Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study.

BACKGROUND AND STUDY AIMS: Gastric outlet obstruction is a late event in the natural history of biliopancreatic tumours. Metallic self-expanding stents inserted under endoscopic and fluoroscopic guidance can be used for palliation. The aim of this study was to evaluate the feasibility, efficacy, and complications of endoscopic duodenal stenting in patients with malignant gastric outlet obstruction. PATIENTS AND METHODS: Between August 1998 and November 2001, 63 patients (31 women, 32 men; mean age 73 +/- 12) presenting with clinical symptoms of duodenal obstruction underwent endoscopic stenting with large metallic prostheses. Complications and clinical outcome were assessed both retrospectively and prospectively. RESULTS: Of the patients, 58 needed one duodenal stent and two overlapping stents were required in five patients. Stenting was immediately successful in 60/63 patients (95%). At the time of the duodenal procedure, 25 previously inserted biliary stents were still patent; biliary stenting was attempted during the same procedure in 18 patients; and 20 patients had no biliary stricture. There was no procedure-related mortality. There were complications in 30 % of patients: 13 stent obstructions, 4 stent migrations and 2 duodenal perforations (treated surgically). For 44 patients (70%) there were no minor or major digestive problem during their remaining lifetime. An exclusively peroral diet was possible in 58 patients (92%), but was considered satisfactory (solid or soft) in 46/63 patients (73%). Of the patients, 53 (84 %) died between 1 and 64 weeks after the duodenal stenting (median survival 7 weeks). CONCLUSIONS: Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and well-tolerated in most patients. Most dysfunctions can be managed endoscopically.

Post-traumatic distal nerve entrapment syndrome.

Eleven patients with paralysis of muscle groups in the upper or lower extremity were clinically diagnosed after previous proximal direct trauma to the corresponding peripheral nerves, without complete nerve disruption. Patients were seen within an average of 8 months after trauma (minimum 3 months and maximum 2 years after). Nerve lesions were caused either by gunshot, motor-vehicle accident, and other direct trauma or, in one case, after tumor excision. All patients presented with complete sensory and motor loss distal to the trauma site, but demonstrated a positive Tinel sign and pain on testing over the "classic" (distal) anatomic nerve entrapment sites only. After surgical release through decompression of the nerve compression site distal to the trauma, a recovery of sensory function was achieved after surgery in all cases. Good-to-excellent restoration of motor function (M4/M5) was achieved in 63 percent of all cases. Twenty-five percent had no or only poor improvement in motor function, despite a good sensory recovery. Those patients in whom nerve compression sites were surgically released before 6 months after trauma had an improvement in almost all neural functions, compared to those patients who underwent surgery later than 9 months post trauma. A possible explanation of traumatically caused neurogenic paralysis with subsequent distal nerve compressions is provided, using the "double crush syndrome" hypothesis.

[Systematic indications of various free transfer flaps in the area of the head and neck]. / Systematische Indikation verschiedener freier Transferlappen im Kopf- und Halsbereich.

Many microsurgical free flaps have been described to tackle various problems in the head and neck. The authors present a system of indications which has proved to be suitable as judged by the functional and cosmetic results obtained. The harvesting of these flaps requires versatile training in surgical techniques for the different anatomical areas. This system of indications comprises the free fasciocutaneous forearm flap, jejunal loops, the fasciocutaneous parascapular flap, iliac crest flaps with vascularized bone and the parascapular cutaneous, latissimus dorsi osteomyocutaneous double flap.

[Tissue expanders in plastic surgery of the head and neck. Indications and use]. / Gewebeexpander in der plastischen Kopf- und Halschirurg. Indikation und Anwendung.

Tissue expansion allows a functional as well as an aesthetic reconstruction of local defects and thus corresponds to the actual state of the art in plastic surgery.-Tissue expansion provides tissue of the same quality for the repair of defects without leaving deformities on the donor site. It creates local flaps with skin of the same texture, colour and preserved sensitivity.-The use of tissue expanders has grown enormously during the last few years.-A higher rate of complications on the cheek and on the neck must be taken into account.

[Reconstruction of the lower third of the face--microsurgical monobloc transfer with vascularized bone]. / Aufbau des unteren Gesichtsdrittels. Mikrochirurgischer Monobloc-Transfer mit vaskularisiertem Knochen.

The authors present two microsurgical options of the reconstruction of the lower third of the face. They outline a systematisation of indications and techniques and emphasise versatility and flexibility of free flaps compared to pedicled flaps, and describe the advantages of the vascularisation and the techniques of the iliac crest osteocutaneous flap and the parascapular cutaneous-latissimus dorsi osteomyocutaneous flap which was developed by Nassif.

The parascapular flap: a new cutaneous microsurgical free flap.

We present the anatomic study and the clinical free transfer of a new donor site. This new flap is called the parascapular flap. It is under the dependence of a direct cutaneous artery that is a vertical terminal branch of the circumflex scapular artery, itself a branch of the subscapular artery. The flap is outlined along the free lateral border of the scapula, and it provides large surface coverage with easy primary closure of the donor site. The surface can even be extended by association of the flap with the latissimus dorsi muscle flap. With this flap, both skin and muscle areas are under the dependence of a single pedicle that is the subscapular artery.