Extensive suprasternal dehiscence reconstruction with NPWT and advancement flaps following cardiac surgery.

Treatment of suprasternal wound infection (SSWI) following cardiac surgery is not a clearly developed procedure. We report our female patient's secondary SSWI treatment following bypass surgery. An obese female patient with unstable angina underwent an urgent, uneventful off-pump coronary artery bypass operation. An SSWI appeared within a week. After negative pressure wound therapy (NPWT), the sternum was rewired. In the previously irradiated territory of the left breast necrosis formed, a plastic surgeon reconstructed a defect. This procedure failed NPWT was restarted again, and a secondary reconstructive plastic surgery intervention was necessary. Despite extensive tissue mobilization, the central part of the reconstructive area necrotized, and we had to cover it with a split thickness skin mash graft. The irradiation therapy increases the incidence of suprasternal and/or sternal infection. It was possible to manage large soft tissue defects with bilateral and rotational advancement flaps.

Surgical repositioning of Jarvik 2000 LVAD power supply pedestal following fall trauma.

Advanced heart failure (HF) is one of the leading causes of mortality and morbidity. With an aging population, its prevalence is expected to rise further. Although orthotopic heart transplantation (HTX) remains the gold standard in therapy, there is a significant deficiency in the ratio of donor organs to recipient patients. Left ventricular assist devices (LVAD) could relieve this problem either as a bridge-to-transplant (BTT) or as a destination therapy (DT). Despite the widespread implantation of ventricular assist devices, their efficacy may be limited by some serious adverse events, while infection is a major issue. A longer period of LVAD support significantly increases the risk of driveline infections (DLI). The Jarvik 2000® ventricular assist device (Jarvik Heart, New York, NY, USA) offers prolonged infection-free survival. In our report, we present the case of a 61-year-old female patient with a driveline pedestal that has become fully detached from the skull following a fall trauma. We describe how the traumatized pedestal was surgically replaced by removing the previous, damaged unit and inserting a repositioned new one. The surgical procedure presented in our case has not been performed before and we have not found any similar one in the literature. It requires individual surgical planning and a multidisciplinary surgeon's team to ensure the procedure is safe and feasible.

Efficiently sampling the realizations of bounded, irregular degree sequences of bipartite and directed graphs.

Since 1997 a considerable effort has been spent on the study of the swap (switch) Markov chains on graphic degree sequences. All of these results assume some kind of regularity in the corresponding degree sequences. Recently, Greenhill and Sfragara published a breakthrough paper about irregular normal and directed degree sequences for which rapid mixing of the swap Markov chain is proved. In this paper we present two groups of results. An example from the first group is the following theorem: let [Formula: see text] be a directed degree sequence on n vertices. Denote by Δ the maximum value among all in- and out-degrees and denote by [Formula: see text] the number of edges in the realization. Assume furthermore that [Formula: see text]. Then the swap Markov chain on the realizations of [Formula: see text] is rapidly mixing. This result is a slight improvement on one of the results of Greenhill and Sfragara. An example from the second group is the following: let d be a bipartite degree sequence on the vertex set U ⊎ V, and let 0 < c1 ≤ c2 < |U| and 0 < d1 ≤ d2 < |V| be integers, where c1 ≤ d(v) ≤ c2: ∀v ∈ V and d1 ≤ d(u) ≤ d2: ∀u ∈ U. Furthermore assume that (c2 - c1 - 1)(d2 - d1 - 1) < max{c1(|V| - d2), d1(|U| - c2)}. Then the swap Markov chain on the realizations of d is rapidly mixing. A straightforward application of this latter result shows that when a random bipartite or directed graph is generated under the Erdos-Rényi G(n, p) model with mild assumptions on n and p then the degree sequence of the generated graph has, with high probability, a rapidly mixing swap Markov chain on its realizations.

Oral administration of pyrophosphate inhibits connective tissue calcification.

Various disorders including pseudoxanthoma elasticum (PXE) and generalized arterial calcification of infancy (GACI), which are caused by inactivating mutations in ABCC6 and ENPP1, respectively, present with extensive tissue calcification due to reduced plasma pyrophosphate (PPi). However, it has always been assumed that the bioavailability of orally administered PPi is negligible. Here, we demonstrate increased PPi concentration in the circulation of humans after oral PPi administration. Furthermore, in mouse models of PXE and GACI, oral PPi provided via drinking water attenuated their ectopic calcification phenotype. Noticeably, provision of drinking water with 0.3 mM PPi to mice heterozygous for inactivating mutations in Enpp1 during pregnancy robustly inhibited ectopic calcification in their Enpp1-/- offspring. Our work shows that orally administered PPi is readily absorbed in humans and mice and inhibits connective tissue calcification in mouse models of PXE and GACI PPi, which is recognized as safe by the FDA, therefore not only has great potential as an effective and extremely low-cost treatment for these currently intractable genetic disorders, but also in other conditions involving connective tissue calcification.

[Modern surgical treatment of breast cancer. 3rd Breast Cancer Consensus Conference]. / Az emlorák korszeru sebészi kezelése. III. Emlorák-konszenzuskonferencia.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue into the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 3rd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

[3rd Hungarian Breast Cancer Consensus Conference - Surgery Guidelines]. / III. Emlõrák Konszenzus Konferencia - Az emlõrák korszerû sebészi kezelése.

Therapy for breast cancer today is characterised by ever more precise diagnostic methods and ever more effective oncological treatments, a trend which will certainly continue in the future. Breast preservation and the application of oncoplastic principles are increasingly popular. A sentinel lymph node biopsy in the surgical treatment of the axilla is primary, with the indication for axillary block dissection (ABD) narrowing and radiation therapy becoming an alternative to ABD in certain cases. This publication summarises our recommendations on the surgical treatment of breast cancer based on the content of the 2nd Breast Cancer Consensus Conference and considering the latest international studies and professional recommendations.

Intra and postoperative evaluations of microcirculation and micro-rheological parameters in a rat model of musculocutaneous flap ischemia-reperfusion.

PURPOSE: To examine how the ischemia-reperfusion injury of latissimus dorsi-cutaneous maximus (LDCM) musculocutaneous flap affects the microcirculatory (flap's skin surface) and hemorheological parameters, and whether an intraoperative deterioration would predictively suggest flap failure in the postoperative period. METHODS: Ten healthy male rats were subjected to the study. In Group I the left flap was sutured back after 2-hour, while the contralateral side was right after its elevation. In Group II the same technique was applied, but the pedicle of the left flap was atraumatically clamped for 2-hour. The contralateral side was left intact. On the flap skin surface laser Doppler tissue flowmetry measurements were done before and after and during the protocols applied in the groups. Microcirculatory and hemorheological examinations were done postoperatively. RESULTS: The microcirculatory parameters significantly decreased during immobilization and ischemia. Afterwards, all the regions showed normalization. In the retrospective analysis there was a prominent difference between the microcirculatory parameters of necrotic and survived flap during the early postoperative days (1-3) in Group II. Erythrocyte aggregation and deformability showed only slight differences. CONCLUSIONS: Two-hour ischemia and reperfusion caused deterioration in latissimus dorsi-cutaneous maximus flap microcirculation. Predicting the possible postoperative complication, the intraoperative laser Doppler measurement can be informative.

Intra and postoperative evaluations of microcirculation and micro-rheological parameters in a rat model of musculocutaneous flap ischemia-reperfusion

PURPOSE:To examine how the ischemia-reperfusion injury of latissimus dorsi-cutaneous maximus (LDCM) musculocutaneous flap affects the microcirculatory (flap's skin surface) and hemorheological parameters, and whether an intraoperative deterioration would predictively suggest flap failure in the postoperative period.METHODS: Ten healthy male rats were subjected to the study. In Group I the left flap was sutured back after 2-hour, while the contralateral side was right after its elevation. In Group II the same technique was applied, but the pedicle of the left flap was atraumatically clamped for 2-hour. The contralateral side was left intact. On the flap skin surface laser Doppler tissue flowmetry measurements were done before and after and during the protocols applied in the groups. Microcirculatory and hemorheological examinations were done postoperatively.RESULTS: The microcirculatory parameters significantly decreased during immobilization and ischemia. Afterwards, all the regions showed normalization. In the retrospective analysis there was a prominent difference between the microcirculatory parameters of necrotic and survived flap during the early postoperative days (1-3) in Group II. Erythrocyte aggregation and deformability showed only slight differences.CONCLUSIONS: Two-hour ischemia and reperfusion caused deterioration in latissimus dorsi-cutaneous maximus flap microcirculation. Predicting the possible postoperative complication, the intraoperative laser Doppler measurement can be informative.

[The use of Integra dermal regeneration matrix in the surgical treatment of a recurrent, extensive, malignant skin lesion in the temporal region]. / Integra irharegenerációs mátrix alkalmazása recidív, kiterjedt, halántéktáji bordaganat sebészi kezelésében.

Authors report on the use of Integra dermal regeneration template after excision of an extended, recurrent skin tumor in the temporal region. The area covered with Integra was 180 cm2. Skin grafting to cover Integra was performed on the 28th day. Both Integra and the skin transplant were taken 100%. Integra dermal regeneration template can provide good functional and aesthetic result in the surgical management of extended skin tumors over the skull.

[The role of Integra dermal regeneration matrix in skin replacement on the upper extremity]. / Integra irharegenerációs mátrix szerepe a felso végtag borhiányainak pótlásában.

Authors report the application of Integra dermal regeneration matrix in 10 patients in 12 indications (ages 25-74 years, 6 female and 4 male patients). The smallest reconstructed area was 6 cm2, the largest was 500 cm2. Skin coverage was needed on the lower arm in two patients, on the lower arm and the hand in two patients and on the hand in six patients. Skin grafting onto the neodermis was made on days 19-25. The take rate of Integra was equal or higher than 97%, and the take rate of the skin graft was equal or higher than 90%. Integra dermal regeneration template proved to be suitable for the management of complex wounds on the hands and upper extremities.

[Combined transplantation of a free skin island flap supplied by a septo-cutaneous perforator of the posterior tibial artery and the underlying fibula for the full reconstruction of the mandible and the mouth floor]. / Az arteria tibialis posteriorból eredo direkt septocutan perforator ér által ellátott különálló borszigetlebeny és a fibula kettos szabad átültetése a mandibula és a szájfenék kombinált rekonstrukciója kapcsán.

Microsurgical transplantation of the osteo-cutaneous fibula as a free flap to reconstruct the defect following radical resection of a mouth floor's tumor is a well-known and often applied procedure. Anatomy of the vessels supplying this flap is recognized but it may have some rare and unexpected variations. In this case report we discuss the reconstruction of the middle and lateral parts of the mandible which was resected due to a T4 gingival tumor. Interestingly, the aforementioned segment of the fibula and the overlying skin island were supplied by different pedicles, both emerging from the posterior tibial vessels. Both flaps were transplanted using autologous arterial and venous grafts of the peroneal artery and vein in case of the fibula. We believe this case is worth publishing due to its relative rarity in the literature and the applied surgical method.

[Definitive treatment of multiple recurrences of sacral dermoid cysts using an inferior gluteal artery perforator fasciocutaneous flap]. / Többszörösen kiújult sacralis dermoid definitív megoldása az arteria glutealis inferior direct fasciocutan ágára nyelezett transzpozíciós lebeny alkalmazásával.

AIM: Treatment of sacral dermoid cysts (SDC) is a surgical challenge. Etiology and adequate operative technique of that are debated widely up to now, and recurrence rates remained high despite various surgical techniques applied. In cases of unsuccessfully operated and repeatedly recurrent SDC a fascio-cutaneous flap on the first perforating branch of the inferior gluteal artery (IGA) is a definitive procedure. MATERIAL AND METHOD: Following preparation and dissection of sidebranches of IGA in cadavers, a repeatedly recurrent SDC was operated. CONCLUSION: a flap harvested and transferred on the first superficial perforating branch(es) of the inferior gluteal artery offers a definitive and recurrence-free surgical solution for SDC.

[Pectoral major muscle-sling flap for treatment of recurrent subareolar abscess: a new surgical technique]. / Pectoralis major izomlebeny a recurráló subareolaris abscessus kezelésében: egy új mutéti módszer.

Recurrent subareolar abscess is an uncommon benign disease of the breast, which is caused by peri-ductal mastitis with various etiology. Radical surgical procedure is necessary for cure instead of inadequate courses of antibiotics or incisions. In some cases the use of the pectoral muscle sling flap can be an alternative technique for the treatment of recurrent subareolar abscess after repeated standard surgical treatment. A 36 year old woman, who successfully underwent this procedure, is presented here.

Hemorheological, morphological, and oxidative changes during ischemia-reperfusion of latissimus dorsi muscle flaps in a canine model.

Although ischemia-reperfusion (I/R) strongly influences muscle flap survival in reconstructive surgery, there is limited knowledge about its relation to hemorheological parameters and oxidative stress markers in flaps. In the present study we investigated these changes during I/R of latissimus dorsi muscle (LDM) flaps in beagle dogs. In four animals LDM flaps were prepared bilaterally. The right side served as control, while the left side's vascular pedicle was clamped for 60 minutes, and a 60-minute reperfusion was allowed afterward. Blood samples (0.5 ml each) were taken from the pedicle's vein bilaterally before and after the ischemia, and at the 5th, 15th, 30th, 45th, and 60th minutes of the reperfusion, for hematological and erythrocyte aggregation tests. In muscle biopsies, taken before and after I/R, histological investigations and tests for measuring gluthation-peroxidase (GSH-PX) activity, glutathione (GSH) and carbonyl concentrations, and thiobarbituric acid reactive substances (TBARS) content were carried out. In I/R side leukocyte count increased during the reperfusion with a peak at the 30th minute. Hematocrit continuously increased from the 15th minute. In the first 5 minutes of the reperfusion, erythrocyte aggregation increased, than tented to be normalized. In muscle homogenates GSH-PX activity did not change markedly, GSH content slightly decreased, carbonyl and TBARS content increased during reperfusion. A 1-hour ischemia and reperfusion of LDM flaps caused local changes of leukocyte distribution and erythrocyte aggregation, supposedly due to the metabolic and inflammatory reactions. Oxidative damage during reperfusion was also demonstrated.

Prognostic role of vascularisation and proliferation in rectal cancer with liver metastasis.

BACKGROUNDS/AIMS: The present study was designed to provide an analysis of factors for tumor vascularisation and proliferation in 37 rectal cancer patients with concurrent and recurrent liver metastasis underwent preoperative radiotherapy, surgery and adjuvant chemotherapy with emphasis on the time of presence of hepatic spread. METHODOLOGY: Immunohistochemistry was used for expression of proliferation (MIB-1) and for detection of microvessel density (MVD, expressed by CD34). Clinicopathological findings were compared with outcome with emphasis on IHC. RESULTS: A vascular enumeration, pN status and the time of presence of the metastases has shown prognostic role along with the factors above. Increased proliferative activity of the tumor as expressed by MIB-1 staining had no prognostic value, similarly to the localization of tumor, gender, age or grading. CONCLUSION: Higher pN status and tumor vascularisation has been linked to poor prognosis in overall survival and recurrence of liver metastases.

[The role of pneumoperitoneum and the "chimney effect" on the development of port site metastasis. A new experimental animal model using Furka's spleen tissue suspension]. / A pneumoperitoneum és a "kémény effektus" szerepe a port site metastasis kialakulásában. Furka-féle lép suspensióval végzett új állatkísérletes modell.

Following the introduction of laparoscopic cholecystectomy, laparoscopic technology has been applied in many other fields of surgery, including surgery for malignancies, even before prospective, randomised trials were available. Many authors observed development of port site metastases following laparoscopic surgery in malignancies (1-2%). The studies report about the pathomechanism of the development of port site metastasis, some describe the role of pneumoperitoneum. We developed a new model to show the role of pneumoperitoneum and the "chimney effect" on the development of port site metastasis, using a large experimental animal with a suspension of its own spleen tissue. On follow up histology viable spleen tissue was found between the layers of the trocar incisions.