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PubMed2005

[Perforator flaps--the evolution of a reconstructive surgical technique].

Trauma, oncological resections and pressure sores can cause major soft tissue defects. The evolution of cutaneous, myocutaneous, and fasciocutaneous flaps currently makes possible the restoration of contour and, in many cases, function. This evolution was closely related to the increased understanding of the vascular anatomy of the skin and subcutis and has led to the development of perforator flaps. A perforator flap is a large flap of skin that survives on a single vascular stalk that perforates the muscle, referred to in briefas a 'perforator'. This has its origin in a larger vascular stalk that runs beneath the muscle. The vascular stalk of such a perforator flap can be lengthened by dissecting the perforator from the muscle in continuity with the vessels running beneath the muscle. Moreover, the larger diameter of these vessels facilitates the creation of a vascular anastomosis in the receptor area. By the use of such perforator flaps, proper innervation and a good blood supply to the flap can be combined with less morbidity at the donor site. Important possibilities include the filling of a dorsal (decubitus) defect and breast reconstruction.

Humans↗

PubMed2005

[Rotated pedicle flap of the floor of nasal cavity to repair nasal septal perforation].

OBJECTIVE: To report a new procedure with rotated pedicle flap of the floor of nasal cavity to repair nasal septal perforation. METHOD: Dissecting mucoperichondrium and mucoperiosteum around the perforation and taking downward to the floor of nasal cavity to make a posterior end pedicle flap. Then rotating the flap backward and upward to overlap the more large perforation and suturing it with the margin of the pocket of mucoperichondrium and mucoperiosteum of the perforation. RESULT: Repair of the perforation in 11 cases were all successful with primary healing. CONCLUSION: Autogenous rotated pedicle flap of the floor of nasal cavity for repairing nasal septal perforation has a lot of advantage. The graft is easy to take, no rejection, having good blood supply, highly survival rate and wide and long enough to be available to the implant for repairing the larger perforation according to its size and shape.

Adolescent↗

PubMed2006

Impaired response of perforating arteries to hypercapnia in chronic hyperglycemia.

Diabetes mellitus increases the risk of cerebrovascular disease, the effects of hypercapnia on CBF (cerebral blood flow) and cerebrovascular reactivity during diabetes are still inconsistent. Here, we have established a new microangiographic technique using synchrotron radiation (SPring-8, Japan), which enabled us to visualize rat cerebral vessels with high spatial resolution in real time. The goal of the study presented here was to identify the effects of chronic hyperglycemia on hypercapnia-induced vascular responses (endothelium-dependent vasodilatation) and nitric oxide (NO) donor- induced vascular responses (endothelium-independent) of perforating arteries and of the deeply located large cerebral arteries. We found a significant vasodilatation of rat perforating arteries after hypercapnia with a maximum diameter of approximately 140% of baseline in normal Wistar rats. Chronic hyperglycemia impaired vasodilatation of perforating arteries in genetically diabetic GK rats. SNP (sodium nitroprusside) caused a similar vasodilatation of perforating vessels in normal and chronic hyperglycemia, indicating that endothelium-dependent vasodilatation of perforating arteries may be specifically impaired in chronic hyperglycemia. Possible impairment of endothelium-dependent vasodilatation in perforating vessels during chronic hyperglycemia may cause decreased vascular reserve capacity of perforating artery, resulting in the increased ischemic insults and cerebrovascular diseases in diabetes.

Animals↗

PubMed2006

Surgical treatment of nasal septal perforations. Our experience.

Septal perforations are difficult problems that the otolaryngologist has to solve. In fact, the otolaryngologist has to identify the cause, which in most cases is either iatrogenic or idiopathic, to decide upon the need for surgery, and select the most suitable surgical technique of those currently available, for the case under consideration. All surgical procedures, aimed at repair of nasal septal perforations, are based on two main principles, namely repair using mucosal, mucoperichondrial, and/or mucoperiosteal flaps from the nasal cavity, or with connective tissue autograft, to be interposed between the mucosal flaps. Surgical repair of septal perforation can be carried out using either the "closed technique" or "open technique". The advantage of the former is that it does not leave any external scar. However, drawbacks related to difficulties due to the narrow operating field may be encountered. Many surgeons prefer the "open" technique, as it offers a wider operating field, thus allowing better access to the superior and posterior margins of the perforation (especially in large and/or posterior perforations), and offering binocular vision. The present report focuses on a short critical examination of the various surgical procedures described in the literature, in the attempt to identify, based also on personal experience, the most suitable techniques to repair septal perforations. A novel technique is presented for the surgical treatment of some types of perforations, which has not, so far, been described in the literature.

Adult↗

PubMed2006

Retrocecal appendix location and perforation at presentation.

Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8-3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.

Adult↗

PubMed1991

Surgical glove perforation in obstetrics.

Perforation of surgical gloves places the obstetrician at risk for blood-borne infectious diseases. Seven hundred fifty-four surgical gloves used in vaginal and cesarean deliveries and postpartum tubal ligations were examined for evidence of perforation by the air inflation-water submersion technique. The overall glove perforation rate was 13.3%, with 62% of the perforations remaining unrecognized during the surgical procedure. The majority of perforations occurred on the fingers of the nondominant hand. Multivariate analysis with logistic regression indicated that cesarean delivery (odds ratio 3.52), any vaginal laceration or episiotomy (odds ratio 4.95), and chief resident status (odds ratio 3.00) were the major risk factors for surgical glove perforation. Surgical technique by assistants, especially in complex cases, is as important as that of the primary surgeon in regard to glove perforations.

Equipment Failure↗

PubMed1990

[Perforation and rupture of the esophagus. Apropos of 35 cases].

A series of 35 oesophageal perforations from the period 1980-1987 is reported. Sixteen perforations followed oesophageal endoscopy, 10 were spontaneous, 8 were due to foreign bodies and one was post-operative. The delay in reaching the right diagnosis was less than 24 hours in 18 cases and more than 24 hours in 17 cases. Oesophageal leak was demonstrated in 86% of our cases by contrast study; in the others by rigid oesophagoscopy. Perforation occurred in the cervical oesophagus in 6 patients, thoracic oesophagus in 28 and abdominal oesophagus in 2 (one had a double perforation). Three patients were managed non operatively and survived. Cervical oesophagostomy and oesophageal diversion were used in 4 patients as primary treatment because of perforation occurring in caustic burn cases (2 cases, both survived) or late severe sepsis (2 cases, both died). Two patients with neoplastic stricture were treated by oesophago-jejunal bypass without resection and partial oesophago-gastrectomy respectively: both survived. Direct suture and closure of the perforation were performed in 26 patients. Two died, one because of oesophageal leak. Post-operative localized leaks developed in 5 other patients without any mortality and 4 healed with conservative management. The overall mortality rate was 11% (4 patients). All had a delayed diagnosis (more than 48 hours). We suggest that even in patients with delayed diagnosis of a non-malignant oesophageal perforation, direct suture and closure should be attempted under protection of functional oesophageal diversion and "contact drainage" to canalize a possible post-operative localized leak. Good oesophageal diversion can be achieved by naso-oesophageal suction and gastric suction through gastrostomy or with oesogastric antireflux procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1990

Gallbladder perforation: correlation of cholescintigraphic and sonographic findings with the Niemeier classification.

We retrospectively analyzed the cholescintigrams and sonograms of 36 consecutive patients with gallbladder perforation to (a) determine the sensitivity of each for the preoperative detection of gallbladder perforation and (b) correlate the findings with the modified Niemeier classification. Cholescintigraphic criteria of perforation (free spill, pericholecystic hepatic activity, and scintigraphic gallstone ileus sign) were detected in 14 of 28 (50%) cases, while sonographic criteria of perforation (pericholecystic fluid or pneumobilia with gallstones) were present in 18% (4 of 22) of patients (p less than 0.05). Cholescintigraphic patterns of perforation associated with the Niemeier classification were: Type I (acute free perforation), 3 of 7 scans demonstrated free spill; Type II (subacute pericholecystic abscess), 9 of 19 scans showed pericholecystic activity; and Type III (chronic cholecystoenteric fistula), 1 of 3 scans showed a scintigraphic gallstone ileus. Thus, although cholescintigraphy appears superior to sonography, both modalities are relatively insensitive for the detection of gallbladder perforation.

Adult↗

PubMed1987

Perforations of the gallbladder and cholecystobiliary fistulae: a review of management and a new classification.

Experiences with seven cases of gallbladder perforation managed in Kingston, Jamaica, at the District of Columbia General Hospital, and other Howard University affiliated hospitals are presented. The results of a review of 197 consecutive biliary operations at DC General Hospital for occurrence of this entity are presented.Gallbladder perforation is a complication of cholecystitis in 1 to 4 percent of cases. Niemeier(1) classified this complication in three types in 1934, and currently these are described as type 1-free perforation, type 2-perforation with abscess, and type 3-chronic perforation with cholecysto-enteric fistula.The gallbladder may, in extremely unusual occurrences, perforate into the biliary tree itself with significant operative implications, and therefore Niemeier's classification can be modified to include cholecystobiliary fistuale formation as type 4. Seven case reports manifesting all four types of perforation are presented, representing the spectrum of current treatment and diagnostic options.

Adult↗

PubMed1987

Risk factors for gallbladder perforation.

Perforation of the gallbladder is a potentially lethal problem due in part to a delay in diagnosis. In an effort to improve our management of these patients, we reviewed all patients seen at the UCLA affiliated hospitals between 1955 and 1983 who had perforation of the gallbladder. Fifty-one patients were reviewed and perforations categorized as either acute (type I) in 16 (31%), subacute (type II) in 20 (39%), or chronic (type III) in 15 (29%). A history suggestive of chronic gallstone disease was obtained in 0% of patients with type I, in 35% of patients with type II, and 60% of patients with type III perforations. The incidence of severe systemic diseases was significantly greater (p less than 0.01) in patients with type I as compared to type III perforation. Based on these data, clinical profiles have been developed for patients at risk of developing acute versus chronic gallbladder perforation. Awareness of these groupings forms the basis for early recognition and treatment of acute gallbladder perforation.

Arteriosclerosis↗

PubMed1981

Perforation of the gallbladder: a clinical study.

An analysis of 3,260 admissions to St. Francis General Hospital during a 20-year period for acute and chronic cholecystitis and two traumatic gallbladder perforations revealed 115 cases for an incidence of 3.5 percent. The most common gallbladder perforation in this series was localized perforation with abscess formation in 72 patients (63 percent). Other perforations were fistulization to another hollow viscus, or to the skin, 32 (27.5 percent), and free perforation, 11 (9.5 percent) into the peritoneal cavity.Nineteen or 46 percent of 41 postoperative complications were related to bacterial infections. In spite of a complication rate of 32 percent, the mortality was zero.Of 115 cases categorized as perforated gallbladder, 63 percent were localized with abscess formation, and 9.5 and 27.5 percent, respectively, were classified as free and as fistulization. Mortality was zero; however, morbidity was 32 percent. The significant complications were related to infection, ie, wound, urologic, subphrenic, and pulmonary and leg vein. Early operation is indicated for acute cholecystitis after rapid preoperative perforation.

Cholecystitis↗

PubMed1995

Type 4a metabotropic glutamate receptor: identification of new potent agonists and differentiation from the L-(+)-2-amino-4-phosphonobutanoic acid-sensitive receptor in the lateral perforant pathway in rats.

Before the discovery of the metabotropic glutamate receptors (mGluRs), the glutamate analogue L-2-amino-4-phosphonobutanoic acid (L-AP4) was identified as a potent presynaptic inhibitor of evoked synaptic transmission in the lateral perforant pathway in rats. The localization and L-AP4 sensitivity of the mGluR4a subtype of mGluRs were consistent with the hypothesis that this receptor mediates the synaptic depressant effects of L-AP4 in the lateral perforant pathway. In the present study, the pharmacology of mGluR4a expressed in baby hamster kidney 570 cells was characterized and compared with that previously reported for the lateral perforant pathway responses. The endogenous excitatory amino acid L-aspartate was inactive at mGluR4a, whereas L-homocysteic acid was only 5-fold less potent than L-glutamate. These data suggest that L-homocysteic acid may be an endogenous agonist at mGluR4a. Of the 30 L-AP4 analogues examined, several compounds were identified as agonists at mGluR4a. The cyclopropyl-AP4 analogue (Z)-(+/-)-2-amino-2,3-methano-4-phosphonobutanoic acid inhibited forskolin-stimulated cAMP production with an EC50 of 0.58 microM, which is comparable to that of L-AP4 (EC50 = 0.43 microM). Two other cyclic analogues of L-AP4 were approximately 10-fold less potent as agonists at mGluR4a, i.e., (+/-)-1-amino-3-(phosphonomethylene)cyclobutanecarboxylic acid (EC50 = 4.4 microM) and (E)-(+/-)-2-amino-2,3-methano-4-phosphonobutanoic acid (EC50 = 7.9 microM). Comparison of the potencies of the compounds for activation of mGluR4a with their potencies for inhibition of lateral perforant pathway responses demonstrates that some compounds have comparable activities in the two systems, whereas several compounds are at least 10-fold more potent in one of the systems. In addition, although the mGluR antagonist (+)-alpha-methyl-4-carboxyphenylglycine blocked the effects of L-AP4 in the lateral perforant pathway, it did not block the effects of L-AP4 at the cloned receptor. These data provide evidence that mGluR4a does not mediate the effects of L-AP4 in the lateral perforant pathway, they provide new tools to identify the function of these receptors in the mammalian central nervous system, and they indicate that the effects of L-AP4 in the lateral perforant pathway are mediated by a (+)-alpha-methyl-4-carboxyphenylglycine-sensitive receptor.

Aminobutyrates↗

PubMed1994

Experiences with the bridge-flap technique for the repair of large nasal septal perforations.

After a review of the literature a modified surgical method called "bilateral bridge-flap technique" for the closure of nasoseptal perforations is outlined. After an extensive elevation of mucoperichondrium and mucoperiosteum from the entire septum as well as from the nasal roof and the nasal floor bipedicle advancement flaps are created: on one side above the perforation by a longitudinal incision along the nasal roof, and on the opposite side below the perforation by a longitudinal incision along the lateral wall of the lower nasal meatus. In very large perforations it may be necessary to create two bridge flaps on each side, one below and the other one above the perforation. After bilateral closure of the mucosal defects the cartilaginous defect is entirely filled with an autogenous cartilage graft taken either from remainders of the septum or from the auricle or rib. Until now this method has been applied in 54 patients with nasoseptal perforations measuring between 0.3 x 0.5 cm and 2 x 5 cm. Forty-eight patients had a follow-up of more than six months; in 45 (93.75%) of these cases the procedure was successful. In the other six patients closure of the perforation could also be obtained, but they were excluded from the evaluation of the overall success rate because of their short follow-up. The essential characteristics illustrating this technique's reliability are: (1) the principally bilateral closure of the mucosal defects; and (2) the additional reconstruction of the cartilaginous septal defect with an autogenous cartilage graft only.

Adolescent↗

PubMed1994

Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients.

This is a report of the results of preoperative color-flow duplex Doppler scanning in the assessment of TRAM flap perforators in 32 consecutive patients. A total of 190 perforators were detected with peak systolic flow velocities ranging from 8 to 81 cm/s. Perforator locations were tabulated according to their vertical position relative to the umbilicus and their lateral location relative to the abdominal midline. The periumbilical region (zones I to III) contained 80.5 percent of the perforators. Asymmetry between the two sides was detected in the majority of patients when perforator positions were evaluated laterally from the midline. The total flap survival rate within the series was 97.9 percent (46 to 47). The present study proposes that the preoperative color-flow Doppler localization of TRAM flap perforators improves the surgeon's ability to design and elevate the flap in order to capture the dominant vessels and maximize survival. In addition, preoperative knowledge of the number and flow velocity characteristics of the perforators allows for the selection of single- and double-pedicle and free TRAM flaps based on each patient's individual perfusion characteristics.

Abdominal Muscles↗

PubMed1993

[The importance of perforators in surgical treatment of varices of the lower extremities].

The authors discuss the role of insufficient perforating veins in the surgical treatment of primary varicosities of the lower extremities. They evaluated the frequency and site of insufficient perforating veins in 284 patients, operated in 1989-1991. Insufficient perforating veins were found in 21.8% operated patients. Most frequently insufficiency of perforating veins of Cockett's group was found, i.e. in 77.4%. Patients who were operated on account of a relapse of varicosities had insufficient perforating veins in 38% and in patients with trophic skin changes insufficient perforating veins were found in 78.5%. The haemodynamic role of perforating veins and their importance with regard to relapses of varicosities is discussed. The authors describe their own diagnostic and therapeutic procedure.

Adult↗

PubMed1993

Retrobulbar anesthesia risk. Do sharp needles really perforate the eye more easily than blunt needles?

PURPOSE: Conventional wisdom in ophthalmology is that the force required to perforate an eye during retrobulbar injection is noticeably greater with a specially designed blunt needle than with a standard hypodermic needle. A search of the literature showed no measurements of scleral perforation pressure with specific needle tips. The authors investigated this concept. METHODS: A computerized search for eye perforations of the surgical records over a 5-year period at Wilford Hall United States Air Force Medical Center was conducted. A double-masked trial by experienced ophthalmologists, using preserved eye bank eyes and several commercially available needles, subjectively assessed the force required to perforate the globe. The authors designed and built a portable transducer system to objectively measure the perforation pressure of human globes with the needles. Measurements were done with preserved and unpreserved human cadaver eyes. RESULTS: No globe penetrations or perforations were found in this consecutive series of over 4000 retrobulbar anesthesia procedures. A subjective difference between the hypodermic and blunt needles was detected. Objective measurements showed a significant difference between the hypodermic and blunt needles, and between types of blunt needles. The difference was present with both eye bank eyes and fresh cadaver eyes. CONCLUSIONS: Blunt-tipped needles do require greater force to penetrate the eye. The noncutting edge, blunt-tipped needles have higher scleral perforation pressures than those with cutting edges.

Anesthesia, Local↗

PubMedDate not supplied

Perforation of dental gloves during prosthodontic treatments as assessed by the conductivity and water inflation tests.

The incidence of latex glove perforation during prosthodontic treatment was investigated on 122 occasions using two methods, a conductivity test and a water inflation test. Latex glove perforation was detected in 38.5% of the treatments by the conductivity test and in 27.9% by the water inflation test. The perforation went unrecognized in 74.7% of the occurrences (35/47 incidents) using the conductivity test and in 64.7% (22/34) when the water inflation test was used. Of the total 55 glove perforations, 21 perforations were detected only by conductivity test, 3 were detected only by the water inflation test, and 31 perforations were detected by both methods, which suggested that the conductivity test is more sensitive than the water inflation test for the detection of glove perforation. The results of this research suggested that even when latex gloves are worn, the risk to prosthodontists of exposure to body fluids remains in four of every six treatments, often without the awareness of the prosthodontist.

Chi-Square Distribution↗

PubMed1997

[Mri and surgical indications in perforating ulcer in diabetic patients].

The authors report a series of thirty-six perforating ulcers of the foot in diabetic patients, evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases, cellulitis in 15 cases, osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2 cases, oedema in 2 cases and abscess in one case. In 19 cases, M.R.I. was used to improve diagnostic accuracy. The medical treatment made use of thermo-moulded soles allowing for the recovery of walking, with a hole facing the perforating ulcer of the foot. The application of insulin-soaked sponges in the event of clean perforating ulcer of the foot and iodized solution in the event of infected perforating ulcer of the foot promoted healing. The treatment was only conservative, when the lesions were limited to the soft tissues. Surgical treatment was performed in 19 cases due to a global involvement of soft and osteoarticular tissues. In fourteen cases the surgical treatment was limited and was performed through the perforating ulcer. Resection of metatarsal heads or metatarso-phalangeal joints was performed in 10 cases, with resection of surrounding pathologic tissue. The surgical treatment was limited to the soft tissues in 6 cases. In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation because the vascular plexus was of poor quality and infection spread from the perforating ulcer to the dorsal aspect of the foot. In our opinion, dorsal infectious involvement in a perforating ulcer of the foot, is a factor of poor prognosis. A below-knee amputation has been performed in one patient.

Abscess↗