Flap Hematoma Research Articles

Arteriovenous fistulas for microvascular head and neck reconstruction.

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks. The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula. The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported. Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

Revisiting the Scapular Flap

Combat injuries commonly result in massive bony and soft-tissue destruction within the extremities. These extremity wounds often require large free tissue transfers and/or composite flaps for definitive reconstruction. In U.S. military war trauma experience, the authors' practice has found the scapular flap increasingly useful for reconstruction of complex extremity injuries. The purpose of this study is to report the authors' experience using the scapular flap in extremity reconstruction and evaluate the indications for use in the authors' patient population. All consecutive limb salvage cases requiring free flaps from 2009 to 2012 at Walter Reed National Military Medical Center were reviewed retrospectively. Scapular flap cases were identified. Data collected included Injury Severity Score, flap characteristics, and complications. Twelve scapular free flaps were performed for extremity reconstruction for combat-related trauma, representing 16.2 percent of all microsurgical reconstructions during that period. Cases included eight traditional scapular flaps, two osteocutaneous scapular flaps, one chimeric latissimus/scapular flap, and one chimeric parascapular/scapular/scapula bone flap. The complication rate was 17 percent, consisting of one flap hematoma and one donor-site dehiscence. Complication rates were similar between scapular flaps, other fasciocutaneous flaps, and muscle flaps. In a decade of war trauma, the authors' practice has found the scapular flap useful for reconstruction of complex extremity injuries. This flap is uniquely suited to the authors' patients, given the severity of their injuries and rehabilitation needs. The scapular flap continues to have various indications in injuries seen within the authors' military population that may be applicable to the authors' civilian patient counterparts. Therapeutic, IV.

Postoperative epidural hematoma covering the galeal flap in pediatric patients with moyamoya disease: clinical manifestation, risk factors, and outcomes

Postoperative epidural hematoma (EDH), a blood collection between the inserted galeal flap and the overlying skull flap (epigaleal flap hematoma), is a frustrating complication of the surgical treatment of moyamoya disease (MMD) in pediatric patients. The symptoms of postoperative EDH are often similar to those of postoperative cerebral ischemia, and may cause confusion during clinical decision making. The authors designed this study to evaluate the incidence, clinical presentation, risk factors, and treatment outcomes of postoperative EDH in pediatric patients with MMD. A retrospective review of 148 pediatric patients with 250 craniotomies who underwent indirect bypass revascularization surgery between January 2002 and December 2006 was performed. This group consisted of 60 male and 88 female patients, and the mean age at surgery was 7.5 years (range 1-18 years). Of the 250 craniotomies, postoperative EDH was detected in 32 cases. In 12 cases of EDH, surgical treatment was necessary (4.8% of 250 craniotomies). During the same period, 743 non-MMD craniotomy operations were performed. In 6 of these 743 operations, patients developed postoperative EDH that required surgical treatment, significantly less than the percentage of EDH requiring postoperative treatment in patients with MMD (0.8%, p < 0.001). The average interval between craniotomy surgery and the detection of EDH was 1.8 days (range 0-5 days) in patients with MMD and 0.5 days (range 0-2 days; p = 0.018) in the non-MMD craniotomy group. Postoperative EDH was observed in significantly fewer cases (17 of 191) when a subcutaneous drain (SCD) was inserted over the bone flap than in cases in which an SCD was not inserted (14 of 55; p = 0.001). The mean international normalized ratio of prothrombin time in the immediate postoperative blood test was 1.27 ± 0.17 in the EDH group and 1.20 ± 0.11 in the non-EDH group (values are expressed as the mean ± SD; p = 0.008). Central galeal flap tenting suture and immediate postoperative platelet count were not related to the incidence of postoperative EDH following pediatric MMD surgery. Postoperative EDH is more likely to be found following craniotomy in patients with MMD than in those without MMD, and may occur in a delayed fashion. Insertion of an SCD and immediate correction of an abnormal value for international normalized ratio of prothrombin time can decrease the incidence of postoperative EDH following surgery for pediatric MMD.

Imaging after Cesarean Delivery: Acute and Chronic Complications

Cesarean delivery is a commonly performed operation and accounts for nearly one-third of all births in the United States. Although it is a safe procedure, cesarean delivery has a variety of acute and chronic complications that prompt imaging with ultrasonography (US), computed tomography, and magnetic resonance imaging. Acute complications include hematomas in specific locations that are unique to the procedure, as well as a variety of infections. A bladder flap hematoma occurs in the space between the bladder and the lower uterine segment, whereas a subfascial hematoma is an extraperitoneal collection located in the prevesical space posterior to the rectus muscles and anterior to the peritoneum. Puerperal infections after cesarean delivery include abscesses, wound infections and dehiscence, uterine dehiscence and rupture, and pelvic thrombophlebitis. The prevalence of chronic complications related to the healed cesarean delivery scar is unknown, but the scar may result in technical limitations for pelvic US due to the adhesions between the anterior lower uterine segment and the anterior abdominal wall. The cesarean delivery scar also leaves the patient susceptible to several unique diagnoses. A cesarean scar "niche" is a tethering of the endometrium that can serve as a reservoir for intermenstrual blood and fluid. Intrauterine devices can be malpositioned in the cesarean delivery scar, and endometrial implants can develop in the abdominal wall years after surgery. These patients are also at increased risk for implantation abnormalities including cesarean scar ectopic pregnancy, retained products of conception, and placenta accreta. Familiarity with the normal postoperative findings following cesarean delivery is necessary to recognize acute and chronic complications, which are being encountered with increasing frequency.

Utility of Multidetector CT in Severe Postpartum Hemorrhage

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. According to the time when postpartum hemorrhage develops, it is classified as (a) primary, or early, postpartum hemorrhage (within the first 24 hours after delivery) or (b) secondary, or late, postpartum hemorrhage (>24 hours to 6 weeks after delivery). Primary postpartum hemorrhage may be caused by uterine atony (75%-90% of cases), trauma of the lower portion of the genital tract, uterine rupture, uterine inversion, bladder flap hematoma, retention of blood clots or placental fragments, and coagulation disorders. Secondary postpartum hemorrhage may be caused by uterine subinvolution, coagulopathies, and abnormalities of the uterine vasculature. Extrauterine sources of bleeding include rectus sheath hematoma, direct arterial injuries, and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Severe postpartum hemorrhage is a life-threatening condition that is diagnosed on the basis of the findings from clinical examination, with or without ultrasonography. Computed tomography (CT) and magnetic resonance imaging are useful in the characterization of postpartum hemorrhage when medical treatment fails. Multidetector CT has an important role when intraabdominal bleeding is suspected and can be considered in cases of recurrent bleeding after embolization, as well as for the evaluation of postsurgical complications. A proposed clinical and CT imaging algorithm for postpartum hemorrhage is presented. A multidisciplinary approach to postpartum hemorrhage is essential to optimize the role of diagnostic and interventional radiology in obstetric hemorrhage, to avoid hysterectomy and thus preserve fertility.

The diagnosis and treatment of Dupuytren' s contracture combined with carpal tunnel syndrome

Objective To investigate the correlation of Dupuytren's contracture and carpal tunnel syndrome and evaluate the clinical outcomes of treating both diseases in one surgery. Methods From March 2003 to August 2011,8 cases of Dupuytren's contracture combined with carpal tunnel syndrome were surgically treated.Through an M-shaped palm incision and a Y-shaped incision extended to the finger,the palmar aponeurosis was partially removed and the flexor retinaculum was cut open to release the median nerve at the same time. Results Primary wound healing was achieved in all of the eight cases.There were no flap edge necrosis and hematoma formation.Numbness of the thumb,index finger and middle finger gradually reduced postoperatively.The numbness disappeared after 3 months.All patients were follow-up for 6 months to 2 years with no recurrence. Conclusion When more predisposing factors of both diseases occur in one patient,the probability of the occurrence of both Dupuytren' s contractue and carpal tunnel syndrome in one patient also increases significantly.The two diseases can be treated in one surgery. Key words: Dupuytren's contracture; Carpal tunnel syndrome; Surgical procedures,operative

P2-16-04: Abdominal Wall Stability and Flap Complications Are Unaltered Following Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Despite Increasing Body Mass Index: Analysis of 418 Patients and 639 Flaps.

Abstract Introduction: Promoted by reports of decreased donor-site morbidity compared to traditional transverse rectus abdominus (TRAM) flap breast reconstruction, deep inferior epigastric perforator (DIEP) flaps have gained significant popularity. Increasing body mass index (BMI) is associated with poor flap-specific and donor-site outcomes in breast reconstruction using traditional techniques. The current study aims at defining flap-specific and donor-site complications with increasing BMI in patients undergoing DIEP flap breast construction. Methods: A retrospective analysis of 639 DIEP flaps on 418 consecutive patients between Jan 2006 to March 2008 was performed. Patients were stratified into five groups based on BMI: normal weight (≤ 24.9), overweight (25-29.9), obese (30-34.9), severely obese (35-39.9), and morbidly obese (≥ 40). Medical co-morbidities, adjuvant chemo-radiation therapy, timing of reconstruction, active tobacco use and surgical history were collected. Primary outcomes were compared between BMI groups. Results: Average BMI for the entire population was 28.3 (range 17–42). There were 100 (23.9 %) normal weight, 153 (36.6 %) overweight, 113 (27.0 %) obese, 45 (10.8 %) severely obese, and 7(1.7%) morbidly obese patients with an average follow-up of 1088 (range 720–1528) days. Increasing BMI was associated with increased incidence of hypertension, previous abdominal surgeries, and length of follow-up. Age, active tobacco use, adjuvant chemo-radiation therapy and timing of reconstruction were similar across all BMI groups. Flap complications stratified by BMI groups demonstrated significantly increased delayed wound healing complications in severely obese patients compared to lower BMI groups. Incidence of flap soft tissue infections, hematoma or seroma formation, fat necrosis, thrombotic and overall complications including flap failure were not significantly different between groups. Donor-site complications stratified by BMI demonstrated significantly increased delayed wound healing and overall complications among morbidly obese patients compared to other groups. Incidence of donor-site infection, acute or subacute hematomas, seroma formation, abdominal wall bulging, and hernia formation were not significantly different between groups despite increasing BMI. Conclusion: Increasing BMI predisposes patients to delayed wound healing complications in both flap and donor-site locations. Nevertheless, overall flap complications remain similar across all BMI groups. Despite increased overall donor-site complications in patients with increasing BMI, abdominal wall stability was maintained during a follow-up period approximating 3 years. Given a similar flap complication profile and maintenance of abdominal stability, DIEP flaps are recommended in patients with increased BMI. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-04.

Liver metastasis from breast cancer: suitability for resection?

s / The Breast 20 (2011) S12–S55 S48 Introduction: Women presenting with inoperable T4 tumours are often offered primary chemotherapy particularly if metastatic disease is present or suspected. Complete clinical response is uncommon, and these tumours may remain inoperable even after chemotherapy. In recent years, we have adopted the use of the vertical rectus abdominis myocutaneous (VRAM) flap to cover large post-mastectomy defects. We present our results here. Material and Methods: Retrospective review was performed of 13 patients who underwent VRAM flap cover following mastectomy from 1st January 2008 to 30th September 2009. Clinicopathological parameters and various surgical outcomes were reviewed. Results: Thirteen patients with T4 tumours underwent VRAM flap following mastectomy. 5 MBC and 8 LABC Median age was 61 years (range 33 to 86 years old). Nine were Chinese and 4 were Malays. Median tumour size at presentation was 100mm (range 30 to 150mm). Nine patients (69.2%) received primary chemotherapy, but either had no clinical response or progressively enlarging tumours. At the time of surgery, 7 patients (53.8%) had fungating tumours and 5 patients had clinical chest wall involvement. All patients underwent mastectomy and axillary clearance. In our practice, surgery is carried out concurrently by 2 separate teams, with the VRAM flap being raised simultaneously with the mastectomy. Mean time taken for the entire operation was 279 minutes. Post-operative recovery was uneventful for most. Two patients required a second surgery: one for evacuation of a flap haematoma, and another for surgical debridement for partial flap necrosis. Another 2 patients developed a superficial wound infection over the breast, which resolved with antibiotics. Median hospital stay was 10 days. One patient required inpatient rehabilitation for functional decline and stayed more than 2 weeks (40 days). Radial resection margins were clear in all 13 cases, although there was involvement of the deep margin in 3. No further radiotherapy was given. Most patients were started on further systemic therapy within 3 weeks of surgery. Three deaths occurred during the median follow-up period of 22 months. Two patients developed chest wall recurrence; one of whom also developed distant disease progression and died 21 months later. Distant disease progression occurred in another 1 patient, who died 6.5 months later. The third death was thought to be from a non-cancer related cause. Conclusions: Mastectomy often provides the best means of local control for large fungating tumours. Increasingly, surgery is being offered to patients in whom distant metastasis respond favourably to chemotherapy. The VRAM flap provides good post-mastectomy defect cover, and is associated with few complications and a short hospital stay. Importantly, further systemic therapy is not unduly delayed.

Perforator flap breast reconstruction in thin patients.

242 Background: Perforator flap breast reconstruction has strong appeal for many women seeking breast reconstruction, but the procedure requires adequate donor site tissue to produce realistic breasts. Thin women requesting perforator flaps are often advised that they lack sufficient donor site tissue for autologous tissue breast reconstruction, and that implants are their only option. We have expanded the reconstructive options for thin women who seek an alternative to implants with innovative new techniques. Methods: A retrospective review was done of 223 patients who underwent 293 consecutive perforator flap breast reconstructions from April 2007-May 2011. Preoperative imaging allowed visualization of the microvascular anatomy and subcutaneous tissue. Donor sites evaluated included the abdomen, medial thigh, buttocks, and back. Complications included flap loss, hematoma, seroma, takeback, and fat necrosis. No patients were turned away for perforator flap breast reconstruction due to insufficient donor site tissue. Results: Out of 293 perforator flap breast reconstructions, 45 perforator flap breast reconstructions (15.4%) were reported in 26 thin women with a BMI &lt; 23 (mean BMI 20.7, range BMI 18.2-22.7). Out of 45 perforator flap breast reconstructions in thin women, donor sites included 35 hemi-abdominal flaps (77.8%), 4 medial thigh flaps (8.9%), 7 buttock flaps (15.6%), and 2 back flaps (4.4%). Of the 35 hemi-abdominal flaps, 8 hemi-abdominal flaps were combined to create 4 stacked DIEP flaps (22.9%) while the remaining 27 hemi-abdominal flaps were regular DIEP flaps (77.1%). There was one seroma (2.2%) and one takeback for postoperative pain (2.2%); there were no flap losses. Conclusions: Even in thin women, perforator flap breast reconstruction is a safe, reliable, and consistent technique for recreating new breasts. While implant-based breast reconstruction may be acceptable to many women, there is a growing subgroup of patients who prefer autologous tissue breast reconstruction. By challenging common conceptions about the amount of donor site tissue required, we have been able to expand reconstructive options in thin women by using perforator flaps to construct natural, aesthetic breasts.

The Treatment of Gustilo Grade IIIB Tibia Fractures with Application of Antibiotic Spacer, Flap, and Sequential Distraction Osteogenesis

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope. The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12-77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5-17). Reconstruction time was 26.5 months (12-73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient. The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Bladder-flap haematoma (BFH) is a puerperal complication after caesarean section; it consists of a blood collection between the bladder and the lower uterine segment, in the vesico-uterine space, and it results from bleeding at the uterine suture. Ten symptomatic women were hospitalized and underwent a laparoscopy performed by tumescence incision, bladder wall detachment from the vesico-uterine space, drainage of the fluid material inside the collection, washing of the haematoma site and peritoneal suturing. After seven days, the time it takes to develop a BFH after caesarean section, laparoscopically collected dates were, on average: Total laparoscopy time 31 min, intrasurgical blood loss 36.5 ml, two patients with a draining catheter in the pelvis, two women who developed post-operative urinary symptoms; the duration of hospital stay was 1.3 days. None of the women had complications during the post-dismissal follow-up, and no further therapeutic intervention was required. No clear, defined and standardized protocols exist for the clinical and surgical management of post-caesarean section BFH; the conservative laparoscopic approach proposed would offer women a potentially safe and feasible minimally invasive treatment, reserving hysterectomy for severe uterine necrosis, myometritis or abscess formations. These findings should be confirmed by large extensive trials.

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Laparoscopic treatment of post-cesarean section bladder flap hematoma: A feasible and safe approach

Conservative laparoscopic treatment of post-caesarean section bladder flap haematoma: two case reports

A bladder flap haematoma (BFH) is an unusual complication of caesarean section and results from bleeding at the uterine suture. This haematoma arises between the posterior bladder wall and lower uterine segment. On ultrasonographic examination, it appears as a solid area or a complex mass with clean walls and reinforcement of the distal echoes. No clear and defined protocol exists for clinical management of BFH; in more severe cases, when the blood loss is continuous or if it transforms into an abscess, it needs non-standardized surgical treatment. When surgery is performed, usually the BFH is only drained, reserving hysterectomy for severe uterine necrosis, myometritis or abscess formations. In our experience, we have performed two conservative laparoscopic treatments with drainage of the BFH.

Early One-Stage Closure in Patients with Abdominal Compartment Syndrome: Fascial Replacement with Human Acellular Dermis and Bipedicle Flaps

Decompressive celiotomy for the treatment of abdominal compartment syndrome (ACS) often results in wounds that are difficult to close. These complicated wounds are frequently managed with a 3-staged surgical approach employing a planned ventral hernia. The authors describe an alternative closure with a single operation using a commercially available human acellular dermis (HACD) as a fascial substitute. Soft tissue coverage is obtained at the same operation by means of bilateral bipedicle flaps. The cohort consisted of 9 patients, ages 19 to 77 years old. On average patients were closed on the ninth postoperative day (range, 3 to 30 days) and were discharged from the trauma center on average 8 days (range, 5 to 29 days) after the abdominal closure. Complications developed in 3 (33%) patients. These complications included a flap hematoma, wound infection, and recurrent hernia. There were no postoperative fistulas. This procedure allows for early, single-staged closure of the abdomen after abdominal compartment syndrome. Once closed, patients were able to be discharged from the hospital early and without need for specialized wound care. Further investigation on the usefulness of this technique is required.

Sonographic Imaging of Maternal Complications of Pregnancy

To show the role of diagnostic sonography in delineating pathologic conditions occurring during and immediately after pregnancy. Cases illustrative of a broad range of pathologic conditions were collected primarily from personal experience in a busy ultrasound clinic serving high-and low-risk pregnancies over the past 15 years, with supplemental cases drawn from departmental teaching files. Sonography was the primary diagnostic tool, with confirmation obtained from other imaging modalities in select instances. Cases were organized on an anatomic and time-of-onset basis. For conditions occurring during pregnancy, the following anatomic areas are considered: the liver and biliary tree, urinary tract, bowel, ovary, and uterus and placenta. For postpartum complications, the following conditions are discussed: subfascial and bladder flap hematomas, retained products of conception, and ovarian vein thrombophlebitis. Although the main imaging modality in these conditions was sonography, correlation with computed tomography and magnetic resonance imaging was also made in several cases. A broad variety of conditions can affect the pregnant patient, both during and immediately after pregnancy. Sonography can show many of these disease processes, with computed tomography and magnetic resonance imaging useful selectively as supplementary tools.

Sonographic examination of puerperal uterus after repeat cesarean section with traditional and Misgav Ladach methods

Purpose: In our Department of Obstetrics, where 1600 deliveries are carried out on average every year, cesarean section (c.s.) with Misgav Ladach methods has been practiced since November 1995, for 2078 cases in all. In our study, we have examined sonographically 309 repeat c.s. with Misgav Ladach methods compared to 318 traditional repeat c.s. The aim of our investigation is the sonographic examination of patients with open peritoneum and those with closed peritoneum to discriminate the frequency of bladder flap hematomas and other complications in the two techniques.Methods: The patients were examined by transvaginal and transabdominal sonography, on the third and 10th postoperative day, to demonstrate the presence of a fluid or mixed mass on the lower‐uterine‐segment (LUS) of 3 cm or more, clean wall, with reinforcement of distal echoes.Results: It has been observed that, in the group open peritoneum c.s., there were masses of mixed echostructure referring to hematomas on the 12th day in nine cases, while in the group closed visceral peritoneum in 51 cases (P &lt; 0.05). In 39 cases, they were collection on the LUS from 3 to 4.2 cm in six from 4.2 to 5 cm and only in one case it was a lateral collection of 6 cm which did not require surgical treatment anyway. Besides in 22 patients, the bladder‐flap hematoma was associated with puerperal fever (values &gt;38.5 °C). In Misgav Ladach method, only seven women had adhesion of light‐medium importance so that uterine exteriorization was not necessary, and not significant (NS) in comparison with the reference of nine women.Conclusion: Peritoneum closure in repeat c.s. lengthens operative time and in some cases favors bladder‐flap hematomas which increase postoperative morbidity (P &lt; 0.05), antibiotics use 2.6 and 4.8% (P &lt; 0.01), length of hospital 3 ± 1 vs. 7 ± 2 days staying (P &lt; 0.01) and costs (P &lt; 0.05). In conclusion, follow up has shown no intraperitoneal compare to repeat c.s. with closed and open peritoneum.

V-Y island flaps for repair of large perianal defects

Background: Some perianal diseases such as Paget disease and Bowen disease are extensive and require a wide circumferential excision including the entire anoderm of the anal canal. Methods: We describe a technique of V-Y island flaps to cover the large perianal defects and the denuded anal canal. It is important to excise the base of the flaps in order to fit them into the anal canal. Results: There were 10 women and 5 men with an average age of 54 years (range 32 to 77). The mean follow-up was 45 months (range 6 to 92). The underlying pathology included various kinds of neoplastic and nonneoplastic diseases. There were no major complications such as flap loss or infection. Most complications were minor, including superficial wound separation, flap hematoma, and anal stricture. Although initially all patients had some degree of incontinence for gas and liquid stool or discharge, none of them had significant fecal incontinence at the time of last follow-up. A diverting ileostomy or colostomy was created in 5 patients. Its role was not clear but it did help in the management of the wounds and minimized the pain.

F90Sonography of bladder flap hematoma in cesarean section with open and closed peritoneum: a prospective randomized study

In our randomized study, we've examined sonographically 238 first c.s. carried out through Stark technique and 46 traditional repeat c.s. with open peritoneum (284 with open peritoneum), compared to 253 women who underwent a first c.s. with the classic technique and 51 previous traditional c.s. (304 c.s. with closed peritoneum) the aim of our investigation is the sonographic evaluation of patients with open peritoneum and those with closed peritoneum to discriminate the frequency of bladder flap hematomas in the two techniques. The statistical analysis has been conducted with the test of Student considering significant a value of P &lt; 0.05. C.s. with PROM, abruptio placentae, and placenta previa have been excluded from our study. For this reason all the patients of the two groups were examined by transvaginal and transabdominal sonography, on the 3rd and 12th postoperative day, to demonstrate the possible presence of retrovescical collections/hematomas, assuming as sonographic criterion the presence of a fluid or mixed mass on the lower‐uterine‐segment (L.U.S.), of three or more centimetres, clean wall, with reinforcement of distal echoes. It has been observed that in the group with open peritoneum c.s., there were masses of mixed ecostructure referring to hematomas on the 12th day in 9 cases (3.16%), while in the group with closed visceral peritoneum in 48 cases (15.78%) (P &lt; 0.05). Sonography, which is a simple reliable riproducible and low cost technique let us confirm previous experiences made by TAC and MR whic indicate that bladder flap hematomas are usual in post‐c.s. In 39 cases (81.25%), they were collections on the L.U.S. from 3 to 4.2 cm, in 6 (12.50%) from 4.2 to 5 cm (4.16%) and only in one case it was a lateral collection of 6 cm (2.08%) which did not require surgical treatment anyway (the last 3 cases have been observed by MR which which confirmed sonographic findings). In addition in 104 patients (36.61%), there was the presence of a fluid collection in Douglas region due to the amniotic liquid usually not removed according to the Stark technique. Besides in 22 patients (45.83%) the bladder‐flap hematoma was associated with fever (values &gt; 38.5 °C), in this group other causes of febrile morbidity were obviously excluded. The characteristic of these c.s. was a significant intraoperative blood loss, evaluated with a drop in Hb of 3 or more g/dL. On the contrary it was observed a significant differences of the intestinal functionality restarting 8.6 h at c.s. with open peritoneum and 42.7 h (P &lt; 0.05) at c.s. with closed peritoneum but a careful examination confirms that therapid resumption is favoured by regional anaesthesia as regards general anaesthesia, rather than by surgical technique. Subsequently 82 women undergoing the first Stark c.s., have been reoperated with the same technique, with open peritoneum, but not significant differences have been observed in comparison to c.s. with closed peritoneum from a postsurgical adhesion profile. According to the data of literature, peritoneum closure in c.s. lengthens operative time and in some cases favours hematomas on the L.U.S. which increase postoperative morbidity, antibiotics use 2.6 and 4.8 (P &lt; 0.01), length of Hospital staying and costs.

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction.

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.

MRI appearance of the pelvis in the post cesarean-section patient

Fever in the post-cesarean section patient may indicate the presence of a potentially life-threatening complication, including abscess, ovarian vein thrombosis, and uterine dehiscence. Imaging findings are often utilized to ascertain the presence or absence of such complications. Familiarity with the normal findings in the post-operative period is essential in making this determination. The purpose of this investigation is to describe the MRI appearance of the post-cesarean section pelvis. Over a 67-month period, 50 patients with persistent low-grade fevers following c-section were referred for MR imaging. Imaging was performed 3–10 days post-operatively. Axial T 1-weighted and T 2-weighted images were acquired in addition to sagittal T 2-weighted images. Coronal images were obtained in some cases. Clinical correlation was obtained through the patients charts, confirming discharge of the patients in stable condition. The uterine incision site usually demonstrated findings consistent with subacute hematoma. The anterior uterine myometrium demonstrated enlargement relative to the posterior uterine wall. Bladder flap hematomas were seen in 64% of cases. Three cases (6%) demonstrated parametrial edema and none of these patients demonstrated ovarian vein thrombosis. Two cases of pelvic hematoma were noted. The normal post-c-section incision site may demonstrate increased or decreased signal intensity on T 2-weighted images and intact endometrial and serosal layers mitigate against the diagnosis of incisional dehiscence. Bladder flap hematomas occurred in slightly more than half the cases. Parametrial edema and pelvic hematoma can be seen as post-surgical changes.