[Investigations with respect to the problem of excentric fixation].
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Amblyopia↗
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Preoperative management of patients with evisceration.
Evisceration is a complication familiar to all abdominal surgeons. This serious complication necessitates immediate return to the operating room for closure of the abdominal wound. Not infrequently, patients may face a significant delay before they can be taken to the operating room. The exposed abdominal contents may be protected by covering them with sponges soaked with povidone-iodine solution and a large plastic drape that sticks firmly to the skin.
Aged↗
A multicentre randomized study of single-unit dose package of EMLA patch vs EMLA 5% cream for venepuncture in children.
Eutectic mixture of local anaesthetics (EMLA) cream with Tegaderm was compared with pre-packaged EMLA patch with regard to analgesic effect, adhesiveness and local reactions during venepuncture in 178 children from three to ten years. One EMLA patch, or half the contents of a 5 g tube of EMLA cream plus Tegaderm was applied to the dorsum of one hand or antecubital fossa for a minimum of 60 min before venepuncture. The subject and observer assessed the degree of pain on a three-point verbal rating scale. The adhesion of the patch vs Tegaderm to the skin and local reactions were recorded. There was no difference between the two groups in pain associated with venepuncture; 95% of the EMLA patch group and 94% of the EMLA cream group reported no or slight pain. There was no difference between the two treatment groups in terms of overall local reactions. The patch was less adhesive (P < 0.001), but this had no apparent influence on its effectiveness. In conclusion, EMLA patch is equivalent to 5% EMLA cream (2.5 g) in cutaneous pain relief when used for venepuncture in children.
Adhesiveness↗
[Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate].
BACKGROUND: There is a high incidence of postoperative complications and late recurrences after operative therapy of a pilonidal sinus. The optimal treatment strategy is still matter of discussion. We studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure. MATERIALS AND METHODS: A total of 73 patients (62 male and 11 female, mean age 26.6 years) underwent a total of 79 operations between 1992 and 2001. Thirty patients (38%) were previously operated on because of a pilonidal sinus.Twenty-four were treated in our institution by an open procedure (five after simple abscess incision, 19 after sinus excision) and 52 by primary midline closure. Another three patients received skin flap procedures. RESULTS: Follow-up was possible for 65 patients (82%) for a median of 50 months.Recurrent pilonidal sinus occurred in 22 cases: 18 after primary midline closure (42%) and four after open procedure (21%, P=0.4). We found no relapse following the three skin flap procedures. There was a significantly higher relapse rate in patients operated with recurrent disease (12/25 vs 10/40; P<0.05). CONCLUSIONS: Despite of numerous previously operated patients (38%), there was a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure. Alternative operative techniques creating a lateral wound or the various skin flap procedures may be promising alternatives. We are in the process of changing our treatment strategy for patients suffering from a pilonidal sinus.
Abscess↗
[Treatment of MRSA infection in orthopedic surgery].
INTRODUCTION: Infection with methicillin-resistant Staphylococcus aureus (MRSA) remains a major challenge both therapeutically and hygienically. METHODS: Between January 2000 and January 2002, 27 patients with MRSA infections were treated and evaluated in a prospective clinical study. For effective wound management, operative revisions were performed every 3rd day. Following debridement, the wounds were vacuum sealed and specific i.v. antibiotics were administered. Wound closure was performed if three consecutive wound samples submitted for bacterial culture remained negative. RESULTS: All patients with MRSA infections were treated successfully until signs of infection disappeared and bacterial cultures were negative. An average of 7.3 operations per patient was required to eradicate MRSA infection. Follow-up of patients revealed recurrence of infection in four patients. CONCLUSION: Prevention of further spreading and successful treatment of MRSA infections in reconstructive orthopedic surgery is possible with appropriate surgical and hygienic concepts. In almost every second patient complex revision procedures were required.
Adolescent↗
[The present state of vacuum sealing].
In cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits in the future will inevitably produce new imperatives for interdisciplinary cooperation.
Extremities↗
[Abdominal vacuum device with open abdomen].
BACKGROUND: For the treatment of peritonitis or abdominal compartment syndrome, an open abdomen can be required. Because of the high complication rate associated with this method, different technical modifications were developed that are now being applied. Abdominal vacuum-assisted closure is increasingly favoured. We analyse our experience with this device in a distinct group of patients from gastrointestinal cancer surgery. PATIENTS AND METHOD: From June 2003 to December 2005, 36 patients were treated with 151 double-layer abdominal vacuum devices. Indications for applying this device were peritonitis (n = 22), abdominal compartment syndrome (n = 11), and necrotising fasciitis (n = 3). Thirty-four patients gave anamneses of malignoma. RESULTS: Overall, the vacuum therapy treatment lasted a median of 13 days (range 3-48). With it, four enteric fistulas (11%) and four abdominal wall bleedings (11%) occurred. In our patient group, no new intra-abdominal abscesses were observed. Four patients died during treatment with the vacuum-assisted device and four afterward because of multiple organ failure in acute sepsis (in-hospital mortality 22%). Twenty-six patients (72%) underwent direct fascial closure after a median treatment duration of 10 days. Six patients (17%) required synthetic mesh for fascial closure. After a median follow-up of 100 days, two patients developed ventral hernias and two others showed ossification of the scar. CONCLUSION: Compared with other methods of temporary abdominal closure, our experience with the vacuum-assisted device demonstrates its advantages concerning clinical feasibility and the relatively low complication rate. The high rate of direct fascial closure with an acceptable rate of ventral hernias following vacuum-assisted abdominal closure are further benefits of this technique.
Abdomen↗
[Treatment of paraungual HPV73-positive Bowen disease with imiquimod cream].
Bowen disease - a squamous cell carcinoma in situ - is associated with oncogenic human papilloma viruses (HPV). The association is best established for genital Bowen disease but also holds for extragenital lesions. The immunomodulatory substance imiquimod is used for the treatment of HPV-induced skin disorders. In the case of paraungual Bowen disease, established treatment options as excision, cryosurgery, radiotherapy or laser treatment might cause persistent nail damage. We successfully treated HPV73-positive Bowen disease in this location with topical imiquimod.
Administration, Topical↗
[Retrograde tibial intramedullary nailing with the Flex Nail--treatment of tibial fracture in an unusual case].
We report a case by a 75 year old female patient suffering a third-degree open fracture of the shinbone with a severe damage of the soft tissue. Primary operation was a temporary fixation with a fixateur externe and a radical debridement of the soft tissue with vacuum-sealing. Ten days later we did the definitive surgery. Osteosynthesis was done by a retrograd nailing with the flexible unreamed humerus nail (Flex-Nail) through the medial ankle. The defect of the soft tissue was treated by a muscle flap and meshgraft transplantation. Healing of the soft tissue and beginning consolidation of the fracture comes after 4 months. In our opinion the retrograd inserted Flex-Nail is a good option for treatment of compound fractures of the lower leg in special cases.
Aged↗
[Treatment of infection by vacuum sealing].
Between 1 January 1992 and 31 July 1995, 313 patients with acute and chronic infections were treated by vacuum sealing (VS). The average duration of VS treatment was 16.7 days, and there was an average of 3.1 changes in the VS system. In acute infections (n = 203) the wounds were closed by secondary suturing (65.5%), spontaneous epithelialization (17.2%), skin grafting (12.3%) and flap transfer (2%). Six patients died (3%). Infection recurred in 3.9% and was cured by another VS treatment. Unstable scar formations (1%) were treated by free flap transfers. When compared with standard open-wound treatment, the low-cost VS technique offers great advantages with regard to hospital hygiene, patient comfort and therapeutic results.
Abscess↗
[Vacuum sealing of extensive wound healing disorders after kidney transplantation].
With the introduction of mycophenolate mofetil (MMF) in renal transplantation, acute rejection episodes diminished and short-term graft survival improved. Better graft outcome, however, is followed by several surgical complications attributed to MMF. Patients with risk factors (adiposity, diabetes mellitus, advanced age) show an increased rate of healing by second intention. We treated two patients with the vacuum sealing technique so that after 15 days a secondary suture became possible in each case. To date the vacuum sealing technique has been used mainly in traumatology, abdominal surgery, surgery for acute infections of soft tissue and bone, and problem wounds with reduced wound-healing capacity (chronic leg ulcer). This article presents two cases of successful application of the vacuum sealing technique in renal transplantation after prolonged wound healing.
Body Mass Index↗
The effect of occlusive and unocclusive exposure to xylene and benzene on skin irritation and molecular responses in hairless rats.
Aromatic hydrocarbons readily penetrate the skin on dermal exposure, leading to irritation, inflammation and cytotoxicity. The effects of short-term occlusive and long-term unocclusive dermal exposure to benzene and xylene on the skin irritation response (transepidermal water loss (TEWL), skin moisture content and erythema) and cytokine/chemokine expression (interleukin-1alpha (IL-1alpha), tumor necrosis factor-alpha (TNF-alpha) and monocyte chemoattractant protein-1 (MCP-1)) were investigated in hairless rats. Occlusive dermal exposure was carried out with 230 microL of the chemicals for 1 h using Hill top chambers. In unocclusive dermal exposure, 15 microL of the chemicals were applied to the skin every 2 h, for 8 h a day, for 4 days. The occlusive dermal exposure revealed a clear difference in the TEWL and erythema response of these chemicals (xylene>benzene) whereas unocclusive exposure revealed similar TEWL and erythema scores for both benzene and xylene. The expression of IL-1alpha was elevated 2.5- and 3.8-fold in response to occlusive and unocclusive exposure, respectively, vs control (P<0.01) for both the chemicals (benzene and xylene). Similarly, TNF-alpha levels were elevated about 2.4- and 6.0-fold as a result of occlusive and unocclusive exposure, respectively, vs control (P<0.01). These results show that unocclusive exposure induced significantly higher TNF-alpha expression than occlusive exposure (P<0.05). The MCP-1 expression in blood was slightly elevated compared with the control group, but this increase was not statistically significant (P>0.05). Similarly, MCP levels in skin were increased approximately 1.7- and 1.8-fold by occlusive and unocclusive exposure, respectively, compared with the control group (P<0.05). Our study demonstrates that the skin irritation profiles of benzene and xylene are similar and unocclusive long-term exposure to small amounts of these chemicals can induce more skin irritation and cytokine response than occlusive exposure.
Administration, Cutaneous↗
Clinical evaluation of a new self-drying silicone gel in the treatment of scars: a preliminary report.
Topical silicone gel sheeting and intralesional steroids are the only evidence-based recommendable forms of treatment to control the quality of a scar. The advantages and disadvantages of both are well known. This study was undertaken to verify the efficacy of a new topical silicone treatment: a self-drying spreadable gel that needs no means of fixation and cannot be seen because of complete transparency. Fresh surgical scars treated with the tested product showed significantly better outcomes than those untreated in a prospective trial involving a group of 160 patients. Patient compliance was particularly good, especially for scars on exposed areas such as the face, where the traditional gel sheeting is frequently discontinued at an early stage by patients who object to its visibility. The results of the self-drying silicone gel have indeed been satisfactory. Considering the effective results obtained and the good patient compliance, the authors currently rate this concept of treatment as the first choice for preventing hypertrophy of recent scars.
Administration, Topical↗
[Some aspects of the current controversy about the treatment of amblyopia].
Occlusion has been used for centuries for treating amblyopia but in recent years an intensive debate about the treatment has arisen. The aim of this article is to summarize some of the new aspects of this discussion: on the one hand the effect of occlusion treatment during childhood is being questioned and on the other hand experimental approaches are being tested which are aimed at treating amblyopia in adults. Evidence from own experimental work is presented showing the influence of occlusion on the spatial localization of visual stimuli. A continuation of research on amblyopia and the effect of the therapy is urgently needed.
Adolescent↗
[I know that I know nothing? Comments on occlusion treatment].
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Adolescent↗
Staged reduction of gastroschisis: a simple method.
Staged reduction of abdominal contents using a silastic sheet has become standard management in gastroschisis where primary closure is not possible. With the introduction of a pre-made Silastic silo coupled to a spring-loaded ring (Ben Tec, Sacramento, CA), the procedure can be done at the bedside. We present a simple technique utilizing a disposable umbilical-cord clamp that makes reduction a fast, one-physician procedure and present a preoperative step that facilitates tension-free closure of the abdominal fascia.
Dimethylpolysiloxanes↗
Intra-operative pulse oximetry can help determine intestinal viability.
The intra-operative assessment of intestinal viability when dealing with ischaemic bowel remains a challenge. Reliable healing of small-bowel anastomoses, using pulse oximetry to exclude critical ischaemia, has been shown in the canine model. In this study, intra-operative pulse oximetry (PO) was used to help determine intestinal viability 48 h after de-torsion of a volvulus. Approximately one-half of the ischaemic, volved bowel was able to be preserved. Intra-operative PO can thus help preserve bowel of doubtful viability.
Anastomosis, Surgical↗
Guideline proposal to reconstructive surgery for complex perineal sinus or rectal fistula.
AIM: To evaluate a guideline approach of reconstructive surgery for complex perineal sinus or rectal fistula. METHODS: pre-, per-, and postoperative data of 28 patients undergoing transposition of rectus abdominis muscle (TRAM), gracilis muscle (GM), gluteal thigh flap (GTF), or omentoplasty (OP) for complex perineal sinus or rectal fistula were analyzed. A fistula higher than 10 cm and a sinus with a length of >10 cm were treated with TRAM or OP. If <8 cm, the first choice was GM or GTF. The operative team made choice between 8 and 10 cm. Vacuum assisted closure (VAC) therapy was used as adjunct therapy before and after muscle transposition in huge sinus. Success was defined as no residual or recurrent sinus or fistula within 6 months, postoperatively. Long-term complaints of perineum and muscle donor site were assessed. RESULTS: Twenty-five out of 28 patients (90%) were treated according to the guideline. VAC therapy was done in six. Three patients died during mean follow up of 40 months (6-90). Initial success rate was 61% (17/28). After secondary surgery in seven, four (57%) were successful. Overall success rate, including VAC therapy, was 79% (22/28). Success was highest with GM and GTF and in small sinus or fistula. CONCLUSION: A guideline approach to complex perineal sinus or fistula based on length or height of the sinus or rectal fistula, respectively, is successful in about 80% of cases. Large defects may best be downsized by VAC therapy, followed by muscle flap. Long-term complaints are acceptable.
Abscess↗