Site Dehiscence Research Articles

A Rare Case of Tubercular Pyo– Pneumothorax Herniating through the Inter-Costal Drainage Site

A 53 year old diabetic male, who was on anti – tubercular treatment, presented with an expansile swelling on his chest, at the intercostal drainage (ICD) site. He was diagnosed to have a left sided tubercular hydro – pneumothorax, about six weeks earlier. He had noticed the swelling at the ICD site, 5 days ago and he had no pain. Clinically, an expansile swelling of size 5 x 4 cm, was seen at the 6th ICS, in the mid axillary line, which was partially reducible, with palpable crepitations [Table/Fig-1]. The left hemi – thorax showed reduced movements and breath sounds. Contrast enhanced computer tomographic (CECT) images of thorax showed left upper lobe consolidation, with cavities and a hydro – pneumothorax. The left pleural space was seen to extend through the dehiscence on lateral chest wall, forming an air – filled subcutaneous swelling. [Table/Fig-2]. Anti-tubercular therapy was continued and a fresh ICD was inserted at the lower intercostal space, which drained the purulent fluid. After a week, repair and layered suturing was done at the site of dehiscence. The wounds approximated and healed over the next 3 – 4 weeks. A pyo-pneumothorax which is caused by tuberculosis is common in endemic areas [1]. There is one report in the literature on herniation of an emphysematous bulla through an ICD site [2]. However, herniation of a pyo-pneumothorax through a closed ICD site was not found in our literature review.

Role of bowel preparation on colocolonic anastomosis: experimental study in dogs

The aim of the present study was to evaluate the efficacy of colocolonic anastomosis with and without preoperative bowel preparation. METHODS: The study compared 42 female dogs (Canis familiaris), divided into 2 groups of 21 animals: Group I (control) - submitted to bowel preparation - and Group II (study) - without previous bowel preparation -. All animals were submitted to laparotomy with sectioning of the descending colon and primary anastomosis using polypropylene thread. Following euthanasia on the 21st postoperative day (POD), a second laparotomy was performed to evaluate the anastomosis with regard to complications, intra-abdominal adhesions and anastomotic burst pressure. RESULTS: One animal from each group (4.5%) died. The death in Group I occurred on seventh POD due to anastomotic dehiscence. The death in Group II occurred on tenth POD due to deep incisional infection at the surgical site and complete dehiscence of the abdominal wall. The groups did not differ significantly with regard to adhesion grade or anastomotic burst pressure (one specimen burst in each group) (p>0.05). CONCLUSION: Colocolonic anastomosis without previous bowel preparation was shown to be safe and efficacious, suggesting it is not an indispensable procedure in colorectal anastomosis surgery.

Thoracodorsal Artery Perforator Flaps and Muscle-Sparing Latissimus Dorsi Myocutaneous Flaps for the Treatment of Axillary Hidradenitis

The purpose of this study was to review a single surgeon's experience with using the thoracodorsal artery perforator (TAP) flap for coverage of axillary defects. This is a retrospective review of all flaps performed by the senior author (D.W.L.) after excision of axillary hidradenitis between 2004 and 2010. Nine TAP flaps were successfully performed, whereas 5 muscle-sparing latissimus dorsi (MSLD) myocutaneous flaps were necessary because of the inability to harvest a perforator flap. Overall, this equates to a 64% success rate in harvesting a perforator flap. The mean sizes of the TAP and MSLD flaps were 75 cm (range, 32-120 cm) and 83 cm (range, 48-160 cm), respectively. There were 2 (14%) flaps with wound complications. One patient had recurrent disease requiring debridement. Another patient who underwent the largest of all flaps (MSLD) had donor site and recipient bed dehiscence requiring debridement and skin grafting. This patient also later required flap debulking and Z-plasty for scar contracture. Overall, TAP and MSLD flaps can be performed reliably for coverage of axillary defects after excision of hidradenitis. Although not free of complications, they do offer improved results compared to historic attempts at primary closure or skin grafting.

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face.

PS108. Impact of Intra-operative Local Vancomycin on Inguinal Wound Complications

Local vancomycin treatment has been shown to decrease sternal wound complication rates. Whether a similar effect can be achieved at other surgical sites is unknown. This study investigates the effect of local vancomycin on inguinal wound complication rates following vascular procedures. Retrospective analysis was performed on 646 patients who underwent open infra-inguinal and hybrid endovascular procedures between 2006 and 2011. Patients received either pre-operative systemic antibiotics alone (Group A) or in conjunction with intra-operative wound application of vancomycin powder and irrigation (Group B). Wound site infection and dehiscence over a 30-day period were recorded. Fisher exact test and multivariate regression analyses were performed. There were 424 patients in Group A and 222 patients in Group B. Both groups had similar demographics and distribution of vascular procedures. There was no significant difference in the 30-day incidence of superficial and deep wound infections (OR: 0.72, P = .19) or dehiscence (OR: 1.2, P = .46) between the two groups after adjusting for type of operation, body mass index, chronic renal dysfunction and presence of chronic lung disease. In contrast to other surgical sites, local vancomycin administration did not improve the rate of short term inguinal wound complications following vascular procedures. A prospective study is needed to further delineate the role of local vancomycin adjunct treatment on inguinal wound outcomes.

Transmastoid Repair of Superior Semicircular Canal Dehiscence

Objective/Hypothesis Superior semicircular canal (Sup SC) dehiscence syndrome is a rare condition, causing a variety of auditory and vestibular symptoms. The traditional surgical management is a middle cranial fossa, extradural approach to resurface the Sup SC. Recently, a transmastoid approach for plugging of the Sup SC has been developed. We present further data supporting the use of the transmastoid approach in preference to the middle fossa approach. Design This is a retrospective multi-institutional case series. Method We included 10 patients in this case series from two tertiary otology institutions. Sup SC dehiscence was confirmed by correlation of clinical symptoms with positive audiometric, vestibular evoked myogenic potential, and computed tomography findings. A transmastoid approach was used for plugging of the Sup SC. Either a single fenestration was created at the site of dehiscence or separate fenestrations sited ampullopetal and ampullofugal to the dehiscence. Results All patients who underwent this procedure had good symptom control and hearing preservation postoperatively. Conclusion In patients with adequate temporal bone pneumatization, the transmastoid approach provides a safe and effective alternative to the middle cranial fossa approach. This series has demonstrated excellent symptom control and preservation of hearing with the transmastoid approach.

The effect of loading in regenerated bone in dehiscence defects following a combined approach of bone grafting and GBR

To evaluate by histology the effect of loading on the regenerated bone at dehiscence type defects around implants when treated with a combined approach of bone grafting and guided bone regeneration (GBR). In twelve Göttingen mini-pigs, the lower premolars and first molars were extracted and the alveolar process was reduced in width. After 3 months, two Straumann SLActive (Straumann AG, Basel, Switzerland) implants were placed in each hemi-mandible. Twelve implants were placed into the reduced alveolar ridge (group P) with no further defect or treatment on the site, while on 36 implants, buccal dehiscence defects were created and treated as follows: Group T1: synthetic bone substitute (Straumann Bone Ceramic, SBC, Straumann AG). Group T2: SBC with a polyethylene glycol membrane (Straumann MembraGel, Straumann AG); Group N: the dehiscence remained untreated. Three months following implantation, long, custom-made, healing abutments were placed in one hemi-mandible only to ensure functional loading. After 2 months, histological analysis was performed. A trend for lower residual defect height and higher bone-to-implant contact was observed in the loaded sites compared with non-loaded sites in groups P, T1 and N. In group T2, the opposite effect was observed. In terms of bone formation, sites treated with SBC grafting and GBR (group T2) exhibited the largest surface area of regenerated bone followed by T1 and N. Significant resorption of the graft particles was noted in group T2 and the graft surface area occupied by SBC was significantly higher in group T1 compared with group T2 (P < 0.05). Loading may have a positive effect on bone-to-implant contact in implants inserted in pristine bone or inserted in dehiscence sites and treated by grafting/no grafting.

Characteristics of Traumatic Cataract Wound Dehiscence

To characterize the clinical course of cataract wound dehiscence. Retrospective, comparative case series. Charts of open globe injuries (848 injuries in 846 patients) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Time from original surgery to wound dehiscence, type of initial surgery, Ocular Trauma Score, age, gender, mechanism of injury, and visual acuity were analyzed. Of 846 patients with 848 open globe injuries, 63 experienced cataract wound dehiscence. The majority of these cataract wounds (89%) were extracapsular cataract extraction (ECCE), with only 7 (11%) phacoemulsification wounds. The mean patient age in the wound rupture group was 78.2 years. Female patients comprised the majority (67%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (23%), and motor vehicle accident (7%). The median raw ocular trauma score was 47 in wound dehiscence patients. Visual acuity at presentation was light perception in the wound dehiscence group. The best postoperative visual acuity was significantly worse in the wound dehiscence group (hand motion) than in the remaining patients (20/40; P=.0002). When considering the phacoemulsification patients alone, these patients fared much better, with a median postoperative vision of 20/60. Despite recent advances in cataract surgery, wound dehiscence remains a significant source of visual disability, mainly in the geriatric population. Rupture ECCE wound patients have a poor visual prognosis. Fortunately, patients with phacoemulsification site dehiscence appear to regain the majority of their vision after open globe repair.

Facial Nerve Dehiscence and Cholesteatoma

We evaluated the incidence of facial nerve dehiscence in a group of patients with cholesteatoma who underwent otologic surgery. We performed a retrospective study in a tertiary referral hospital of 336 patients (298 adults, 38 children) with cholesteatoma who underwent surgery in the years 1998 to 2008. Using intraoperative findings, we assessed the incidence of facial nerve dehiscence in a group of patients with cholesteatoma. We quantified, in adult versus pediatric patients and in primary versus revision surgeries, the occurrence of facial nerve dehiscence, the predisposed anatomic sites, and the coexistence of semicircular canal fistula. In a selected group of 67 patients, preoperative 0.55-mm collimation computed tomography (CT) scans were compared with the intraoperative findings. The frequency of facial nerve dehiscence in this group of patients was 27.1%. The dehiscence was detected in 29.5% of the adults, but in only 7.8% of the patients 16 years and younger. Dehiscence was present in 42.3% of the patients who underwent revision surgery. The most common site of dehiscence (92.3%) was the tympanic segment. The sensitivity and specificity of CT were 69% and 87%, respectively. Dehiscence of the facial nerve was found in 27.1% of patients with cholesteatoma, with a significant difference between patients of pediatric and adult ages. A dehiscent facial nerve was more commonly seen during revision surgery and more frequent in patients older than 16 years. The site of dehiscence most frequently involved by cholesteatoma was the tympanic segment. The presence of a semicircular canal fistula increases the risk of facial nerve dehiscence. Finally, the results of preoperative CT scans are encouraging for the use of CT in predicting facial nerve dehiscence.

Candida albicansperitonitis in a dog

To describe the clinical management of a case of Candida albicans peritonitis in a dog and discuss the pathogenicity of Candida peritonitis along with treatment using the fungistatic agent, fluconazole.A 15-week-old Papillon developed peritonitis secondary to enterectomy site dehiscence. A pure growth of Candida albicans was obtained from the abdominal fluid. Surgical repair of the dehiscence was performed and antifungal therapy instituted with fluconazole postoperatively. A marked exudative process was noted postoperatively with production of large volumes of fluid from the abdominal drain. Fresh frozen plasma and pentastarch were provided for oncotic support. Recovery was complicated by megaesophagus, however, the patient gradually improved and was discharged 11 days after surgery.To our knowledge, this is the first case report of successful treatment of Candida albicans peritonitis in a dog. A marked exudative process was noted during therapy requiring significant oncotic support. Resolution of the disease process was achieved with surgical intervention and antifungal therapy.

Traumatic Wound Dehiscence and Lens Extrusion After Penetrating Keratoplasty

The purpose of this study was to investigate risk factors for and results of treatments in patients with traumatic wound dehiscence and lens extrusion after penetrating keratoplasty. In this retrospective case series, 7 eyes (4 right eyes and 3 left eyes) of 7 patients who had traumatic wound dehiscence and lens extrusion were studied at Rassoul Akram Hospital. Six patients were male and one patient was female. After emergency treatment for the trauma, the wound was checked under general anesthesia, and anterior vitrectomy was performed. The iris was repositioned as needed and the dehiscence site was sutured in all patients using 10-0 nylon thread. Follow up was similar to that after keratoplasty. All recorded data were statistically analyzed using SPSS software (version 15; SPSS Inc., Chicago, IL). Mean age at trauma was 21 years (range, 10-30 years), and the mean interval between keratoplasty and trauma was 15.6 months (range, 2.5-26.5 months). Mean best-corrected visual acuity of patients before blunt trauma and after final treatment was 20/80 and 20/160, respectively. In one case, visual acuity decreased to light perception after final treatment. The dehiscence site was superior to the graft in 4 patients. Hitting by a hand was the cause of most cases of blunt trauma. No cases of endophthalmitis were seen. Patients who undergo penetrating keratoplasty are susceptible to graft wound dehiscence resulting from trauma, especially during the first year after keratoplasty. This type of dehiscence is more prevalent in young people, who engage in more social activities and are more exposed to trauma that may lead to blindness. Patient education about the effects of trauma, use of protective eye shields by patients, and performance of lamellar keratoplasty instead of penetrating keratoplasty can decrease trauma and its effects in these patients.

Surgical Outcomes and Nipple Projection Using the Modified Skate Flap for Nipple-Areolar Reconstruction in a Series of 422 Implant Reconstructions

Numerous techniques have been used in an attempt to achieve long-term nipple projection following nipple-areolar reconstruction (NAR). A common setback, however, is the diminution of projection over time; this phenomenon is particularly evident following implant based breast reconstruction. The purpose of this report was thus to evaluate surgical outcomes and long-term nipple projection with the use of "modified skate flap" technique in exclusively implant based postmastectomy reconstructions. A retrospective review was performed for the period between 1993 and 2007. All consecutive patients with 2-staged tissue expander/implant reconstructions followed by NAR using the modified skate flap technique performed by the senior author (P.C.) were identified in a prospectively maintained breast reconstruction database. Only patients with a minimum of 1-year follow-up were included in the study. Patients with a history of irradiation to the breast were excluded from nipple projection assessment. Clinical outcome measurements included long-term nipple projection as well as incidence of complications from the NAR procedure using the modified skate flap technique. Over the 15-year study period, 475 patients underwent 2-staged tissue expander/implant reconstruction followed by NAR using the modified skate flap technique. Of these, there was a total of 292 patients with the minimum requirement of 1-year follow-up post NAR (61% follow-up rate). The total number of reconstructed nipple areolar complexes evaluated in this series was 422 (130 bilateral and 162 unilateral NAR). Forty patients (28 unilateral and 12 bilateral NAR) who received radiation to their breasts were excluded from nipple projection assessment. At a median follow-up of 44 months (range: 12-84 months), mean nipple projection was 2.5 mm (range: 1-4 mm). Minor complications occurred in 7.2% of the patients (n = 292). Skin graft donor site dehiscence was the most common complication (3.1%) followed by partial skin graft nontake of the areola (2.1%). This report documents the largest series of NAR using a single technique in the setting of postmastectomy reconstructions. This technique can be safely performed over breast implants with acceptably low rates of complications and predictable results. Long-term nipple projection over implant reconstructions using this technique is modest and this must be forewarned to patients completing the final stage of their implant reconstruction.

Effect of Body Mass Index on Short-Term Outcomes after Colectomy for Cancer

Obesity is associated with an increased risk of postoperative complications after colectomy for cancer, but it is unclear which specific complications occur more frequently in obese patients. Our objective was to assess the association of body mass index (BMI) on short-term outcomes after colectomy for cancer. Using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) dataset, we identified patients who underwent colectomy for malignancy at 121 hospitals. Logistic regression models were developed to assess risk-adjusted 30-day outcomes by BMI while adjusting for preoperative risk factors. There were 3,202 patients identified: 33.4% normal weight (BMI 18.5 to 24 kg/m(2)), 35.1% overweight (BMI 25 to 29 kg/m(2)), 19.0% obese (BMI 30 to 34 kg/m(2)), and 12.4% morbidly obese (BMI>/=35 kg/m(2)). Compared with normal weight patients, complications occurred more frequently in the morbidly obese (31.8% versus 20.5%, odds ratio [OR] 1.75, 95% CI 1.33 to 2.31). Specifically, the morbidly obese had a higher risk of surgical site infection (20.7% versus 9.0%; OR 2.66, 95% CI 1.91 to 3.73), dehiscence (3.3% versus 1.1%; OR 3.51, 95% CI 1.55 to 7.95), pulmonary embolism (1.3% versus 0.3%; OR 6.98, 95% CI 1.62 to 30.06), and renal failure (3.0% versus 1.5%; OR 2.75, 95% CI 1.21 to 6.26). Pneumonia, urinary tract infection, stroke, cardiac arrest, myocardial infarction, deep venous thrombosis, length of stay, sepsis, and 30-day mortality did not differ significantly by BMI. Compared with normal weight patients, morbidly obese patients had a higher risk of surgical site infection, dehiscence, pulmonary embolism, and renal failure, but not other complications or mortality. Quality initiatives should include these specific complications.

Bevacizumab -- News from the Fast Lane?

The introduction of bevacizumab (Avastin), an antibody to the vascular endothelial growth factor (VEGF), into the repertoire of the medical management of malignant gliomas has influenced the area of glioma treatment quite markedly. First, after decades of aiming at stopping tumor growth and being quite satisfied with documenting “stable disease,” we are suddenly observing objective response rates at a never-seen frequency exceeding 50%.1 Admittedly, we have not been convinced by any report that the high response rate translates into a gain in survival. The progression-free survival rate at 6 months— our current gold standard of assessing novel treatments for recurrent glioblastoma—may be in the range of 40%, but similar figures are also achieved with dose-intense regimens of temozolomide. Second, we may need to reconsider the MacDonald response criteria, which overall have served us well in assessing the efficacy of novel treatments, but which are heavily based on contrast enhancement. Yet in the era of antiangiogenic agents like bevacizumab, which may soon be joined by cilengitide or enzastaurin, altered patterns of recurrence resulting from a change from vessel/VEGF-dependent growth to vessel/VEGF-independent tumor growth2 may necessitate the development of new response criteria. Third, and perhaps heralding new patterns of toxicity common to the new class of antiangiogenic agents for glioma treatment, the fear of intratumoral hemorrhages may not have been justified, but craniotomy site dehiscence is increasingly noted as a relevant complication in a minority of glioma patients treated with bevacizumab.3 Fourth, the impressive effects of the combination of bevacizumab and irinotecan were unexpected and initially suggested strong synergistic potential for two agents that appeared to have limited activity when administered alone. Yet the results from the first randomized trial of bevacizumab alone versus bevacizumab plus irinotecan presented by Cloughesy and colleagues at the 2008 American Society for Clinical Oncology meeting in Chicago appear to confirm the suspicion that irinotecan is contributing little to the overall effect of this novel regimen. Along these lines, switching patients who progress under bevacizumab and irinotecan to another bevacizumab-containing regimen seems to offer little hope for response.2 In the current issue of Neuro-Oncology, Ingeborg Fischer and colleagues report on their investigation into histological features of malignant gliomas after treatment with bevacizumab.4 Five paired tissues obtained prior to and after exposure to bevacizumab were available and compared with four paired tissues from patients never exposed to bevacizumab. Decreased vessel density correlated with radiographic responses to bevacizumab, whereas the levels of VEGF-A and various other histological and immunochemistry parameters did not. While the case numbers of this study are low, such tissues are difficult to assemble, and approaches as outlined here are very important. They are likely to result in the identification of biomarkers associated with response, or the lack thereof, to experimental brain tumor treatments and will help to design a scientific basis and possibly new endpoints for upcoming clinical trials, notably in the emerging field of novel antiangiogenic agents.

Hybrid myocardial revascularization complicated by delayed anastomotic bleeding

We present a case of hybrid coronary revascularization complicated by delayed bleeding from an anastomotic site. Anastomosis of the left internal mammary artery to the left anterior descending coronary artery was successfully performed via a lateral anterior small thoracotomy. Scheduled subsequent percutaneous coronary intervention of residual stenoses was successfully performed 13 days after the surgery, but cardiac tamponade due to anastomotic site dehiscence was disclosed soon after the percutaneous procedure. We discuss the causation of the delayed bleeding that occurred after the hybrid coronary revascularization.

An Unusual Cause of Aortic Regurgitation

HomeCirculation: Cardiovascular ImagingVol. 1, No. 2An Unusual Cause of Aortic Regurgitation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBAn Unusual Cause of Aortic Regurgitation Sherif F. Nagueh, MD Sherif F. NaguehSherif F. Nagueh From the Department of Cardiology, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Tex. Search for more papers by this author Originally published1 Sep 2008https://doi.org/10.1161/CIRCIMAGING.108.790931Circulation: Cardiovascular Imaging. 2008;1:e13–e14A 42-year-old man presented with acute onset of severe dyspnea, fever, and positive blood cultures for Staphylococcus aureus. His medical history was relevant for aortic root surgery, including replacement of the aortic root and aortic valve with a homograft 3 years ago. His physical examination revealed sinus tachycardia, a heart rate of 120 bpm, and a blood pressure of 84/45 mm Hg. Bibasilar rales were present, and the jugular veins were distended to the angle of the mandible. Transesophageal echocardiography was performed to examine the underlying reasons for his acute deterioration.Transesophageal echocardiography revealed the presence of a dehiscence of the homograft, with flow occurring between the left ventricular outflow tract and a pseudoaneurysm in the plane of the intervalvular fibrosa, without vegetations on the aortic valve. Hemodynamically significant aortic regurgitation (AR) was present through the site of the dehiscence, but not the aortic valve itself (Data Supplement Movies I-IV), and pulsed wave Doppler of the descending aorta revealed holodiastolic flow reversal (Figure 1). Continuous wave Doppler signal of the AR jet was consistent with significant AR, showing a short pressure half-time (Figure 2). In addition, echolucent areas with septations were seen surrounding the homograft (Data Supplement Movie I), consistent with multiple abscess cavities. Doppler interrogation showed early closure of the mitral valve and diastolic mitral regurgitation (Figure 3, left). Pulmonary venous flow (Figure 3, right) revealed a reduced systolic velocity to diastolic velocity ratio and a prominent atrial reversal signal. Collectively, these Doppler findings are consistent with a highly elevated left ventricular end-diastolic pressure (atrial reversal >50 cm/s, premature closure of the mitral valve, and diastolic mitral regurgitation), as well as an increased mean left atrial pressure (systolic/diastolic, <1) due to AR. Download figureDownload PowerPointFigure 1. Pulsed wave Doppler recording from the descending thoracic aorta shows forward flow in systole (above the baseline), with holodiastolic flow reversal (below the baseline and delineated by the arrows). This finding is consistent with hemodynamically significant AR.Download figureDownload PowerPointFigure 2. Continuous wave Doppler of the AR jet. Notice the rather dense signal when compared with forward flow across the aortic valve and the steep deceleration, leading to a very short pressure half-time (95 ms, arrow).Download figureDownload PowerPointFigure 3. Left side shows mitral inflow by pulsed wave Doppler. Diastolic flow is abbreviated with premature closure of the mitral valve (arrow above baseline) and diastolic mitral regurgitation (arrow below baseline). Both observations are diagnostic of highly elevated left ventricular end-diastolic pressure. On the right, is a recording from the left pulmonary vein. Forward flow in systole (S) is reduced, whereas forward flow in diastole (D) is increased. This finding indicates increased mean left atrial pressure. In addition, the increased atrial reversal velocity with left atrial contraction confirms the increased left ventricular end-diastolic pressure.Aortic graft dehiscence is a rare complication after aortic root surgery, whether with composite grafts or homografts. The hemodynamic consequences depend on the extent of dehiscence and can lead to severe perivalvular regurgitation and acute heart failure, as in this case. Aortography may not visualize a single site dehiscence, nor the mechanism of regurgitation. On the other hand, transesophageal echocardiography has a high accuracy in identifying the location and extent of the dehiscence, the presence of aortic root and aortic valve pathology, and the severity of regurgitation, as seen in this case.The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/1/2/e13/DC1DisclosuresNone.FootnotesCorrespondence to Sherif F. Nagueh, MD, Methodist DeBakey Heart Center, 6550 Fannin, SM-677, Houston, TX 77030. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails September 2008Vol 1, Issue 2Article InformationMetrics Download: 285 https://doi.org/10.1161/CIRCIMAGING.108.790931PMID: 19808521 Originally publishedSeptember 1, 2008 PDF download Advertisement SubjectsCongenital Heart DiseaseEchocardiographyHeart FailureValvular Heart Disease

Fallopian canal dehiscence: can it be pridicted

The aim of the study is to give an idea about true incidence and most common location of fallopian canal dehiscence and to identify predictive factors associated with fallopian canal dehiscence based on preoperative and peroperative clinical correlates so as to facilitate preemptive prediction of the condition. The study design pertains to a prospective study. The setting of the study was tertiary referral hospital and a total of 146 patients underwent radical and modified radical mastoidectomy as primary procedure between Jan. 2003 to Dec. 2004. The site of dehiscence and associated pre-operative and per-operative findings were noted. Our results showed the incidence of fallopian canal dehiscence among cases undergoing radical and modified radical mastoidectomy was 82/1000 per year. Around 66.6% dehiscence was located in tympanic segment. The preoperative factors significantly associated with the fallopian canal dehiscence (p< 0.05) were Aural polyp, Extra-cranial complications, Cholesteatoma and Facial palsy. Per-operative findings were Cholesteatoma, All ossicles necrosed except stapes footplate and Lateral semicircular canal fistula.

Prosthetic Rehabilitation of Orofacial Donor Site Fistula Following Surgical Reconstruction: A Clinical Report

Orofacial defects can be either congenital or acquired. Rehabilitation of these patients can be done using a surgical and/or a prosthetic approach. In situations where surgical reconstruction is not possible, prosthetic management becomes the only option. This clinical report describes a simple, economical, and effective technique for the prosthetic rehabilitation of a patient with oro-cutaneous fistula due to donor site dehiscence following tumor defect reconstruction.

Microvascular head and neck reconstruction in patients with liver cirrhosis

The aim of this retrospective case series was to review the safety, complications, and outcomes of free-tissue transfer in head and neck cancer reconstruction in patients with liver cirrhosis. A retrospective review of all microvascular head and neck reconstruction cases with concomitant liver cirrhosis treated in our institution from 1994 to 2005 was performed. Data collected included patient demographics, etiology, and severity of liver cirrhosis, defect site, choice of free flap, complications, and clinical follow-up. Seven patients were identified. They were all males and underwent microvascular head and neck reconstruction due to ablative cancer surgery. Their Child-Pugh classification of liver cirrhosis was graded as follows: Child A (n = 3); Child B (n = 3); and Child C (n = 1). Eight free flaps were transferred (1 patient received 2), including anterolateral thigh (n = 4); radial forearm (n = 3); and fibula (n = 1). All flaps survived without the need for any microvascular revision procedures. Two patients died within postoperative 30 days due to hepatic decompensation. Other complications included neck hematoma (n = 1), neck wound infection (n = 2), and donor site dehiscence (n = 1). Only 2 patients with Child A cirrhosis remained free from complications and survived more than 1 year after the surgery. Microvascular head and neck reconstruction may be performed in patients with liver cirrhosis with a certain degree of technical success. However, the procedure is associated with significant mortality and morbidity in Child class B and C patients. Therefore, we recommend avoiding free-tissue transfer in patients with head and neck cancer with advanced liver cirrhosis.

FACIAL NERVE IN MIDDLE EAR AND MASTOID SURGERY

In Reply: We concur with Dr. Eftekharian's comments that experience and good surgical technique are essential to prevent injury to the facial nerve during mastoid surgery. In this study, we attempted to demonstrate that the perineural vascular plexus is a useful landmark for the position of the facial nerve. In order to demonstrate that the vessels may be seen through the bone of an intact facial nerve canal in the horizontal segment, cases found to have a dehiscence of the facial nerve were specifically excluded. There were only two exclusions in this series. This is less than we might usually expect, but, in our experience, the figure of 33% facial nerve dehiscence seems a relatively high incidence. We would agree that a relatively common site of dehiscence is in the region of the “second genu” in the region of the stapes. For this reason the senior authors practice has been to identify the nerve in the horizontal portion well ahead of the second genu. This has the advantage of avoiding the need for early dissection of cholesteatoma in the region of the lateral semicircular canal, where an unsuspected fistula may be encountered. The presence of cholesteatoma or granulations overlying a dehiscent nerve has never presented difficulties. Evacuation of the contents of the cholesteatoma sac often allows the vessels to be identified and careful palpation will confirm whether or not the nerve is dehiscent prior to dissection of the sac from the nerve. It must be admitted that the presence of granulations makes the task more of a challenge but careful and meticulous dissection aided by cotton wool pledgets makes it possible to dissect granulations off a dehiscent facial nerve. The appearance and texture of granulation tissue is quite different to that of the nerve. The use of a facial nerve monitor can be helpful in this context. The authors still contend that the best way to avoid injury is to positively identify the position of the facial nerve at an early stage in the operation. The use of the perineural vascular plexus can be helpful in that it provides a direct, as opposed to an indirect, landmark for the position of the nerve. Vindhi Paleri Carl Watson Department of Otolaryngology-Head and Neck Surgery, Darlington Hospital Darlington, England, U.K.