses away from the infected wound.

One-stage closure of the entire primary palate.

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.

The role of lidocaine, epinephrine, and flap elevation in wound healing after chemical peel.

We have observed 5 patients with hypertrophic scarring at the lateral boundaries of the chemically peeled area when circumoral peel was combined with facial rhytidectomy. Some of the potential contributory factors include flap elevation, epinephrine, and lidocaine hydrochloride. To discover whether any one of these three factors or a combination played a role, a rat model study was designed. Initially, 40, 400-gm Sprague-Dawley rats were divided into 4 groups, each comprised by 10 rats. Injections with lidocaine or lidocaine with epinephrine, and chemical peel were done in 2 groups. The same injections were used in the remaining 2 groups together with simultaneous preliminary flap elevations and chemical peeling. After the review of the initial study results, another 40 Sprague-Dawley rats were used to repeat the study and compare on a larger scale the effects of lidocaine with and without epinephrine on the depth of chemical peel. The findings of the rat model studies indicate that preliminary injections with lidocaine containing solution (with or without epinephrine) result in a major delay in healing time. Flap elevation and chemical peeling were associated with major morbidity and mortality in the test rats. The presence of epinephrine in lidocaine solution had no significant role in increasing the delay in the healing process.

Replantation of an amputated upper lip.

Soft tissue defects of the face are a difficult reconstructive problem. Replantation of large amputated segments of the face has been rarely successful and has lagged well behind extremity trauma due in part to the relative rarity of these defects. Presented is a case of successful microvascular replantation of half of the upper lip after a dog bite.