Limited resection and free jejunal graft interposition for squamous cell carcinoma of the cervical oesophagus.

BACKGROUND: Therapeutic strategies for cervical oesophageal squamous cell carcinoma (SCC) are controversial. Treatment options range from definitive radiotherapy to multimodal treatment. Outcome after limited resection and reconstruction with a free jejunal graft interposition was evaluated retrospectively. METHODS: Patients with clinical T1-4 Nx M0 tumours treated between 1986 and 2006 were included. RESULTS: Of 109 patients, 94 underwent preoperative chemoradiotherapy and 15 had a primary resection. Complete or partial preservation of the larynx was achieved in 93 patients (85.3 per cent). Minor and major complications occurred in 74.3 per cent, with 44.0 per cent of all patients having more than one complication. Reoperation was necessary in 29.4 per cent. The 30-day mortality rate was 1.8 per cent, and the in-hospital mortality rate 2.8 per cent. The complete R0 resection rate was 72.5 per cent. Median overall survival was 34.3 months; 1-, 3- and 5-year survival rates were 83.8, 47.0 and 47.0 per cent respectively. Survival was not influenced by complications (P = 0.401) or reoperation (P = 0.428). CONCLUSION: Despite high complication and reoperation rates, the mortality rate was low, even after preoperative chemoradiation. This complex surgical strategy is a treatment option for cervical SCC in oncological centres with an infrastructure providing multidisciplinary management.

Fetal spina bifida repair--current trends and prospects of intrauterine neurosurgery.

Myelomeningocele is a common dysraphic defect leading to severe impairment throughout the patient's lifetime. Although surgical closure of this anomaly is usually performed in the early postnatal period, an estimated 330 cases of intrauterine repair have been performed in a few specialized centers worldwide. It was hoped prenatal intervention would improve the prognosis of affected patients, and preliminary findings suggest a reduced incidence of shunt-dependent hydrocephalus, as well as an improvement in hindbrain herniation. However, the expectations for improved neurological outcome have not been fulfilled and not all patients benefit from fetal surgery in the same way. Therefore, a multicenter randomized controlled trial was initiated in the USA to compare intrauterine with conventional postnatal care, in order to establish the procedure-related benefits and risks. The primary study endpoints include the need for shunt at 1 year of age, and fetal and infant mortality. No data from the trial will be published before the final analysis has been completed in 2008, and until then, the number of centers offering intrauterine MMC repair in the USA is limited to 3 in order to prevent the uncontrolled proliferation of new centers offering this procedure. In future, refined, risk-reduced surgical techniques and new treatment options for preterm labor and preterm rupture of the membranes are likely to reduce associated maternal and fetal risks and improve outcome, but further research will be needed.

Accuracy and precision of the three-dimensional assessment of the facial surface using a 3-D laser scanner.

Three-dimensional (3-D) recording of the surface of the human body or anatomical areas has gained importance in many medical specialties. Thus, it is important to determine scanner precision and accuracy in defined medical applications and to establish standards for the recording procedure. Here we evaluated the precision and accuracy of 3-D assessment of the facial area with the Minolta Vivid 910 3D Laser Scanner. We also investigated the influence of factors related to the recording procedure and the processing of scanner data on final results. These factors include lighting, alignment of scanner and object, the examiner, and the software used to convert measurements into virtual images. To assess scanner accuracy, we compared scanner data to those obtained by manual measurements on a dummy. Less than 7% of all results with the scanner method were outside a range of error of 2 mm when compared to corresponding reference measurements. Accuracy, thus, proved to be good enough to satisfy requirements for numerous clinical applications. Moreover, the experiments completed with the dummy yielded valuable information for optimizing recording parameters for best results. Thus, under defined conditions, precision and accuracy of surface models of the human face recorded with the Minolta Vivid 910 3D Scanner presumably can also be enhanced. Future studies will involve verification of our findings using test persons. The current findings indicate that the Minolta Vivid 910 3D Scanner might be used with benefit in medicine when recording the 3-D surface structures of the face.

[Quality of life and patient satisfaction after breast reconstruction]. / Lebensqualität und Zufriedenheit nach Brustrekonstruktion.

BACKGROUND: Nowadays, the array of methods for reconstruction of the female breast following mastectomy is vast. In this study, we investigate and compare quality of life after breast reconstruction and satisfaction with the results of two commonly used techniques (autologous tissue vs. expander/implant). METHODS: Ninety-one consecutive patients who underwent breast reconstruction at a German clinic between 1996 and 2001 were included in the study. Patient satisfaction and quality of life were assessed retrospectively using self-evaluation questionnaires. RESULTS: Patients were generally more satisfied with the outcome of the operation when autologous tissue was used. This was significant in the following areas: breast size, form, definition of the lower breast fold, softness of the breast, and symmetry of the breasts. In both groups the quality of life following breast reconstruction at least 2 years after the operation was equal to that of healthy women of the same age group. CONCLUSION: Although patients were more satisfied with the results of autologous breast reconstruction, procedure choice did not affect quality of life.

[Transsexuals' life satisfaction after gender transformation operations]. / Lebenszufriedenheit transsexueller Patienten nach geschlechtsangleichenden Operationen.

BACKGROUND: More and more frequently, the registration of life satisfaction is being used to evaluate different medical treatments. So far, there have been only few such surveys on transsexuals (TS). Therefore, the aim of this study was to evaluate the general and the health-related life satisfaction of transsexuals after gender transformation operations. PATIENTS AND METHODS: Forty patients took part in this German cross-sectional study. The Questions on Life Satisfaction Module (FLZ) and free questions on different aspects of the new gender identity were used as measuring instruments. RESULTS: Of the TS studied, 85-95% were "very satisfied" or "satisfied" with the results of their gender transformation operation in respect to gender identity. The TS were significantly less satisfied (P>0.001) in overall "general life satisfaction" than the general population. In overall FLZ scores for "health-related life satisfaction", no differences were seen. CONCLUSION: These data indicate a discrepancy between subjective satisfaction with new gender identity and current life situation, and they identify problems with life satisfaction.

Computer aided surgical reconstruction after complex facial burn injuries -- opportunities and limitations.

In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.

[Evaluation of perfusion in skin flaps by laser-induced indocyanine green fluorescence]. / Evaluation der Perfusion von Lappenplastiken mittels Laserfluoreszenz von Indocyaningrün.

Prediction of necrosis in critically perfused skin flaps is difficult and rarely precise. An early detection of insufficiently perfused skin is highly desirable since it may lead to surgical decisions such as operative flap revision or early resection. The application of laser-induced indocyanine green (ICG) fluoroscopy allows an objective quantification of skin perfusion and a high topographical resolution. Aim of the present study is to determine a threshold value for flap perfusion under well-defined experimental conditions and test the validity of the results in the clinical application. Twenty overdimensioned random pattern flaps with a length to width ratio of 4 : 1 (8 x 2 cm) were dissected at the anterior abdominal wall of 20 male Sprague-Dawley rats weighing 365 g on average. ICG fluorescence was performed at the end of the operation by intravenous injection of 1 g ICG/kg bodyweight into a tail vein and digital recording. On the seventh postoperative day, both the necrotic and surviving areas of the flaps were measured and the ICG-fluorescence was analysed in the areas that had undergone necrosis. 41 flaps with areas of critical perfusion (18 skin flaps, 13 muscle flaps, 8 replantations) were analysed in 39 patients. The surviving part of the flap had a mean perfusion index of 62 % compared to reference skin. The distal parts of the flap that necrotized during the experiment showed an average perfusion index of 19 % postoperatively. Differences were statistically significant (p < 0.001). In clinical application, a number of 13 flaps were found to have a perfusion index less than 25 % in a region of critical perfusion. Eleven of these developed a partial necrosis in that region, one flap underwent total necrosis. Indocyanine green fluoroscopy allows a detailed topographical analysis of flap perfusion and the prediction of necrosis. Experimental findings presented a threshold value for the perfusion index of 25 % which could be confirmed in clinical application.

[Angiogenesis VEGF165 gene therapy with AdVEGF- a new delay procedure for flaps]. / Angiogenese-Gentherapie mit AdVEGF.

A regular tissue functioning requires the adequate supply of oxygen and nutrient via blood vessels. The sequences of formation and maturation of vessels are initiated and maintained by different growth factors. The VEGF growth factor plays an exceptional role in these mechanisms. The creation of sublethal ischemia as an angiogenic stimulus known as "Delay" is a well established procedure in plastic surgery, although the underlying molecular biological mechanisms still remain unknown. The important role of VEGF and its regulation depending on oxygen pressure suggest a strong connection between this growth factor and the delay phenomenon. The VEGF concentration in skin and underlying muscle was measured in overdimensioned random pattern flaps on 32 male Sprague-Dawley rats after either VEGF gene therapy or circumcision without elevation of the flap and compared to controls. Additional random pattern flaps were raised seven days post gene therapy or delay. The effect on the flap perfusion was measured postoperatively using Indocyanine green Laser Fluoroscopy and the size of the surviving and necrotic areas of the flaps were analysed. The skin of the random pattern flaps showed both in the Delay group and in the VEGF gene therapy group a significantly elevated VEGF concentration compared to the controls. The underlying rectus abdominis muscle showed no significant differences in VEGF concentration between the groups. The flap perfusion postoperatively was significantly increased solely in the VEGF gene therapy group. The analysis of the surviving area of the flaps showed a significant increase over the controls in the gene therapy group. The Delay procedure results in a significantly and locally raised concentration of the VEGF growth factor. The gene therapeutical use of this growth factor allows us to raise flap perfusion and to reduce necrosis. Both VEGF gene therapy and Delay seem to promote similar mechanisms whereas the gene therapy produced superior results in this setting.

Insulin receptor kinase in human skeletal muscle.

Receptor-associated protein kinase activity has been shown in all primary target tissues of insulin action in the rat and a function of insulin receptor phosphorylation in signal transmission was proposed. Insulin receptor phosphorylation so far has not been demonstrated in human target tissues of insulin. We describe here insulin receptor kinase activity in human skeletal muscle. Insulin (10(-8) mol/l) stimulates the phosphorylation of a 95-kDa protein from skeletal muscle 2-fold. The phosphoprotein is quantitatively immunoprecipitated with insulin receptor antibody identifying it as the beta-subunit of the insulin receptor. The insulin stimulation of phosphorylation is detectable also at physiological insulin concentrations (10(-9) mol/l) showing that receptor phosphorylation could be involved in insulin action in human skeletal muscle as well.

Penile construction by the radial arm flap.

Penile construction in transsexuals has always been a challenge for plastic surgeons. After a long period of exploration with different techniques of penile construction, the author has found the free radial arm flap to provide the best results.

Microvascular anastomosis by invagination: an experimental study.

A technique of end anastomosis of microvessels of equal or unequal diameter, requiring only two sutures is described. In the present investigation we used the common carotid artery and the femoral vein of 37 white rats. The adventitia of the proximal part of the anastomosed artery was subsequently prepared and removed. However, in case of vein anastomosis, the adventitia of the distal part was removed. Following this washing with saline solution was done. 10-0 Nylon monofil sutures, were used which were placed at 180 degrees. The anastomosis was completed by ligation in such a way that one end was invaginated into the other and was fixed firmly. Five months later the anastomoses were examined after careful preparation under the surgical microscope and photographed. A SEM examination was then done in half of them and photos were taken at 24X, 80X, 1,200x magnification. The remaining tissue was examined histologically. The findings after surgical microscope SEM and histological examination are described.

Treatment of post-replantation retardation of bone growth by callus distraction. A report of two cases.

Hand and forearm replantation in children may lead to premature closure of the distal radial or ulnar growth-plates. Following successful replantation, bone growth may be retarded, resulting in a length discrepancy between the radius and ulna with secondary deviation of the replanted hand. We present two cases in which callus distraction was employed to correct a length discrepancy. The relative merits of the various treatment options are discussed.

Salvage operations for complication following replantation and free tissue transfer.

Venous and arterial thrombus formation is the typical complication of microvascular surgery. Treatment is based on reoperation (thrombectomy), the administration of heparin, low moleecular weight dextran and platelet antisludge (dipyridamol and acetylsalicylic acid). As the reoperation must be performed promptly, careful postoperative monitoring of the transplant is required.

Vein grafts in microvascular surgery.

The judicious use of vein grafts will lessen the incidence of thrombosis in microvascular surgery and help to overcome problem of vessels loss. Vein grafts are readily available and do not pose any major disadvantages.

Experience in replantation surgery in the upper extremity.

This page reports our experience of 423 digital and hand replantation over the period of 35 months. A classification based on the levels of amputation is suggested. The operative technique and indication of replantation are discussed.

[Defect coverage of the extremities with distal pedicled flap-plasty]. / Defektdeckung an den Extremitäten mit distal gestielten Lappenplastiken.

Clinical consideration of anatomy of skin vascularity led to the establishment of distally pedicled flaps in the extremities. In certain situations, distally pedicled flaps are a quick and safe alternative to free microvascular tissue transplantation or distant pedicled flaps. However, an exact indication for this method as well as exact planning and performance of the operation is necessary for success. A synopsis of clinical applications of distally pedicled flaps is given.

[Degloving injuries of the soft tissues of the heel. An indication for microvascular revascularization!]. / Skelettierungsverletzungen der Fersenweichteile. Eine Indikation zur mikrochirurgischen Revascularisierung!

The sole of the foot has a unique soft tissue structure which allows weightbearing. There is no adequate reconstructive method for soft tissue defects of the weightbearing sole. Soft tissue reconstructions in this area frequently develop stress lesions. After degloving injuries of the heel, the unique vascularisation of the sole may lead to ischemia and consecutive soft tissue necrosis. Revascularisation of degloved heel pads e.g. by reconstruction of the medial calcaneal branch of the posterior tibial artery is recommended as a salvage procedure. In the primary treatment of extremity injuries with severe soft tissue damage a plastic surgeon should be involved.

[Plastic-surgical therapy of extensive radiogenic recurrence of pharyngo-esophagostoma]. / Plastisch-chirurgische Therapie des ausgedehnten radiogenen Pharyngo-Oesophagostomarezidivs.

Reconstruction of extended post-irradiation pharyngo-esophagostomy is still a formidable challenge in head and neck surgery. Early rehabilitation of speech, swallowing and chewing and prevention of severe hemorrhage of the carotid artery by soft tissue coverage is mandatory. If previous attempts with local lipocutaneous and myocutaneous flaps have failed, a two stage reconstruction by microsurgical transfer of a jejunal patch in combination with a myocutaneous latissimus dorsi flap will lead to sufficient lining and a permanent closure of the defect. The indication and the technical procedures in two clinical cases following multiple recurrences of pharyngo-esophagostomy due to irradiation damage of the neck are discussed.

[Limb-sparing surgery in recurrent soft tissue sarcomas?]. / Gliedmassenerhaltung bei rezidivierenden Weichgewebssarkomen?

Limb sparing resection in combination with radio-chemotherapy is recommended in cases of locally recurrent soft tissue sarcomas of the extremities. The clinical results of 41 patients, who underwent radical resection and additional plastic surgical reconstructive procedures for functional improvement are discussed. The integration of patients suffering from soft tissue sarcomas of the extremities into the treatment protocols of interdisciplinary tumor boards is mandatory.

[Primary management and secondary reconstructive surgery of severe combined hand injuries]. / Primärversorgung und sekundäre Wiederherstellungschirurgie der schweren kombinierten Handverletzung.

Primary treatment and secondary reconstructive surgery of severe mutilating hand injuries are associated with challenging problems. Conventional and microneurovascular reconstructive methods must be integrated into the therapeutical rationale. The technical and tactical principles essential to obtain an optimal rehabilitational result are discussed. Simple sensitive grip tools will provide better functional long time results than modern prosthetic devices.