Leech Therapy For The Treatment Of Venous Congestion In Flaps, Digital Re-Plants And Revascularizations - A Two-Year Review From A Regional Centre.

BACKGROUND: Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of leech therapy for salvage of venous congested flaps and congested replanted or revascularized hand digits over a 2-year period. METHODS: All patients treated with leeches between 1 Oct 2010 and 30 Sep 2012 (two years) at Queen Elizabeth Hospital, Birmingham, UK were included in the study. Details regarding mode of injury requiring reconstruction, surgical procedure, leech therapy duration, subsequent surgery requirement and tissue salvage rates were recorded. RESULTS: Twenty tissues in 18 patients required leeches for tissue congestion over 2 years: 13 men and 5 women. The mean patient age was 41 years (range 17-79). The defect requiring reconstruction was trauma in 16 cases, following tumour resection in two, and two miscellaneous causes. Thirteen cases had flap reconstruction and seven digits in six patients had hand digit replantations or revascularisation. Thirteen of 20 cases (65%) had successful tissue salvage following leech therapy for congestion (77% in 10 out of 13 flaps, and 43% in 3 of 7 digits). The rate of tissue salvage in pedicled flaps was good 6/6 (100%) and so was in digital revascularizations 2/3 (67%), but poor in digital re-plants 1/4 (25%) and free flaps 0/2 (0%). CONCLUSIONS: Leeches are a helpful tool for congested tissue salvage and in this study, showed a greater survival benefit for pedicled flaps than for free flaps or digital replantations.

The Data Protection Act 1998: an audit of its effect on surgical trainees' practice.

The Data Protection Act 1998 came into force in March 2000 and has significant implications on our normal practice. A survey of surgical specialist registrars was made to establish knowledge of the Act and adherence to its eight principles. Knowledge was patchy and adherence minimal, Simple guidelines are suggested to help juniors keep within the principles of the Act.

A prospective randomised controlled trial to investigate the effect of local anaesthetic in vivo on cell culture.

Cell culture is an important adjunct in the management of major burns in that it enables keratinocytes derived from the patient to be grown and used to attain cover when there is little autologous skin available. The purpose of this prospective randomised trial was to determine if the type of local anaesthetic used to harvest the skin biopsy in vivo affected the subsequent culture of keratinocytes. Lignocaine 1% was compared with a eutectic mixture of local anaesthetic (EMLA) and a control. The subjects recruited were patients undergoing abdominoplasty. Sixteen patients were recruited but two were excluded from final analysis due to infection of the culture medium in one and poor yield from biopsies in all groups in the other. The tissue to be removed from the abdomen was divided into three areas. EMLA was applied to a 5x5 cm randomised area 2 h prior to surgery. Lignocaine 1% was injected into a 5x5 cm randomised area of abdominal skin immediately after anaesthesia. The third 5x5 cm randomised area was used as a control. Three 4-mm punch biopsies were harvested from each site of local anaesthetic application as well as the control area. The Rheinwald & Green method was used to culture these cells [Rheinwald JG, Green H. Serial cultivation of strains of human epidermal keratinocytes: the formation of keratinizing colonies from single cells. Cell 1975;6:331-5.] Cell counts were performed after harvesting keratinocytes from the biopsy and after 10 days of culture. Statistical analysis was undertaken. In conclusion, in contrast to in vitro studies when lignocaine 1% or EMLA is applied in vivo, there is no inhibition of cell culture. In vivo EMLA was also found to significantly increase cell multiplication.

Can we rely on a general practitioner's referral letter to a skin lesion clinic to prioritize appointments and does it make a difference to the patient's prognosis?

INTRODUCTION: This study was designed to: (i) determine if the priority of referral letters by general practitioners to a plastic surgery skin lesion clinic adhered to the national guidelines, what happened to these patients, and what was the histological diagnosis; and (ii) analyse whether the prognosis at diagnosis of malignant melanoma had improved since the introduction of the 2-week wait for patients with suspected cancer. MATERIALS AND METHODS: The study involved a prospective audit questionnaire, retrospective note review and histology report review in the Plastic Surgery Department in a district general hospital and their 'bespoke' out-patient clinics. RESULTS: Of 202 referral letters, 58 (29%) were referred as 2-week cancer referrals of which 13 (22%) suggested diagnoses that did not fall within the guidelines, and 11 gave no diagnosis. In addition, 84 (42%) had no indication of priority, though the text may suggest the need for it, either explicitly or implied. The prognostic indices for malignant melanoma have not altered since the 2-week wait rule has been implemented. CONCLUSIONS: The guidelines are not being adhered to, thus patients with benign lesions are being given undue priority. The history and examination of skin lesions given in the referral letters is insufficient to allow the consultant to prioritize. Since the 2-week rule has be implemented, malignant melanomas have not been diagnosed at an earlier stage.

Early presentation of an extremity arteriovenous malformation.

We report a very rare case of a high flow arteriovenous malformation (AVM) of the upper limb that caused high output cardiac failure at birth. There was early transfer of the baby to the care of a multidisciplinary team. After radiological intervention, the arm distal to the malformation became ischaemic and an urgent amputation through the upper-humerus followed. Methods of treatment are discussed, together with a review of results in the literature.