Effective excision of cutaneous squamous cell carcinoma of the face using analysis of intra-operative frozen sections from the whole specimen.

BACKGROUND AND OBJECTIVES: We excised cutaneous squamous cell carcinoma (cSCC) of the face while using intra-operative frozen section analysis of the margins in an optimized bread-loafing fashion (WIFSA). METHODS: Medical records were reviewed of 160 cSCCs of the face that were treated by surgical excision with WIFSA between April 2007 and January 2013. The accuracy of WIFSA was verified by comparing results with postoperative formalin-fixed paraffin-embedded (FFPE) sections. Also, recurrence and metastasis during follow-up were studied and duration of treatment and complications were analyzed. RESULTS: The 160 cSCCs affected 152 patients. In 131 cSCCs (mean follow-up: 41.0 months, SD: ±26.3, range: 3.0-110.7) occurred 6 (4.6%) recurrences and 2 (1.5%) metastases. Of the WIFSA results, 98.8% corresponded with postoperative FFPE sections. Mean duration of treatment was 77 min (SD: ±25, range: 34-159) and complication rate was 8.1%. CONCLUSIONS: Surgical excision with WIFSA is an excellent treatment modality for cSCC of the face because of its accurate method for assessment of complete tumor removal, low recurrence and metastasis rate, short average duration of treatment, and low complication rate.

Treatment of Recurrent and Persistent Carpal Tunnel Syndrome: The Fasciocutaneous Dorsal Ulnar Artery Flap.

Surgical treatment of recurrent and persistent carpal tunnel syndrome by repeat carpal tunnel release combined with soft tissue nerve coverage results in a higher success rate for symptomatic relief in the presence of a scarred median nerve. Several techniques, including local pedicled flaps, transposition flaps from the distal forearm, and free flaps, have been described, but consensus regarding a preferred technique has not been reached. The dorsal ulnar artery flap or Becker flap is a local fasciocutaneous flap based on a dorsal perforating branch of the ulnar artery that can be used for soft tissue coverage of the median nerve. Advantages of this technique are the quick and easy dissection and low donor site morbidity. Studies of its use for the treatment of recurrent carpal tunnel syndrome are limited.

Congenital unilateral absence of the vas deferens with ipsilateral renal agenesis encountered during laparoscopic totally extraperitoneal inguinal hernia repair in an adult patient: A case report.

INTRODUCTION AND IMPORTANCE: Congenital unilateral absence of the vas deferens and ipsilateral renal agenesis is a rare condition in which the vas deferens is absent unilateral due to a congenital anomaly. This report illustrates the clinical relevance of absence of the vasa deferentia. This occurs either unilateral, which is associated with renal anomalies, or bilateral which leads to azoospermia and often has a genetic link to cystic fibrosis. CASE PRESENTATION: We report the first incidental finding of congenital unilateral absence of the vas deferens and ipsilateral renal agenesis during bilateral laparoscopic totally extraperitoneal inguinal hernia repair in a 70 year old patient. CONCLUSION: Surgeons who encounter unilateral absence of the vas deferens should assess bilateral absence of the vasa deferentia by palpation in adult patients or by laparoscopic exploration of the contralateral inguinal canal in pediatric patients. Renal ultrasonography should be performed in all patients to assess renal anomalies. Genetic counselling is advised when absence of the vasa deferentia is present bilaterally of unilaterally with associated infertility.

Surgical Treatment of Diabetic Foot Ulcers Complicated by Osteomyelitis with Gentamicin-Loaded Calcium Sulphate-Hydroxyapatite Biocomposite.

Diabetic foot ulcers, complicated by osteomyelitis, can be treated by surgical resection, dead space filling with gentamicin-loaded calcium sulphate-hydroxyapatite (CaS-HA) biocomposite, and closure of soft tissues and skin. To assess the feasibility of this treatment regimen, we conducted a multicenter retrospective cohort study of patients after failed conventional treatments. From 13 hospitals we included 64 patients with forefoot (n = 41 (64%)), midfoot (n = 14 (22%)), or hindfoot (n = 9 (14%)) ulcers complicated by osteomyelitis. Median follow-up was 43 (interquartile range, 20-61) weeks. We observed wound healing in 54 patients (84%) and treatment success (wound healing without ulcer recurrence) in 42 patients (66%). Treatment failures (no wound healing or ulcer recurrence) led to minor amputations in four patients (6%) and major amputations in seven patients (11%). Factors associated with treatment failures in univariable Cox regression analysis were gentamicin-resistant osteomyelitis (hazard ratio (HR), 3.847; 95%-confidence interval (CI), 1.065-13.899), hindfoot ulcers (HR, 3.624; 95%-CI, 1.187-11.060) and surgical procedures with gentamicin-loaded CaS-HA biocomposite that involved minor amputations (HR, 3.965; 95%-CI, 1.608-9.777). In this study of patients with diabetic foot ulcers, complicated by osteomyelitis, surgical treatment with gentamicin-loaded CaS-HA biocomposite was feasible and successful in 66% of patients. A prospective trial of this treatment regimen, based on a uniform treatment protocol, is required.

Infrared thermography for monitoring severity and treatment of diabetic foot infections.

Monitoring of diabetic foot infections is largely based on clinical assessment, which is limited by moderate reliability. We conducted a prospective study to explore monitoring of thermal asymmetry (difference between mean plantar temperature of the affected and unaffected foot) for the assessment of severity of diabetic foot infections. In patients with moderate or severe diabetic foot infections (International Working Group on the Diabetic Foot infection-grades 3 or 4) we measured thermal asymmetry with an advanced infrared thermography setup during the first 4-5 days of in-hospital treatment, in addition to clinical assessments and tests of serum inflammatory markers (white blood cell counts and C-reactive protein levels). We assessed the change in thermal asymmetry from baseline to final assessment, and investigated its association with infection-grades and serum inflammatory markers. In seven included patients, thermal asymmetry decreased from median 1.8°C (range: -0.6 to 8.4) at baseline to 1.5°C (range: -0.1 to 5.1) at final assessment (P = 0.515). In three patients who improved to infection-grade 2, thermal asymmetry at baseline (median 1.6°C (range: -0.6 to 1.6)) and final assessment (1.5°C (range: 0.4 to 5.1)) remained similar (P = 0.302). In four patients who did not improve to infection-grade 2, thermal asymmetry decreased from median 4.3°C (range: 1.8 to 8.4) to 1.9°C (range: -0.1 to 4.4; P = 0.221). No correlations were found between thermal asymmetry and infection-grades (r = -0.347; P = 0.445), CRP-levels (r = 0.321; P = 0.482) or WBC (r = -0.250; P = 0.589) during the first 4-5 days of hospitalization. Based on these explorative findings we suggest that infrared thermography is of no value for monitoring diabetic foot infections during in-hospital treatment.

[A man with a painful index finger]. / Een man met een pijnlijke wijsvinger.

A 52-year-old man presented with pain in his right index finger. No history of trauma was reported. His finger nails were dystrophic and the X-ray of the finger showed typical osteolysis of the distal phalanx of his right index finger. This was caused by acrodermatitis continua of Hallopeau. We administered naproxen, methotrexate and folic acid as a systemic anti-inflammatory treatment.

[Digital necrosis after local anaesthesia with epinephrine]. / Vingertopnecrose na lokale anesthesie met adrenaline.

BACKGROUND: To date, there is a lack of consensus concerning the application of local anaesthetics with epinephrine in fingers, due to the alleged risk of ischaemic complications. CASE DESCRIPTION: We present the case of a 70-year old woman, with a medical history of diabetes mellitus and an ischemic cerebral infarct, who underwent operative trigger finger release under local anaesthetics with 1% lidocaine-epinephrine (1:100,000) solution. A few hours later, she developed persisting numbness and ischemic symptoms of the digits. Initial antithrombotic treatment with nadroparin did not resolve the issue, but vasodilatory treatment with nifedipine improved symptoms. Nevertheless, digital necrosis developed in the affected fingers several weeks later. Post-operatively, severe atherosclerosis was diagnosed in the affected hand. CONCLUSION: The use of local anaesthesia in conjunction with epinephrine for surgery on digits does offer advantages, but caution is warranted for patients with risk factors predisposing for local circulatory insufficiency. Timely vasodilatory treatment with phentolamine is the preferred option for patients who develop acute ischaemia following local anaesthesia with epinephrine.