Free Transplantation Research Articles

Ureterocystoplasty: An Ideal Method for Vesical Augmentation in Children

Inadequate therapy endangers upper urinary tract function in children with low compliance bladders. We report our approach of increasing bladder compliance using the patients own (mega)-ureter for bladder augmentation. A total of 8 children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in 5 children, posterior urethral valves in 2 children and in one child the situation after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. After nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE stoma was made in 3 patients, antireflux surgery for the contralateral kidney was necessary in 2 patients and one patient underwent stone removal in the remaining kidney. In 1 patient the ureter was used as a free transplant and was covered by an omental flap. In addition, a simultaneous living donor kidney transplant was performed (case 2). Bladder capacity and compliance improved significantly in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years. Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.

Anomalous V-shape Palmaris Longus Tendon: Two Cases

We describe an incidental rare finding of V-shape tendon of Palmaris Longus (PL) in two cases. Examination of 253 subjects/506 hands for detection of PL Tendon by the standard clinical tests was undergone. The sample mean age was 21 years and M/F ratio was 1:3.The identification of V-shape bifid tendon was revealed only by Schaeffer’s test whiles both Thompson’s and Mishra’s tests failed to demonstrate the anomaly. These two cases with anomalous tendon did not provoke any symptom. The importance of this finding being a potential source of V-shape support that can be used as tendon transfer to extensor tendons, in restoration procedure of radial palsy, and as free transplant in reanimation of oral and lid angles in facial palsy or any where when a V-shape support is required. Therefore surgeon awareness of this anomalous tendon and pre-operative identification is warranted. J Med Cases. 2010;1(2):68-70 doi: https://doi.org/10.4021/jmc114e

Anomalous V-shape Palmaris Longus Tendon: Two Cases

We describe an incidental rare finding of V-shape tendon of Palmaris Longus (PL) in two cases. Examination of 253 subjects/506 hands for detection of PL Tendon by the standard clinical tests was undergone. The sample mean age was 21 years and M/F ratio was 1:3.The identification of V-shape bifid tendon was revealed only by Schaeffer’s test whiles both Thompson’s and Mishra’s tests failed to demonstrate the anomaly. These two cases with anomalous tendon did not provoke any symptom. The importance of this finding being a potential source of V-shape support that can be used as tendon transfer to extensor tendons, in restoration procedure of radial palsy, and as free transplant in reanimation of oral and lid angles in facial palsy or any where when a V-shape support is required. Therefore surgeon awareness of this anomalous tendon and pre-operative identification is warranted. doi:10.4021/jmc114e

A Comparative Evaluation of the Innervation Paths of Free Functional Muscle Transplants Used in the Reanimation of the Irreparably Paralyzed Face

A Comparative Evaluation of the Innervation Paths of Free Functional Muscle Transplants Used in the Reanimation of the Irreparably Paralyzed Face

Experimental study of the effect of adipose tissue derived stem cells on the survival rate of free fat transplantation

To investigate the feasibility of using adipose tissue derived stem cells (ASCs) to promote neovascularization and survival rate of free fat transplantation. ASCs were isolated from aspirates from human liposuction and cultured in vitro. The cells were incubated in adipogenic, osteogenic, and chondrogenic medium for 2-4 weeks to induce adipogenesis, osteogenesis and chondrogenesis, respectively. ASCs were labelled by DiI. ASCs (A group), Insulin (B group), Medium (C group) were respectively mixed with free fat graft from aspirates. The mixtures were injected subcutaneously at the three random points on the back of eighteen 4- 6-week-old nude mice. Transplanted fat tissue was harvested after 6 months. The grafts were assessed by morphological observation, HE staining and immunohistochemistry. ASCs can be easily harvested from liposuction aspirates and differentiate into adipogenic, osteogenic, chondrogenic lineages. The wet weight of transplanted fat tissue in ASCs group was (165.97 +/- 5.51) mg, significantly higher than that in the insulin group (93.42 +/- 5.12) mg and control group (67.64 +/- 5.09) mg (P = 0.000). The rate of fibrosis and steatonecrosis in ASCs group was( 152.2 +/- 9.8)/10HF, significantly lower than that in the Insulin group (743.9 +/- 20.4)/10HF and control group (892.2 +/- 16.5)/10HF (P = 0.000). DiI labelled ASCs were found between adipocytes and in the connective tissue in free transplanted fat tissue, and some of these cells were immunopositive for antihuman CD31 and FITC, suggesting differentiation into vascular endothelial cells. ASCs can differentiate into vascular endothelial cells and contribute to angiogenesis in free transplanted fat tissue. ASCs can increase the survival rate and decrease the rate of fibrosis and steatonecrosis of free transplanted fat tissue. These findings suggest that ASCs-assisted transplantation may be an ideal cell therapy.

Extensor digitorum brevis and extensor hallusis brevis transplantation for treatment of long-standing facial paralysis

To evaluate the efficacy of free transplantation of denervated muscles and vessels in the treatment of long-standing facial paralysis. A total of 26 patients with facial paralysis (10 males and 16 females, aged 16-65 years, mean: 47 years) were enrolled in this study to receive transplantation of denervated extensor digitorum brevis (EDB) and extensor hallusis brevis (EHB). The muscle tendon was slung to the ala nasi, the middle point of the nasolabial sulcus, the angulus oris and the chin to correct the nasal and oral deformity. The muscle belly was buried around the nerves that innervated the masseter muscle. Microsurgery was applied to anastomosing the tarsus lateral vessels to the superficial temporalis vessels. After operation, all the patients immediately obtained satisfied static appearance. The movement of the paralyzed corner of the mouth could be obtained one month later and the smile of the paralyzed side could be restored after 3 months of training. And 88% patients achieved perfect results, 8% obtained satisfactory results, and 4% got improvement 6 months after operation according to Stennert's paresis scoring system. Free transplantation of denervated muscles and vessels for the treatment of long-standing facial paralysis, which seldom causes atrophy or liquefaction of the transferred muscles, can maintain muscle viability and induce reliable nerve regeneration. Therefore, it is a safe and efficient treatment method for the patients suffering from facial paralysis.

Comparison of postoperative complications following bone harvesting from two different donor sites for autologous bone replacement (hipbone and proximal epiphysis of the tibia)

Whereas autologous bone replacement was earlier applied in maxillofacial surgery virtually only for the restoration of mandibular defects and for the osteoplasty of patients with cleft alveolar process, the free transplantation of autologous bone (spongiosa or cortical bone or both) is nowadays primarily used for implantation purposes. Autologous bone is still the gold standard for bone replacement. This is the case even though a wide selection of bone substitutes is currently available, with which new bone equivalent to autologous bone can be produced in certain cases. Autologous bone is often obtained from intraoral sources, but if a larger quantity of spongiosa is required, these sites (the chin, the retromolar area of the mandible, the muscular process, etc.) are not suitable. Of the extraoral donor sites, the most frequently used site is the iliac crest, but the proximal epiphysis of the tibia is also appropriate for this purpose since we have recently performed bone transplantations on appreciable numbers of patients, we decided to compare the morbidity data relating to the two donor sites. In the 9 months between March and November 2007, sinus elevations were carried out on 14 patients with bone taken from the tibia, while in 38 patients bone was taken from the iliac crest for osteoplasty on clefted alveolar process. The comparison was based on postoperative clinical examinations, the complaints of the patients and objective study of the morbidity relating to the two donor sites. Clinically the patients tolerated both interventions well. Mobilization took place on the day of intervention. There were no major complications; one minor haematoma was observed after each type of surgery. The postoperative complaints of the patients did not reveal any essential difference. Following bone harvesting from the iliac crest, the gait of the patients slightly hampered for up to 10 to 14 days. In the tibia cases, the patients experienced no pain on walking by the second day. As regards donor site morbidity, protracted (1-2 weeks) oedema was observed after hip surgery, with paraesthesia of the area of innervation of the n. cutaneous femoris lateralis in 1 case, while there was a minor seroma following tibia surgery in 1 case. Our clinical experience suggests that, if 10-15 cm(3) spongiosa is required for augmentation purposes and there is no need for cortical bone, the patient is exposed to less stress when bone is taken from the proximal epiphysis of the tibia.

Autogenous Greater Omentum, as a Free Nonvascularized Graft, Enhances Bone Healing: An Experimental Nonunion Model

Reconstruction of vascularity is an early event in fracture healing and upregulation of angiogenesis may therefore promote the formation of bone. We have investigated the potentiality of autogenous free nonvascularized greater omentum to stimulate the formation of bone in an experimental hypertrophic nonunion model. Twelve dogs assigned into two identical groups underwent a standard nonunion operation. In the experimental group, this was followed by application of autogenous greater omentum as a free nonvascularized graft around the osteotomy gap. Radiographic assessments were conducted time-sequentially until euthanasia 16 weeks after surgery. Histological analysis was performed on the mid-radial diaphysis containing the 4-month-old osteotomy site. Radiological and histological properties of the group treated with free transplant of the greater omentum revealed complete union. In contrast, there was no evidence indicating union in the control group. Analyses of the radiological and histological scores confirmed that osteotomies treated with free transplant of the autogenous greater omentum had united, whereas the osteotomies of the control group failed to unite. Significant differences between the mean values for radiological and histological-grading score in the control and experimental groups were detected (p < 0.05). We showed that free graft of autogenous greater omentum could stimulate the formation of competent bone in an environment deprived of its normal vascularization. Hence, it could be recommended to enhance healing when the fractures are at risk of nonunion.

Functional microsurgical reconstruction in a severe case of contact burn of the forearm

The most common causes of muscle loss of the forearm are direct trauma, Volkmann’s ischemic paralysis, electrical burns, post-replantation and gas gangrene [1–4]. Forearm injuries caused by prolonged contact with hot surfaces are quite rare, but can cause severe damage to skin, muscles, tendons, nerves and bones. When the extension of the lesions is limited, with involvement of single muscletendinous units, functional recovery can be achieved by relatively simple palliative surgical procedures. However in the presence of complete loss of dorsal or ventral compartments of the forearm with loss of functionality of the hand, free innervated-muscle transplantation is the only surgical option to achieve acceptable functional recovery [5,12].

Experimentelle freie funktionelle Muskeltransplantation zur Reanimation des Gesichtes: Vergleich zwischen einzeitigem und zweizeitigem Vorgehen am New-Zealand-White-Kaninchen

To investigate functional results of either one- or two-staged free muscle transplantation, the scutuloauricularis model in the New Zealand white rabbits was used. 30 rabbits were divided into 2 groups with 15 animals each. In group 1 (one-stage approach) the peroneus brevis (PB) muscle was harvested as a free muscle graft with a 7-cm long motor branch. The graft was positioned in the place of the right scutuloauricularis (SCUT) and its vascular supply microsurgically re-established. The motor branch was transferred to the contralateral side and its proximal end coapted to the cut facial motor branch to the left SCUT. Before nerve coaptation, biopsies were harvested from the cut motor branch for morphological analysis. In group 2 (two-stage approach) a 7-cm long saphenous nerve graft was taken and coapted to the cut motor branch of the SCUT and crossed over to the contralateral side. Nerve specimens from the cut motor branch were taken. Eight months later, free transplantation of the PB was performed and its motor branch coapted to the distal end of the cross-over nerve graft. After a total time period of 13 months the final experiments were carried out in each group. Maximal tetanic tensions in the reinnervated PB were measured and biopsies of muscle grafts together with nerve biopsies from the distal part of the motor branch were harvested for morphological analysis. Muscle grafts of group 1 revealed tetanic tension values of 12.5 N (SD 3.1) in comparison to 10.6 N (SD 3.5) obtained in group 2. This difference was not statistically significant (p = 0.303). In group 1 the amount of regenerated nerve fibres counted at the distal motor branch site (mean: 2798, SD 1242) was significantly higher (p = 0.008) than in group 2 (mean: 1138, SD 1004). Muscle graft morphology revealed significantly less type I fibres (p = 0.016) and more type II b/d fibres (p = 0.011) in group 1 compared to group 2. However, the overall amount of perimysial connective tissue showed no significant difference in both groups (p = 0.478). Free muscle transplantation in a one-stage approach offers similar functional results in comparison to the two-stage approach. Although muscle grafts of the one-stage transplantation underwent a longer period of denervation, similar contents of perimysial connective tissue could be observed.

Wiederherstellung von Gewebedefekten der Glans penis mittels Mundschleimhauttransplantation

The purpose of the present communication is the presentation of a surgical method for treating tissue defects of the glans penis through free transplantation of a piece of the patient's buccal mucosa. Defects of the glans penis are most frequently formed from excision of a primary tumour or benign lesions through partial or total glansectomy. During a 2-year period (2004-2005), at the Clinic of Urology of the Medical University, Sofia, 10 patients having penile cancer were diagnosed and treated. Out of these, 6 (60%) were found to be in T1 N0 M0 stage. In 5 (50%) of the said cases, a free mucosa transplant was used to cover the tissue defect remaining after partial or total glansectomy. In 4 (80%) cases buccal mucosa was used, and in 1 (20%) lower lip mucosa. The histological results from the operations performed confirmed the staging of the disease, with 4 flat-cell and 1 verrucosa cancer. Within the early post-operative period, no surgical complications were noted, not only at the site of extraction of the transplant, but also at the site of its transplantation. Late complications and relapses have not been observed. Our initial experience utilising the free transplantation of mucosa extracted from the oscular cavity for replacement of a surgical defect after partial or complete glansectomy has proven to be an alternative to the available treatment methods. Buccosa is more suitable in the case of a partial glansectomy because it has a thicker wall.

Repairing and reconstruction of microsurgical flap in leg serious defection

Objective To explore and solve the repairing and reconstruction in leg serious damage.Methods Using microsurgical technique to reconstruct 9 cases leg serious defection,especially free combining flap with two area flap were applied in 4 cases,two set of vessel were anastomosised to repair the tremendous defection with deep tissue including in tendon, vessel, nerve injury and exposure. Another 5 cases were repaired with paraumbilical flap with opposite lateral vessel anastomosis. Results All 9 cases were applied successfully with 100%survived and were followed-up for one month to four vears. all flaps were good and appearance was excellent,and there were satisfied function recovery. Conclusion It is better choice for repairing complex tissue defection in leg by combining giant free flap transplantation and it is also reliable method for flap circulation by opposite lateral vessel anastomosis. Key words: Surgical flap; Transplantation; Leg; Microsurgical operation

Successful autologous peripheral blood stem cell transplantation in a Jehovah’s Witness with multiple myeloma: review of literature and recommendations for high-dose chemotherapy without support of allogeneic blood products

We present a case report of a successful high-dose melphalan therapy and autologous stem cell transplantation without the use of allogeneic blood product support in a 70-year-old patient suffering from multiple myeloma. Based on the experience in this case and thorough evaluation of the literature, we consider pre-transplant Hb level of 11-12 g/dl, platelet count higher than 70/nl, good WHO performance status of two and lower and informed consent as important eligibility criteria. During cytopenia recommended supportive measures include growth factor support with erythropoietin and G-CSF, p.o. iron treatment as well as prophylactic use of anti-fibrinloytic agents. Furthermore we discuss additional options that might be considered depending on the individual factors as e.g. pre-transplant collection and cryoconservation of autologous platelet concentrates. Moreover, an analysis of socio-economic issues regarding this procedure is presented. We conclude that allogeneic blood product free transplantation is a feasible procedure that can be offered to the patients belonging to distinct religious groups refusing allogeneic blood products as Jehovás Witnesses and patients presenting other contraindications for transfusions.

Ureteraugmentation der Blase bei Kindern mit „Low-compliance-Blase“

In cases of inadequate or insufficient conservative treatment of non-compliant bladders the function of the upper urinary tract is jeopardized. We present our experience with ureterocystoplasty as one possible treatment option.A total of eight children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in five children, posterior urethral valves in two children, and in one child after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. Following nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE procedure was performed in three patients, antireflux surgery for the contralateral kidney in two patients, and one patient underwent stone removal in the remaining kidney. In one patient the ureter was used as a free transplant and was covered by an omental flap. In addition a simultaneous living donor kidney transplant was performed. The storage function could be improved in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years. Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.

The anatomic study of musculocutaneous nerve branch to brachialis muscle in treatment of lower brachial plexus injury by free gracilis transplantation

目的 通过解剖学研究,设计选择性肌皮神经肱肌支移位联合股薄肌移植术重建屈拇屈指功能术式,验证该术式在下臂丛神经损伤治疗中的安全性和有效性.方法 30侧甲醛固定的成年国人上肢标本,经逐层解剖,观察肌皮神经肱肌支的走行,测量肱肌支的长度、直径.对2例创伤性下臂丛损伤上肢功能障碍患者进行选择性肌皮神经肱肌支移位联合股薄肌移植术重建屈拇屈指功能术式.术后观察屈拇屈指功能及手握持功能恢复情况.结果 在30侧标本中,肌皮神经肱肌支分型:单支型25侧,占83.33%,粗细两支型1侧,多支型4侧,未见变异及异常发出.肌皮神经肱肌支长度平均为(52.66±6.45)mm,横径平均为(1.39±0.09)mm.肌皮神经肱肌支神经束平均为(2.83±0.46)束.2例患者术后4～6个月出现股薄肌收缩,恢复屈拇屈指功能.其中1例术后6个月屈拇屈指肌力达M4,可握持200 g物品;术后12个月可握持500 g物品,初步恢复手握持功能.结论 以肌皮神经肱肌支为缝接神经的股薄肌移植治疗下臂丛根性撕脱伤可较好地恢复屈指屈拇功能,初步重建手握持功能.肌皮神经肱肌支可作为股薄肌移植治疗下臂丛神经损伤移位神经较理想的供体。

Comparative study of the integration and viability of autonomised and nonautonomised autologous fat tissue grafts – experimental model in rabbits

The free transplant of fatty tissue has gone through several phases of interest over the last 100 years of medical history, having undergone cycles of use and disuse. In the present study we aimed to create, through a delaying process, an improvement in the integration and lower resorption rates of autologous fat grafts. Similar research has not been found in the literature, and this was the motivating factor for the present study. Twenty-three New Zealand male rabbits were used. The study consisted of two different modalities of autologous fatty tissue transplants [autonomised graft (A) vs nonautonomised grafts (NA)]. In order to characterise the histological differences that could contribute to the different macroscopic aspects in the samples of the autonomised and nonautonomised groups, three anatomic-pathological criteria were considered: steatonecrosis, viable adipocytes, and fibrous proliferation. For this analysis, the 'point-counting' technique proposed by Gundersen et al. was used, with a reticulum of 100 points and 50 lines. Statistically significant differences were found between the autonomised (A) and nonautonomised (NA) groups in both the macroscopic and microscopic aspects after the 6 month study period (P<0.05). We conclude that autonomisation of the fatty tissue and its transfer as an autologous implant, in rabbits, is capable of promoting lower rates of resorption and greater integration of the transplanted tissue, characterised by a greater number of viable adipocytes, lower rates of fibrosis and steatonecrosis in comparison with the nonautonomised graft.

CMS Issues Regulations for Kidney Transplant Programs

CMS Issues Regulations for Kidney Transplant Programs

Education is key to controlling visceral leishmaniasis

Education is key to controlling visceral leishmaniasis

Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery

Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456-61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567-72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869-73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166-94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233-50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breast-conserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28-108 g), while mean FDFG weight was 78.3g (range, 35-148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG.

O.303 Free fat transplantation for augmentation of the face

O.303 Free fat transplantation for augmentation of the face