Urokinase protocol for free-flap salvage following prolonged venous thrombosis.

The incidence of free-flap failure is reported at 4 to 5 percent. Often, these failures are attributed to postoperative venous thrombosis with salvage rates reported at 42 percent. The use of thrombolytics has been effective in laboratory protocols; however, there have been only case reports to substantiate their use in humans. In this study, we establish a protocol for the administration of urokinase for postoperative venous thrombosis. Upon clinical evidence of venous thrombosis, all patients were urgently returned to the operating room, where the venous anastomosis was resected and a new venous anastomosis was performed. A solution of 250,000 units of urokinase was then infused over 30 minutes through a 25-gauge butterfly inserted into the recipient artery just proximal to the arterial anastomosis. Patients were continued on a daily aspirin (325 mg). More than 600 free flaps have been performed by our group since 1990. In that group of patients, five were diagnosed with postoperative venous thrombosis. Flaps consisted of four radial forearm flaps and one free transverse rectus abdominis muscle flap. All patients were diagnosed late based upon significant changes within the flap. Thromboses were clinically apparent on postoperative days 1 through 6, with an average of 3.6 days. All five patients received urokinase as described. The average age of the patients treated was 43. There were no postoperative hematomas, blood transfusions, or bleeding complications. There were no allergic or anaphylactic reactions to the urokinase. All flaps survived (100 percent) with a mean follow-up of 27 months. The use of urokinase as described in our protocol has been an effective thrombolytic, capable of reversing clinically advanced venous thrombosis when combined with repeated venous anastomosis. We believe this protocol provides a viable option for the treatment of postoperative venous thrombosis.

Obliteration of empyema tract with deepithelialized unipedicle transverse rectus abdominis myocutaneous flap.

Four patients with chronic empyema after pneumonectomy have undergone successful obliteration of the empyema tract with a deepithelialized transverse rectus abdominis myocutaneous flap. The deepithelialized skin island has provided sufficient bulk for tract obliteration. Rotation of the skin island into the long axis of the rectus muscle has added considerable length to this flap, allowing it to reach the apex of the thoracic cavity. A recurrent loculation developed 4 months after the obliteration procedure in one patient. This was successfully treated with open pleural drainage and a second Clagett procedure. Over a mean follow-up period of 35 months, all four patients are free of further infectious sequelae. Chest roentgenograms have confirmed eradication of the tracts in all four patients.

Free tissue transfer in pediatric patients.

The majority of reports on free tissue transfer involve adults; few have specifically addressed children. During the past 5 years, 20 free tissue transfers were performed in 19 pediatric patients. Patients ranged in age from 3 to 17 years, with a mean age of 10 years. Eight patients were 6 years and younger; 11 patients were 13 to 17 years old. Soft-tissue defects requiring reconstruction resulted from acute trauma in 12 patients, tumor ablation in 5 patients, infection in 1 patient, and hemifacial atrophy in 1 patient. Soft-tissue defects occurred in the lower extremity in 16 patients, the head and neck in 2 patients, and the upper extremity in 1 patient. The donor tissues included the latissimus dorsi muscle in 7 patients, the radial forearm flap in 7 patients, the rectus abdominis muscle in 4 patients, and the scapular fasciocutaneous flap in 2 patients. All patients received aspirin preoperatively. Mean operative time was 6.5 hours, with a range of 4 to 8 hours. Postoperative heparin infusion was used for 5 days in 7 of the 8 patients age 6 years and younger. All free tissue transfers were successful. One flap to a traumatic foot wound (patient age, 4 years) had a venous thrombosis on the second postoperative day, and was successfully treated with urokinase and heparin infusions and repeat venous anastomosis. There were no other significant morbidities and no mortalities. Hospitalization following free tissue transfer averaged 13 days, with a range of 6 to 37 days. Follow-up has averaged 31 months, with a range of 8 to 59 months. Late complications included a progressive equinus deformity 3 years after a heel reconstruction following a lawn mower injury and a contour deformity following a scapula flap to a gunshot wound of the foot. Sixteen of the 17 lower extremity reconstructions have shown normal growth. No growth disturbances or significant functional losses have occurred at the donor sites. Most patients have maintained normal extremity function including participation in athletics. Special considerations in this group of patients have included subtherapeutic heparin infusion during the postoperative period in young children, minimizing the aesthetic defect at the donor site and providing composite reconstructions whenever possible.

Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage.

Atherosclerosis of the lower extremity frequently leads to limb-threatening ischemic soft-tissue wounds. Over the past 44 months, 30 selected patients with arterial disease documented by angiography were treated with combined vascular reconstruction and free-tissue transfer for limb salvage. Soft-tissue defects occurred on the plantar and dorsal surfaces of the foot and distal tibia with significant bone, tendon, or joint exposure. Thirteen patients had osteomyelitis. Eighteen patients underwent simultaneous soft-tissue and vascular reconstruction, while 12 patients underwent delayed soft-tissue reconstruction. The free-flap tissues included the rectus abdominis flap in 13, the latissimus dorsi flap in 7, the radial forearm flap in 5, the scapular flap in 3, and the omentum flap in 2. Autogenous venous bypass was performed to the popliteal segment in 6 patients and the infrapopliteal arteries in 18. Five patients had inadequate outflow for complete vascular reconstruction and were treated with proximal vein grafts directed into the free flap. Twenty-two patients (73 percent) had successful free-tissue transfer and bypass graft patency and were independent ambulators over the mean follow-up period of 22 months. Of the 8 unsuccessful reconstructions, 3 patients had early free-flap and graft failure. Five patients developed new areas of ischemic disease despite graft and flap patency. All 8 patients were treated with amputation; 7 never regained ambulation. The combined application of vascular and free-flap soft-tissue reconstruction for the threatened ischemic lower extremity has produced excellent functional results in the majority of our patients.

Comparison of the operating microscope and loupes for free microvascular tissue transfer.

A retrospective study of 200 consecutive free microvascular tissue transfers over a 3-year period was done to compare the performance of free-tissue transfers with loupes and with the operating microscope. One-hundred and nineteen flaps (59.5 percent) were performed under 3.5 x loupe magnification and 81 under the operating microscope (40.5 percent). The magnification selection process was based on cumulative past experience, with all early anastomoses performed with the microscope and the vast majority of the more recent operations performed with loupe magnification. Loupes were used preferentially for head and neck reconstruction and breast reconstruction. The microscope was required for performing vascular anastomoses on children and on vessels less than or equal to 1.5 mm in diameter. Results were compared with respect to etiology of defect, type of flap, age of patient, free-flap success, complications, and overall success of the reconstruction. There was no difference in outcome between the two groups, with free-flap success rates of 99 percent for both the loupe and the microscope groups. We believe that our success with loupe-only free-tissue transfers is attributable to our prior considerable experience with the microscope. We would caution that comfort and experience with microanastomoses under the operating microscope should be obtained prior to beginning a loupe-only experience.

Efficacy of prophylactic antibiotics in reduction mammoplasty.

The use of prophylactic antibiotics in reduction mammoplasty has been random and its efficacy unproven. This study reviewed 106 consecutive inferior pedicle technique reduction mammoplasties. Two groups were identified; 47 patients received prophylactic antibiotics and 59 patients did not. The decision of who received prophylactic antibiotics was random based on resident rotation and resident preoperative orders. The demographics were equal between the antibiotic group and the control group. The wound infection rate and the rate of delayed healing were examined in both groups. There were no statistically significant differences in the infection rate or the rate of delayed wound healing in either the antibiotic group or the control group. Individual risk factors were also studied in each group. These risk factors included obesity, older age, smoking history, and large reductions. The use of prophylactic antibiotics did not reduce the infection rate in any of these high-risk groups. Comparing the individual risk factors for the remainder of the patient population showed that the infection rate was higher in obese patients but was unaffected by prophylactic antibiotics. Delayed healing was also higher in larger reductions but also was unaffected by the use of prophylactic antibiotics. We conclude that the use of prophylactic antibiotics in reduction mammoplasty is not efficacious in reducing the rate of wound infection or delayed healing.

Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer.

PURPOSE: Vascular reconstruction alone can be insufficient for extremity salvage in some patients with severe soft-tissue wounds. We present our experience in 20 patients with vascular reconstruction for ischemic disease and free-tissue transfer for limb-threatening soft-tissue wounds. METHODS: Nineteen patients underwent autogenous venous bypasses and one patient underwent an aortobifemoral bypass. Ten soft-tissue reconstruction were performed at the time of the vascular reconstruction and 10 were delayed. Free-tissue transferred included muscle, fasciocutaneous flaps, and omentum. Inflow to the flap was from the bypass graft (n = 12) or the distal tibial artery. RESULTS: One free flap and graft failed immediately in the same patient. One successful flap and graft required a below-knee amputation for ongoing infection in the surrounding soft tissues. Eighteen of 20 patients have had free-flap and graft patency during the mean follow-up period of 17 months (range 6 to 33 months). These 18 patients ambulate independently. CONCLUSIONS: In patients with arterial insufficiency and severe soft-tissue wounds, combined vascular reconstruction and free-tissue transfer permits extended limb salvage with excellent functional results.

Revascularization of the lower extremity with omentum.

The use of the omental graft with multiple level arterial anastomoses may prove useful for salvaging the severely ischemic lower limb. Because the long-term results of full free omental grafts may depend on neovascularization of the omentum from the surrounding tissue, the technique described here should be utilized only in those patients who are not suitable candidates for other procedures.

Methods for the endoscopic photographic and visual detection of helium cadmium laser-induced fluorescence of Photofrin II.

Endoscopic detection of small tumors is key to the early diagnosis and treatment of malignancy. This paper describes a simple, endoscopic detection system which enables tumor localization and a permanent record based on the laser-induced fluorescence of dihematoporphyrin ether (LIFD). Spectral analysis of dihematoporphyrin ether (DHE, Photofrin II) was performed with a Perkin Elmer LS-5 scanning fluorimeter. DHE at concentrations of 50 micrograms/ml and 5 micrograms/ml in 95% ethanol were tested, demonstrating fluorescence quenching at 50 micrograms/ml DHE at 406 nm excitation. This phenomenon was not observed at 442 nm excitation. Based on this data and the availability of the helium cadmium laser, a series of endoscopic detection systems was developed and tested utilizing a LiConix 4240NB helium cadmium laser (TEMoo, 442 nm, 40 mW). A fiber with a microdiverging (MDL) lens was used. Irradiance achieved at the tip of the fiber was 31.58 mW/cm2 for MDL. A Corning 34832 (550 nm) sharp cutoff barrier filter was coupled to an Olympus OES BF2T10 bronchoscope. Successful detection of LIFD was obtained. Direct observation of LIFD is possible when wearing Laserguard argon safety goggles (OD 15 at 488 nm, OD 11 at 514 nm). Photographic recording of LIFD was performed with the following cameras and parameters: Olympus OM-2S camera (OM2) with EES135 film (ISO 1600) with a 4-second exposure (method 1) and the Olympus OES SCP-10 instant camera with Polaroid 779 (ISO 640) film and a 120-second exposure (method 2). The photographic methods demonstrate the red fluorescence of DHE on filter paper disks at concentrations of 0.5 micrograms/ml (500 ng/ml). (ABSTRACT TRUNCATED AT 250 WORDS)

Mechanisms of reduction of tumor recurrence with carbon dioxide laser in experimental mammary tumors.

This study compares local tumor recurrence after low energy CO2 laser wound sterilization with recurrence after scalpel, laser or electrocautery excision. Wound histologic changes were studied to understand the mechanism of the interaction between the laser and wound. Single implants of R3230AC mammary tumor were grown to an average diameter of 24 millimeters in the mammary ridge of 80 female fisher 344 rats. Rats were anesthesized with pentobarbital and randomized into groups, each with similar tumor size: scalpel (S), laser (L), laser with wound sterilization (LV), scalpel with sterilization (SV) and electrocautery (E). All surgical procedures were performed by the same surgeon with the same technique, with the exception of the instruments used. Tow rats from each group were sacrificed immediately and the wounds examined histologically. The Sharplan 1100 CO2 laser was used with a 125 millimeter hand piece in focus and in continuous wave for groups L and LV. Sterilization in groups LV and SV was performed with 5 millimeter spot size by heating the site gently without causing blanching of tissue. Excision in group E was performed with coagulating current from a monopolar cautery (Valley Lab). Rats were examined periodically for 30 days and those dying during this period were excluded from analysis. The incidence of wound recurrence was eight of 12 in group S; five of eight, L; four of 13, E; three of 12, LV, and two of nine, SV (p less than 0 .05). Histologic changes in the wound demonstrated viable tumor in all groups, with fewer areas present in groups E, SV and LV. Local thermal effects and the noncontact nature of the CO2 laser make it an effective adjunct in reducing local tumor recurrence by enhancing the cytoreductive capability of surgical procedures.

The use of the carbon dioxide laser permits primary closure of contaminated and purulent lesions and wounds.

Excision of contaminated and purulent wounds with the carbon dioxide laser makes it safe to close the wounds primarily when certain steps are observed during the operation. The contaminated surface is sterilized with the defocused beam. The surgeons' and assistants' hands should not touch the contaminated areas, and both should wear two pairs of rubber gloves to protect against accidental contamination. All infected tissue is excised completely, and the wound cleansed by copious irrigation and the defocused laser. The wound may then be safely closed by simple sutures, skin graft, or by the rotation of a vascularized musculocutaneous flap. A series of cases are presented in order to illustrate these points.

The influence of hands-on laser training on usage of the CO2 laser.

A questionnaire was distributed to all participants in the Rochester General Hospital CO2 laser training workshops for surgeons (1982 to January 1985). The results of this study indicate that, while laser training is necessary prior to being able to use the laser, only a small fraction of trainees actually use the laser in their clinical practice. Surgeons who are using the laser do so in a minority of their cases. New incentives for laser usage must be investigated.

Effect of hematoporphyrin derivative 2 on estrogen receptors in experimental mammary tumors.

This study reports the effect of hematoporphyrin derivative 2 (HPD2) on estrogen receptors (ER) in the animal model used to develop the clinical ER assay. Fifty 200-g female Sprague-Dawley rats were given 20 mg of dimethylbenzanthracene by gastric intubation. Spontaneous mammary tumors occurred in 35 animals. Animals were anesthetized and 50% of each tumor was removed when the tumors were 2 cm in diameter. Animals were then randomized to receive 5 mg/kg (group A), 10 mg/kg (group B), or 0 mg/kg (group C) HPD2 intravenously 48 hours after biopsy. The remaining tumor was excised 48 hours post HPD2 injection. All samples were weighed, placed on ice, and frozen to -70 degrees C. ER assay was performed by batch run. Results (fmol/mg cytosol) were as follows: All animals (n = 35) pre HPD2 34.2 +/- 5.4, post HPD2 34.2 +/- 5.8; group A: (n = 11) pre HPD2 33.9 +/- 7.9, post HPD2 37.1 +/- 7.8; group B: (n = 13) pre HPD2 29.2 +/- 3.8, post HPD2 25.5 +/- 3.6; group C: (n = 11) pre HPD2 40.3 +/- 5.2, post HPD2 41.5 +/- 7.9. HPD2 does not affect ER in this animal model. Confirmatory studies with human tumor material must be completed.

The effect of CO2 laser excision on local tumor recurrence.

This study was undertaken to determine the effect of CO2 laser surgery on the incidence of local recurrence following tumor recurrence and to study the effect of "sterilization" of the operative site on this phenomenon. Sixty Fisher 344 rats were implanted with R323OAC mammary carcinoma. Animals were anesthetized with intraperitoneal pentobarbital, and all tumors were completely excised at 21 days postimplantation. The animals were randomized into groups of 12 as follows: Group S underwent excision with the scalpel. Group E underwent excision with electrocautery (Bovie, Valley Labs, Boulder, CO). Group L and LV underwent excision with the Sharplan 733 CO2 laser (Laser Industries, Israel) (TEMoo, 125-mm handpiece, 25-W continuous wave). Group LV wounds were then "sterilized" by using the laser defocused to a 5-mm spot size and gently heating the site without producing blanching or charring of the tissues. Primary tumor size was 2.0 +/- 0.5 cm and was similar in all groups. Animals were observed for recurrence for 33 days postoperatively. Mortalities were excluded from analysis. Tumors recurred in 7/9 (78%) in group S, 5/11 (45%) in group E, 4/10 (40%) in group L, and only 1/12 (8%) in group LV. All results are significant at P less than 0.05. The CO2 laser is an effective surgical adjunct to reduce local tumor seeding and recurrence. This effect is enhanced by "sterilizing" the surgical site with the defocused laser beam.

Mediastinal cutaneous fistulae arising as a complication of major cardiac surgery: the value of sinography and injection of methylene blue in their radical excision and immediate repair.

The management of chronic sternal wound infections is a difficult problem. Fistulography can be extremely useful in defining the extent of the infection. Staining the fistula with methylene blue aids the surgeon in the operative dissection and removal of infected material. A technique of reconstruction is described using an omental flap to fill in the retrosternal space and partially de-epithelialised pectoralis major myocutaneous flaps to cover the sternum.