Coverage strategies in exposed implants.

Implants are widely used and are not without complications. The most serious complication is infection with consequent exposure of the implant and is characterized by increased morbidity and mortality. Until recently, infected implants were removed and replaced with another one. These operations are accompanied by increased morbidity and might result in permanent disability. Coverage of the implant with a flap is an alternative solution. The objective of this article is to study the effectiveness of muscle or myocutaneous flaps in covering infected and exposed implants. A series of 17 patients with infected implants, which were treated with coverage of the implant with muscle or myocutaneous flap, is presented. Eight patients had an orthopedic implant, seven a vascular implant, and two had a pacemaker. The flaps ensured immediate coverage of the implant and the biologic ability of eliminating the infectious process with the increased concentration of antibiotics resulting from increased blood flow of the muscle. In all the patients, the implants were preserved and the infectious process was eliminated. The use of muscle and myocutaneous flaps in the treatment of infected implants is therefore effective and in some cases it is superior to other methods because of lower morbidity and cost.

Paclitaxel-ifosfamide-cisplatin as salvage chemotherapy in ovarian cancer patients pretreated with platinum compounds and paclitaxel.

BACKGROUND: The role of combination chemotherapy regimens in the management of ovarian cancer patients with tumors previously exposed to platinum compounds and paclitaxel has not yet been defined. The present phase II study evaluated the activity and toxicity of a paclitaxel-ifosfamide-cisplatin combination in the aforementioned group of patients. Given the in vitro and in vivo synergism between these three agents, it was believed that using a three drug combination would overcome tumor resistance to cisplatin. PATIENTS AND METHODS: Thirty-five patients were enrolled in the study. The median age was 55 and the median performance status 1. Thirteen (37%) had potentially platinum sensitive, 12 (35%) had primary platinum-resistant and 10 (28%) patients had secondary platinum-resistant tumors. Treatment consisted of paclitaxel 175 mg/m2 as a 3 h i.v. infusion on day 1, cisplatin 75 mg/m2 i.v. over 2 h fractionated over days 1 and 2, and ifosfamide 5 mg/m2 i.v. over 1 h fractionated on days 1-2 with mesna uroprotection. Courses were administered every 3 weeks on an outpatient basis. Granulocyte-colony stimulation factor (G-CSF) was given at a dose of 5 microg/kg/day on days 4-10. A median of 4 cycles were administered with the delivered dose intensity at 85% of the planned dose for the three agents. RESULTS: Among 35 patients evaluable for response and toxicity, there were 10 partial responses with a response rate of 28.6% (95% confidence interval 12%-45%). Stable disease was recorded in 9 (25.7%) and progressive disease in 16 (45.7%) patients. Subgroup analysis revealed a response rate of 38.5% in potentially platinum-sensitive, 16.5% in primary platinum-resistant and 30% in secondary platinum-resistant tumors. The median response duration was 5 months (range 3-14 months), the median time to progression 6 months (range 3-18 months) and the median survival 12 months (range 3-44 months). Myelotoxicity was significant with neutropenia grade 3 and 4 occurring in 35% and 45% of patients, respectively. Eight episodes (5% of all cycles) of febrile neutropenia were documented and well managed with oral or i.v. antibiotics and G-CSF continuation until complete recovery. Grade 1, 2 and 3 peripheral neuropathy developed in 30%, 30% and 10% of patients, respectively. In conclusion, the three drug combination demonstrated a significant effectiveness in potentially platinum-sensitive tumors and a moderate efficacy in platinum-resistant tumors. The regimen, although myelotoxic, is tolerable with G-CSF support. Further investigation via comparative studies is required to define any superiority of the present regimen over doublets of the three agents in this group of patients.

Outcome of Fowler-Stephens operation for undescended testes: an experimental study.

The aim of this study was the outcome of Fowler-Stephens (FS) operations in prepubertal Wistar rats. Thirty-two 30-day-old rats underwent laparoscopic FS procedures on the right testicles (8 of them formed the control group). Nine, 30, 70, and 90 days later we assessed the testes histologically and determined inhibin betaB serum concentrations; 1 day earlier, ultrasonography was also performed. Decreases in central testicular vascularity and heterogeneous parenchymal echogenicity were the initial sonographic evidence of testicular damage, which either regressed in time or extended toward the periphery. Early degenerative changes either remained mild and restricted in the germinative epithelium or became more severe, affecting additional structures. Decreases in the seminiferous tubule area, thickening of the tunica albuginea, and increases in the number of mast cells were changes that reached significance. Significant decreases in the amount of serum inhibin betaB were also found, and the decreases correlated significantly with both the thickening of the tunica albuginea and the increases in the number of mast cells but not with the decreases in the seminiferous tubule area. Division of the spermatic vessels caused severe testicular degeneration as evidenced by changes in ultrasonographic and histologic features combined with drops in the levels of serum inhibin betaB.

Pancreatic tuberculosis: a medical disease posing surgical dilemmas.

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.

Myelofibrosis-associated massive splenomegaly: a cause of increased intra-abdominal pressure, pulmonary hypertension, and positional dyspnea.

We describe a patient with myelofibrosis, giant splenomegaly, and pulmonary hypertension related to increased intra-abdominal pressure. Focusing on alterations in hemodynamic studies, we conclude that in patients with myelofibrosis, dyspnea, and hypoxemia, the measurement of intra-abdominal pressure should be included in the initial evaluation. It is an inexpensive, non-invasive diagnostic tool that can provide crucial information about the cause of dyspnea and disclose the pathogenetic link between massive splenomegaly and pulmonary compromise in myelofibrosis.

Congenital diaphragmatic hernia complicated by tension gastrothorax during gastroscopy: report of a case.

Bochdalek's hernia typically manifests early in childhood, but it is uncommon in adults. We report the case of a 77-year-old woman who suffered sudden acute cardiorespiratory distress during an upper gastro-intestinal endoscopy, caused by a massive gastrothorax, confirmed by a chest radiograph and thoracic computed tomography. Laparotomy revealed a posterolateral diaphragmatic defect and an acutely distended stomach occupying the left hemithorax, caused by an incomplete organoaxial volvulus of the organ. The stomach was reduced and secured inside the abdominal cavity by a Nissen fundoplication and the defect was repaired with interrupted sutures. Unfortunately, the patient succumbed to generalized sepsis resulting from Pneumocystis carinii bilateral pneumonia. To our knowledge, this is the first reported case in the English literature of an adult with a congenital posterolateral hernia presenting in this manner. However, it demonstrates that a symptomatic congenital diaphragmatic hernia should be surgically repaired to prevent the numerous complications that may arise, many of which can prove fatal even in an adult.