Free-tissue transfer experience at a county hospital.

As reimbursement for free-tissue transfer decreases, the authors find an increase in the number of free flaps performed at their county facility. Over 60 percent of the free flaps performed during the past 10 years were completed within the last 4 years. This influx of patients prompted a review of their experience with free-tissue transfer. This retrospective study of the free-flap experience at a county hospital reviewed 49 patients with 53 free flaps between 1991 and 1999. Forty-five free flaps (85 percent) were successful, with an overall failure rate of 15 percent. Most free flaps were performed on traumatic wounds. Risk factors, such as smoking, diabetes, and peripheral vascular disease, did not reliably predict free-flap failure. Irradiated, chronic wounds were associated with the highest failure rates. Seventy-five percent of the free-flap failures were due to delayed return to the operating room, once the flap appeared compromised. Delay in reexploration resulted in a zero salvage rate. Prompt recognition of failed flaps and emergent exploration will improve the success rate.

The outcome of unretrieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy. A prospective analysis.

BACKGROUND: Gallbladder perforation during laparoscopic cholecystectomy (LC) with spillage of bile and gallstones occurs in a substantial number of patients (up to 40%). Most surgeons believe that free intraperitoneal stones are not a justification for conversion to laparotomy even if a large number of stones are left in situ. There are, however, a number of reports demonstrating that, on occasion, these unretrieved gallstones may cause infection or abscess, inflammation, fibrosis, adhesions, cutaneous sinuses, small bowel obstruction, or generalized septicemia. The aim of this study was to determine the outcome of unretrieved gallstones in the peritoneal cavity after gallbladder perforation during LC. METHODS: In a 7-year period between 1989 and 1996, prospective data were maintained on 856 patients who underwent LCs by a single surgeon (R. J.F.). Of the 856 patients, 165 (16%) had gallbladder perforations resulting in lost gallstones in the peritoneal cavity. A concerted attempt was made to remove the lost stones using a variety of extraction devices. Of these 165 patients, 106 (64%) were available for follow-up through mail (76%) and by telephone (24%). The mean age of these patients was 64.9 years (range, 18 to 98 years), and the mean follow-up was 44.8 months (range 4.9 to 92.3 months). RESULTS: Of the 106 patients with unretrieved gallstones, we identified four patients with short-term complications and one patient with a long-term complication. The first patient with a short-term complication had pyrexia for 10 days postoperatively. Diagnostic evaluation, which included computed tomography (CT) scan, failed to reveal any abnormality. The patient was treated conservatively with a course of oral antibiotics. In the second patient, cellulitis developed at a drain site after its removal, which resolved with oral antibiotics. The third patient acquired an umbilical wound abscess, which drained spontaneously, requiring no treatment. A sterile subphrenic collection developed in the fourth patient 1 month postoperatively, which was treated with percutaneous drainage under CT guidance. The only long-term complication was spontaneous erosion of a gallstone from the back of a patient with a questionable history of inflammatory bowel disease 8 months postoperatively. All of the patients made complete recoveries. CONCLUSIONS: In most patients, unretrieved gallstones are of no consequence, but complications occur occasionally. It is therefore advisable to retrieve as many gallstones as possible during LC short of converting to a laparotomy.

Abnormal cholangiograms during laparoscopic cholecystectomy. Is treatment always necessary?

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. METHODS: Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single "soft" indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more "soft" indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. RESULTS: In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. CONCLUSIONS: The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%).

Identification of novel heparin-releasable proteins, as well as the cytokines midkine and pleiotrophin, in human postheparin plasma.

The heparin-releasable proteins are a group of proteins that are targeted to the endothelial surface by attachment to glycosaminoglycans and may have functions specific to the endothelium-blood interface. In this study, heparin-affinity chromatography of human postheparin plasma was used as a method to identify and study novel heparin-releasable proteins. Six proteins seen on sodium dodecyl sulfate-polyacrylamide gel electrophoresis gels have increased levels in plasma after intravenous heparin. The six proteins are platelet factor 4, midkine, pleiotrophin, and several novel proteins. Midkine and pleiotrophin are related cytokines that are developmentally regulated, neurotrophic, and mitogenic. Additional studies show that levels of midkine and pleiotrophin peak at 10 to 30 minutes after injection of heparin. Heparin-releasable midkine and pleiotrophin do not originate from blood cells or the kidney. Heparin-releasable midkine may originate from endothelial cells. Soft agar culture of an adenocarcinoma cell line (SW-13) demonstrates growth-stimulating activity similar to that described for pleiotrophin in the heparin-agarose eluate of postheparin plasma but not in the heparin-agarose eluate of preheparin plasma. It is concluded there are more heparin-releasable proteins than previously identified, including midkine and pleiotrophin, and that heparin-affinity chromatography of postheparin plasma is a useful technique for identifying novel heparin-releasable proteins.