Persistent Drainage Research Articles

Die Bedeutung der De- / Vaskularisation des Harnleiters bei der Rekonstruktion nach Verletzungen

Serious errors may occur in the reconstruction of injured ureters if the degree of -devascularisation is not taken in account. The problems involved in ureter reconstruction after traumatic reconstruction are presented by means of two case -studies reviewed by the Expert Committee for Re-viewing Errors in Medical Treatment of the Ärztekammer Nordrhein. In a 55-year-old man there was a persistent drainage disorder of the left kidney following implantation of a Y-prosthesis with "lateralisation of the ureter". Following renewed splint-ing of the ureter and percutaneous nephrostomy, operative ureterolysis with partial resection of the ureter and end-to-end anastomosis resulted in anastomostic necrosis with a ureter-skin fistula. Fol-lowing a renewed nephrostomy, the left kidney had to be removed because of considerable loss in function. In a 66-year-old woman with right-sided salpingo-oophorectomy and right-sided -colonectomy there was extensive devascularisation of the right ureter with complete -severance in the lower third. An emergency uretero-uretero anastomosis led to scar-induced stenosis of the anastomosed segment of the ureter. Following unsuccessful attemps at splinting, the ureter was reimplanted using the psoas hitch procedure. Because of a fistula to the small intestine, relaparotomy with segmental resection of the small intestine and opening of an abscess -because of wound infection were necessary. A satisfactory final result was obtained after about nine months. When reconstructing damaged -ureters, numerous factors must be taken into account, e. g., the type, extent and location of the -damage to the ureter(s), the time of detection, the duration and severity of the sequelae for the kidney(s), the patient's concomitant condition and the suitability of the reconstruction procedure. Further-more, the degree of de- / vascularisation is of decisive impor-tance.

Incidence and implications of early postoperative wound complications after total elbow arthroplasty

Other than an awareness, there is little detailed information regarding wound problems after total elbow arthroplasty. The purpose of this study was to (1) determine the incidence of wound complications after elbow arthroplasty, (2) document the long-term implications, (3) characterize risk factors, and (4) discuss a management strategy. We hypothesize that the incidence of this complication can be reduced with careful preoperative planning. We reviewed 1749 total elbow arthroplasties. The average patient age was 61.5years (range; 30-91 years). Wound complications were diagnosed according to the criteria of the Centers for Disease Control and Prevention. We identified and studied 97 patients (5.5%) from the 1749 procedures. The most common problems were delayed healing and drainage in 34 and wound hematoma in 33, of which 9 (27%) progressed to secondary deep infection. Of the 97 patients, 86 (88.7%) healed with the retention of the implant, 24 (∼25%) progressed to a septic elbow, and 11 (∼50%) required resection. Patients with rheumatoid arthritis represented 33% of the entire sample, but represented 45.8% of those with septic complications. Posttraumatic arthritis patients represented 58% of the entire sample and only 33% of those with septic problems (P < .05). The overall incidence of serious wound complications was slightly less than anticipated; however, the significance was considerable. Patients with rheumatoid arthritis are most vulnerable. Persistent wound drainage showed a high correlation for deep infection and subsequent implant removal. Anticipation of potential problems and appropriate prophylactic management may avoid wound complications.

Repulsion of Maxillary and Mandibular Cheek Teeth in Standing Horses

To report the technique and results of cheek teeth repulsion in standing, sedated horses. Case series. Horses (n = 12), ponies (6). Medical records (2006-2009) of horses that had cheek tooth repulsion while standing were reviewed. Inclusion criteria included: maxillary or mandibular cheek tooth disease diagnosed by clinical and radiographic examination where attempted oral extraction failed necessitating repulsion. Horses were sedated and a local nerve block performed. Intraoperative radiographs facilitated instrument positioning and ensured repulsion of all dental remnants. Alveolar cavities were packed postoperatively and secondary dental sinusitis treated with lavage. Median horse age was 7 years (range, 1-30 years). Maxillary (n = 15) and mandibular (5) cheek teeth were removed successfully. One horse was euthanatized 1 week after tooth removal because of concurrent liver disease and 10 horses (59%) had resolution of discharge after the 1st treatment; 41% of extractions required follow-up medical or surgical treatment to resolve signs [6/12 maxillary sinusitis and 1/5 persistent mandibular drainage]. Standing repulsion of diseased and fractured cheek teeth is an effective means of resolving clinical signs of dental disease when oral extraction fails. Chronic sinus involvement increased the risk of postextraction surgical treatment for sinusitis.

Novel use of unilateral galeopericranial flaps for closure of sino‐orbital cutaneous fistulas

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. Challenges to successful closure of this common complication include complex anatomy, communication with sinonasal mucosa, persistent mucopurulent drainage, compromised wound healing due to previous irradiation, and wound infection. We describe a novel approach for closure of sino-orbital cutaneous fistulas in two patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. Additionally, it obviates the need for a more cosmetically disfiguring closure. Although used successfully in a variety of skull base and ophthalmologic surgeries, the galeopericranial flap has not been previously described for closure of sino-orbital cutaneous fistulas. Both patients' defects have remained closed at follow-up with excellent cosmetic results.

The N-terminal pro-B-type natriuretic peptide as a predictor of disease progression in patients with pericardial effusion

BackgroundThe purpose of this study was to evaluate the value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a predictor of disease progression in patients with pericardial effusions (PE). MethodWe retrospectively studied consecutive patients that had moderate or large PEs. Patients with pericardial events, such as reaccumulation of PE, persistent drainage through a catheter longer than one week, or newly developed constrictive pericarditis were defined as the progression group (Group A), and patients without these findings were defined as the group with no progression (Group B). The NT-proBNP assay was performed when PE was detected. ResultsCompared to Group B (27 patients), Group A (15 patients) exhibited lower systolic and diastolic blood pressures (106±13 vs. 118±19mmHg, p=0.028; 69±9 vs. 75±11mmHg, p=0.047), higher NT-proBNP levels (1063±756 vs. 578±1090ng/L, p=0.002), larger inferior vena cava (21±6 vs. 17±5mm, p=0.039) and higher estimated right ventricular systolic pressure (37±5 vs. 32±6mmHg, p=0.024). NT-proBNP was the only independent predictor of disease progression (p=0.034) by multivariate regression analysis. The receiver-operating characteristic curve analysis showed that NT-proBNP values ≥548ng/L demonstrated a sensitivity of 80% and a specificity of 78% for identifying disease progression (p=0.001). ConclusionsThe NT-proBNP value may predict disease progression in patients with PE. However, additional prospective studies with more patients are needed.

Society of Gynecologic Surgeons' Survey

: To evaluate the practice patterns of the Society of Gynecologic Surgeons (SGS) members and guests regarding the use of synthetic mesh in vaginal prolapse repair. : A 26-item questionnaire regarding synthetic mesh use in vaginal prolapse repair was placed on the desks of those SGS attendees present at the fourth scientific session of the 2008 annual scientific meeting. Voluntary participation was requested and the survey questionnaires were retrieved at the session's conclusion. Descriptive statistics and cross-tabulation using χ tests were performed with SPSS. : One hundred twenty-eight of the 180 scientific session attendees completed the surveys. Sixty-nine percent (88/128) of the respondents identified themselves as urogynecologists and 45% (83/128) were male. Forty-five percent (58/128) were SGS members. Sixty-six percent (84/128) described their practice setting as academic, 28% (36/128) as community-based, and 6% (8/128) as other. The majority of the urogynecologists, 65% (64/88), used mesh at the time of survey completion versus 40% (8/18) of the obstetrician/gynecologists (P < 0.001). Fifty-nine percent (74/125) respondents were currently using mesh and 11% (14/125) reported using mesh at one time. Fifty-six percent (48/86) used mesh in both primary and recurrent repairs. For anterior repair, 97% (82/86) used mesh; of these, 31% (26/86) used only mesh kits, 33% (28/86) used only free mesh and 33% (28/86) reported using both. For posterior repair, 70% (62/88) used mesh; of these 18% (16/88) used only mesh kits, 26% (23/88) used only free mesh and 26% (23/88) used both. For anterior repair, 84% (71/85) dissected full-thickness and 43% (35/85) plicated connective tissue prior to inserting the mesh. The respondents had excised mesh for indications including: persistent drainage (59%), persistent pain (21%), hispareunia (21%), dyspareunia (16%), and asymptomatic exposure (11%). Fifty percent (44/88) initially managed mesh erosion with estrogen cream whereas 29% (26/88) started with mesh excision. : This survey suggests that the majority of urogynecologists attending the 34th SGS annual scientific meeting have used vaginal mesh for prolapse repair, and they more commonly used it in the anterior as compared to the posterior compartment. This has occurred in the absence of prospective, controlled, high-quality studies supporting its efficacy and safety. Research is clearly needed in this area.

Hepatic Hydrothorax without Ascites Successfully Treated with Octreotide Infusion

Purpose: Hepatic hydrothorax is the presence of pleural fluid (>500 ml) in a cirrhotic patient without any underlying cardiopulmonary disease. We report a case of a 72-year-old Caucasian male with history of alcohol abuse who presented with hepatic hydrothorax without any ascites. The patient was brought to the ER with progressively worsening dyspnea and bilateral leg swelling for two weeks. Physical examination was remarkable for hepatosplenomegaly without any fluid thrill or shifting dullness, and pedal edema. CT Abdomen/Thorax showed large right-sided pleural effusion, cirrhosis of the liver without any ascites or lung disease. Echocardiogram showed a normal LVEF. The patient was admitted to medical ICU, started on a 2 g Na diet, diuretics, and a large volume thoracocentesis was performed. Pleural fluid revealed a low protein (<2.5 g/dL) effusion with serum-pleural albumin gradient (SPAG) > 1.1 suggestive of hepatic hydrothorax. On day 3, the patient developed acute respiratory distress requiring intubation and emergent placement of a chest tube. CXR showed complete opacification of the right hemithorax with massive pleural effusion (Figure 1). Despite aggressive diuresis, chest tube persistently drained large amounts of pleural fluid and could not be removed. An octreotide drip was then started to decrease the portal hypertension and pleural effusion. Subsequent serial radiographs showed decreasing pleural effusion (Figure 2) facilitating tube removal on day 7 and extubation on day 8. Although hepatic hydrothorax is often seen in association with ascites, our patient had an unusual presentation without any ascites. Moreover, chest tube placement must be avoided as it may be associated with the development of a peritoneal-pleural fistula and persistent drainage delaying the tube removal. Beneficial effects of octreotide have been reported (three-five cases in literature) in facilitating tube removal by decreasing the portal hypertension and subsequently the pleural effusion, as was the case with our patient.FigureFigure: [740]

Hyperbaric oxygen therapy in a patient with autosomal dominant polycystic kidney disease with a perinephritic abscess

A 68-year-old female in hemodialysis due to autosomal dominant polycystic kidney disease underwent resection of cysts in her right kidney via a laparoscopic approach due to abdominal pain. Three weeks after surgery, she was admitted with sepsis. A CT scan showed a large abscess around the right kidney. Percutaneous drainage of abscess was performed. The pus smear showed Gram-positive cocci and the culture contained methicillin-resistant Staphylococcus aureus. Ciprofloxacin, clindamycin and vancomycin were given. In the 3 weeks following admission, she remained febrile and septic and showed a progressive deterioration in her general condition, along with malnutrition and persistent drainage of purulent material from her right flank. The antibiotic therapy was changed to vancomycin, metronidazole and meropenem, but no improvement was observed. Because of the high risk associated with carrying out an open nephrectomy, we decided to use hyperbaric oxygen therapy (HBOT) as a potentially useful measure to control her infection. The patient underwent 26 daily sessions of 100% hyperbaric oxygen (2.5 atm). The use of HBOT induced a notable break in the clinical course of this patient's retroperitoneal infection. She was discharged after day 58 without any signs of inflammatory activity, and she has not presented reactivation of infection since then. We think that this case suggests that this therapy could be a new therapeutic tool in the management of patients with similar clinical features when all other therapeutic measures have failed. We did not find any other reports of the use of HBOT in infections of renal cysts.

Urinary fistulae after partial nephrectomy

To report the risk factors and natural history of urinary fistula (UF) after partial nephrectomy (PN), as their incidence has been reported to be 3-6% in large series of PN but there are few reports of the risk factors associated with the development of UF after PN, and the natural history of UF in a large group of patients. This was a retrospective review of 1118 PN at one tertiary-care institution. Most patients had a drain placed in the perinephric space after surgery. Fifty-two patients were identified as having a UF if they had persistent flank drainage for >14 days after surgery, or presented with evidence of a UF after the drain had been removed. Risk factors for development and the course of the UF are reported. Fifty-two patients developed a UF after PN (4.4%, 95% confidence interval, CI, 3.5-6.1%) The rate of a persistent urine leak (defined as drain fluid consistent with urine for >2 weeks after surgery) was 4.0 (95% CI 2.9-5.3)%. The overall rate of delayed UF presentation was only 0.4 (0.09-0.9)%. Patients who developed a UF had larger tumours (3.5 vs 2.6 cm, P= 0.03), a higher estimated blood loss (400 vs 300 mL, P < 0.001), and longer ischaemia time (50 vs 39 min, P < 0.001) than patients who did not develop a UF. Differences in tumour histology, laterality, multifocality, type of surgery (laparoscopic vs open), and intraoperative collecting system entry were not statistically different in patients who did or did not develop a UF. Patients with tumours of >2.5 cm were twice as likely to develop a UF than patients with tumours of <2.5 cm (P= 0.02). Most patients were managed conservatively with a percutaneous drain until the UF resolved, if they were asymptomatic. Overall, in 36 patients (69%) the fistula resolved with no intervention, while 16 (31%) required intervention. Stenting was the commonest intervention (15%). No patient required re-operative open surgery. The rate of development of UF after PN is low. Tumour size, blood loss and ischaemia time were all associated with the development of a UF. In most patients with a urine leak immediately after surgery the UF will resolve with no intervention, and can be managed conservatively with patience, in the absence of clinical symptoms.

Experiences in Laparoscopic Removal of Upper Ureteral Stones: Multicenter Analysis of Cases, Based on the TurkUroLap Group

Laparoscopic surgery for ureteral stones was restricted to special cases-those with large or impacted ureteral stones. We present special cases of patients who underwent laparoscopic ureterolithotomy at various clinics in Turkey. Forty-one patients were included in the study from five urology clinics in which laparoscopic surgery was being performed. After a disease-specific history and physical examination, age and sex were recorded. The mean patient age was 41.8 years (30 men and 11 women). Urinalysis, determination of creatinine level, intravenous urography, and ultrasonography were performed. The parameters of stone size, presence of hydronephrosis, previous shockwave lithotripsy, previous ureteroscopic stone therapy, type of laparoscopic approach, operative time, ureteral incision, insertion of a Double-J stent, amount of drainage, hospitalization period, and perioperative complications were evaluated. Mean ureteral stone size was 22 mm. The retroperitoneoscopic approach was preferred in 35 (85.3%) patients, while the transperitoneal approach was used in 6 (14.7%) patients. Grade I hydronephrosis was detected in 4 patients, grade 2 in 22 patients, and grade 3 in 12 patients. In six patients, a history of shockwave lithotripsy was confirmed. The ureteral wall was incised with a cold knife in 5, scissors in 16, J-hook in 3, and a monopolar or bipolar dissector in 17 patients. In six patients, a Double-J stent was inserted, while in one patient, the operation was converted to an open procedure. The mean operative time was 124 minutes. The mean amount of drainage was 220 ml. Mean hospitalization time was 4.8 days. In five (12.5%) of seven patients, persistent drainage was a major complication that was managed by insertion of a Double-J stent. All patients were discharged stone free. Increased hospitalization and operative time can be related to the large stone sizes and prolonged urine leakage. In our opinion, however, the overall success of laparoscopic ureterolithotomy makes it a feasible and effective procedure, especially for stones that could not be managed easily with ureteroscopic stone therapy.

Comparison of Endoscopic Therapeutic Modalities for Postoperative Biliary Fistula of Liver Hydatid Cyst

Hydatid disease most commonly affects the liver, and rupture into the bile ducts is a frequent complication occurring in 5% to 25% of patients. Biliary endoscopic procedures have become the treatment of choice for the management of biliary fistulae. Objective parameters for the endoscopic management of biliary fistulas are still necessary. In this multicentric retrospective study, a total of 109 patients who underwent surgery for a hydatid cyst localized to the liver and presented with persistent drainage of bile from a lodge drain after surgical intervention were included in this study. All patients were treated by an endoscopic retrograde cholangiopancreatography. Patients were divided into 3 groups according to the therapeutic endoscopic procedure: group 1 (n: 70) included patients who underwent only endoscopic sphincterotomy; group 2 (n: 22) included patients who had a 10 F biliary stent inserted; and group 3 (n: 17) included patients who had a 7 F biliary stent inserted. Recorded data were reviewed and the groups were compared. The mean daily fistula output was 247 mL (range: 100 to 600 mL) in group 1, 534 mL (range: 200 to 1000 mL) in group 2, and 372 mL (range: 120 to 780 mL) in group 3, respectively. There were significant differences between the sphincterotomy group and the stenting groups (P<0.001). The closure time of the external biliary fistula was 23.7 days (range: 6 to 60 d) in group 1, 12.6 days (range: 7 to 23 d) in group 2, and 20 days (range: 6 to 33 d) in group 3, respectively. When compared with the sphincterotomy group, the fistula closure time was shorter in group 2 than in group 1 (P<0.001). There were no differences in this respect between the groups 1 and 3 (P=0.214). Group 2 also had a shorter fistula closure time than group 3 (P<0.001). There was no mortality in any of the study groups. Mild bleeding was observed in 3 cases in group 1 and in 1 in group 3. CONCULUSIONS: Endoscopic retrograde cholangiopancreatography and related therapeutic procedures are safe and valuable in the postoperative management of external biliary fistulae in the hepatic hydatid disease. In high-output fistulae (>300 mL/d), indicating a major cystobiliary communication, stent placement may be preferred. The diameter of the stent should preferably be 10 F. This 10 F stent is superior to other endoscopic approaches in the treatment of biliary fistulas.

Drain tube migration into the anastomotic site of an esophagojejunostomy for gastric small cell carcinoma: short report

BackgroundIntraluminal migration of a drain through an anastomotic site is a rare complication of gastric surgery.Case PresentationWe herein report the intraluminal migration of a drain placed after a lower esophagectomy and total gastrectomy with Roux-en-Y anastomosis for gastric small cell carcinoma. Persistent drainage was noted 1 month after surgery, and radiographic studies were consistent with drain tube migration. Endoscopy revealed the drain had migrated into the esophagojejunostomy anastomotic site. The drain was removed from outside of abdominal wound while observing the anastomotic site endoscopically. The patient was treated with suction via a nasogastric tube drain for 5 days, and thereafter had an uneventful recovery.ConclusionsThough drain tube migration is a rare occurrence, it should be considered in patients with persistent drainage who have undergone gastric surgery.

Treatment of long ureteric strictures with buccal mucosal grafts

To describe the reconstruction of long ureteric strictures using buccal mucosal patch grafts and to report the intermediate-term functional outcome. Between November 2000 and October 2006 reconstruction of seven long ureteric strictures using buccal mucosal patch grafts and omental wrapping was performed in five women (one with bilateral strictures) and one man. The surgical steps of stricture reconstruction and wrapping with omentum are described in detail. Stricture recurrence was defined as persistent impaired ureteric drainage as displayed by imaging techniques or the necessity to prolong JJ stenting. Patency rates and stricture recurrence-free survival rates are provided. With a median follow up of 18 months five of the seven strictures were recurrence-free. Graft take was good in all patients. In one asymptomatic patient, there was impaired ureteric drainage on the reconstructed side, and in one patient with reconstruction of both ureters prolonged JJ stenting of one side was necessary. In both patients, the impaired drainage was caused by persistent stricture below the reconstructed ureteric segments. At intermediate-term follow-up in a small group of patients with long ureteric strictures, treatment with buccal mucosal patch grafts and omental wrapping showed good functional outcome.

Risk Factors for Incisional Complications after Exploratory Celiotomy in Horses: Do Skin Staples Increase the Risk?

To assess risk factors for celiotomy incisional infection in horses, especially the use of staples for skin closure. Case series. Horses (n=356) that had 1 exploratory celiotomy for colic and survived >2 weeks after surgery between March 1, 2004 and December 31, 2007. Incisions were classified as "normal" (no complication, only edema, serous drainage lasting <24 hours) or as "surgical site infection (SSI)" (persistent serosanguinous drainage or purulent drainage with or without positive bacterial culture). All possible risk factors, including method of skin closure (monofilament sutures or staples), were statistically analyzed using univariate and multivariate logistic regression. Of 356 horses, 303 (85%) had normal wound healing and 53 (15%) developed a SSI (purulent: 48 [14%]; persistent serosanguinous: 5 [1%]). Bacterial cultures were positive in 33 of 40 cases. Factors significantly associated with SSI in the multivariate analysis were: use of staples for skin closure (odds ratio [OR] 3.85, P<.001) and surgical site closure by a 1st or 2nd year resident (OR 2.20, P=.016). Lavage of the linea alba with sterile saline solution after closure was a protective factor (OR 0.38, P=.004). Use of staples for skin closure and less experienced surgeons closing the abdomen are risk factors for incisional infection. Incisional lavage after linea alba closure was a protective factor. Despite their ease and speed of application, skin staples can lead to an increase in celiotomy wound complications in horses.

Pararectal Cystotomy for Urolith Removal in Nine Horses

To report outcome of horses after standing pararectal cystotomy for removal of uroliths. Case series. Horses (n=9) with cystic calculi. Medical records (December 1998-May 2007) of horses with cystic calculi that had standing pararectal cystotomy were reviewed. Signalment; urolith number, size, and type; surgical technique; sedation and analgesia protocols; intra- and postoperative complications and outcome were analyzed. Uroliths (mean diameter, 6.37 cm; median, 6 cm; range, 3-10 cm) were removed intact without need for fragmentation. Eight (89%) horses had no complications and 1 horse (11%) developed persistent drainage from the perineal incision and incisional healing was prolonged. The complications resolved after wound revision, and although cystoscopy showed absence of uroliths, the clinical signs associated with cystitis recurred. Cystic calculi can be removed safely in standing horses using a pararectal approach. The procedure was well tolerated and no serious complications were encountered. Pararectal cystotomy allows removal of cystic calculi in standing sedated horses. The technique may offer an economic advantage over approaches that require general anesthesia.

Ectopic gastric and pancreatic tissue: a rare cause of umbilical discharge

Persistent umbilical drainage may be due to vestigial remnants of the omphalomesenteric duct. Rarely, it may be owing to the presence of ectopic pancreatic tissue within these remnants. An 18-month-old boy underwent surgical exploration for umbilical discharge. An umbilical nodule containing both ectopic gastric and pancreatic tissue was found. This is the first instance where both tissue types have been implicated as a cause.

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children

Purpose The aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing. Methods A retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution. Technique Two mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly. Results One hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation—4 with loop drains and 2 with incision and packing with complete healing. Conclusion The use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.

Reduced glacier sliding caused by persistent drainage from a subglacial lake

Abstract. We present velocity observations of a glacier outlet in Vatnajökull, Iceland, deduced from interferometric SAR (InSAR) data obtained during the ERS1/2 tandem mission in 1995–2000. More than a 50% decrease in glacier velocity was observed subsequent to a large jökulhlaup from the subglacial lake Grímsvötn in 1996. The glacier had not reached its former flow rate in 2000. The jökulhlaup damaged the lake's ice-dam causing persistent drainage from the lake. InSAR based studies of water accumulation within Grímsvötn suggest that a leakage of &gt;3 m3 s−1 prevailed throughout our study period. We suggest that the lake leakage kept open a tunnel at low water pressure underneath the whole length of the glacier. The tunnel flow drained water from its surroundings, hence lowering the water pressure of a distributed drainage system, underneath the upper and centre parts of the glacier, which prior to the jökulhlaup sustained significant basal sliding. This is in accordance with theoretical prediction that tunnel flow in a steady state may cause slow-down in glacier velocity by reducing the subglacial water pressure. The width of the affected areas was ~5 km on the upper part of the glacier and ~8 km on the centre part of the glacier. This indicates that the water pressure reduction propagates laterally from the tunnel over a distance of a few km.

Curetagem de lesões periapicais refratárias com simultânea obturação dos canais radiculares

Two extensive periapical lesions associated with the maxillary right and left central incisors developed after a trauma; there was also consistent, painless swelling of the cortical bone plate. After establishment of apical patency, there was persistent and abundant drainage of bloody serous exudate. Aspiration of the lesions produced 10 mL of the inflammatory exudate. The pathology persisted after biomechanical preparation and application of calcium hydroxide root canal dressing. Surgery was then performed, comprising periapical curettage associated with simultaneous root canal filling. Histopathological examination confirmed the cystic

Novel Use of Unilateral Galeopericranial Flaps for Closure of Sino‐Orbital Cutaneous Fistulas

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. However, these defects remain a difficult to close due to persistent mucopurulent drainage and previous irradiation. We describe a novel approach for closure of sino-orbital cutaneous fistulas in 2 patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. The flap has been used successfully in a variety of skull base and ophthalmologic surgeries. Additionally, the galeopericranial flap obviates the need for a more cosmetically disfiguring closure. Both patients' defects have remained closed at follow-up with excellent cosmetic results.