Karin M. Dunst

Cardiac hepatopathy before and after heart transplantation

Chronic cardiac hepatopathy is a common entity in patients evaluated for heart transplantation (HTX). Hepatic injury is caused by severe heart failure resulting from prolonged recurrent congestion and/or impaired arterial perfusion. No data are available on the reversibility of cardiac hepatopathy in patients undergoing HTX. Data of 56 consecutive adult patients undergoing HTX during 2000–02 at the University Hospital of Innsbruck were analysed retrospectively. The following parameters were evaluated at the time of listing and 3, 6 and 12 months after HTX. Plasma levels of gamma‐glutamyl transferase (γ‐GT), alkaline phosphatase (AP), bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and total plasma protein. When listed for HTX, only 12% of all patients analysed had physiological values throughout the seven laboratory parameters assessed. Elevated levels of γ‐GT, AP, bilirubin, AST, ALT, LDH and total plasma protein were detected in 66.6%, 29%, 50%, 16.7%, 10%, 40% and 18% of all patients respectively. Accordingly, median plasma levels of γ‐GT, bilirubin and LDH were elevated, whereas the mean plasma level of AP was at the upper normal range. In contrast, median plasma level of AST and mean plasma levels of ALT and total plasma protein were within the normal range: γ‐GT (median, 109.0; range, 634.0 U/l; n = 36), AP (mean, 120.2 ± 78.9 U/l; n = 29), bilirubin (median, 1.3; range, 16.1 mg/dl; n = 32), LDH (median, 226.0; range, 2355.0 U/l; n = 33), AST (median, 29.0; range, 145.0 U/l; n = 36), ALT (mean, 28.3 ± 20.8 U/l; n = 36) and total plasma protein (mean, 7.2 ± 1.1 g/dl; n = 25). Within 3 months after HTX, elevated parameters except LDH significantly ameliorated: γ‐GT (median, 59.0; range, 1160.0 U/l; P = 0.011), AP (92.2 ± 75.2 U/l; P = 0.016), bilirubin (median, 0.9; range, 8.1 mg/dl; P = 0.004), LDH slightly increased (median, 281.0; range, 543.0 U/l; P = 0.039), but there was a delayed improvement of this parameter after 6 and 12 months post‐HTX. End‐stage heart failure is characterized by a cholestatic liver enzyme profile with elevated plasma levels of γ‐GT and bilirubin. These parameters significantly improve within 3 months after HTX. Therefore, chronic cardiac hepatopathy seems to be a benign, potentially reversible disease.

Comparison of the effectiveness of gene therapy with transforming growth factor-β or extracorporal shock wave therapy to reduce ischemic necrosis in an epigastric skin flap model in rats

The induction of neoangiogenesis by exogenous growth factors in failing skin flaps has recently yielded promising results. Gene transfer with virus vectors has been introduced as a highly capable route of administration for growth factors, such as vascular endothelial growth factor or fibroblast growth factor. Extracorporal shock waves (ESW) deliver energy by means of high amplitudes of sound to the target tissue and have been shown to induce angiogenesis. We compared the effectiveness of gene therapy with adenovirus‐mediated transforming growth factor‐β (TGF‐β) and ESW therapy to treat ischemically challenged epigastric skin flaps in a rat model. Thirty male Sprague‐Dawley rats were divided into three groups of 10 each with an 8 × 8 cm epigastric skin flap. Rats received either subdermal injections of adenovirus (Ad) encoding TGF‐β (108 pfu) or ESW treatment with 750 impulses at 0.15 mJ/mm2. The third group received no treatment and served as a control group. Flap viability was evaluated after 7 days and digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area calculated. Histologic evaluation and increased angiogenesis were confirmed by CD31 immunohistochemistry. Overall, there was a significant increase in mean percent surviving area in the Ad‐TGF‐β group and the ESW group compared to the control group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0% and control group: 82.6 ± 4.3%; p < 0.05). Furthermore, in the ESW group mean percent surviving areas were significantly larger than in the Ad‐TGF‐β group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0%; p < 0.05). Flap vascularization was increased by Ad‐TGF‐β and ESW with numerous vessels, however, there was no significant difference between the two treatment groups. We conclude that treatment with ESW enhances epigastric skin flap survival significantly more than Ad‐TGF‐β treatment and thus represents a modality that is feasible, cost‐effective, and less invasive compared to gene therapy with growth factors to improve blood supply to ischemic tissue.

Solid apocrine carcinoma of the skin : report of a rare adnexal neoplasm mimicking lobular breast carcinoma

The so called ‘sweat gland carcinoma’ is a rare skin malignancy. The differentiation between apocrine and eccrine neoplasms remains difficult. Skin tumors of the axilla are often suspected to be metastasis of other neoplasms in particular breast cancer. A 71‐year‐old man presented with a morphea‐like plaque of the right axilla which in punch biopsy was first suspected as metastasis of primary lobular breast carcinoma. After further clinical and laboratory work up including immunohistochemistry the original diagnosis of a breast cancer had to be changed to solid apocrine carcinoma of the skin. Wide excision with en‐bloc axillary lymph node dissection was performed. Final tumor stage was pT2 N0 M0 (V0 L0). No adjuvant treatment was necessary, and there is no evidence of disease after 3 years. Solid apocrine carcinoma of the skin is a rare variant with apocrine differentiation. A survey of the stereotypical presentation of this lesion and a comparison with lobular breast carcinoma and other types of apocrine carcinoma of the skin is given.

Pulsatile perfused porcine coronary arteries for microvascular training.

Microsurgery is today an established technique in specialties such as plastic surgery, neurosurgery, and trauma surgery. However, specialized training is a prerequisite for mastering anastomosis of small-diameter vessels or coaptation of nerves in the operating room. The training should be as realistic as possible and thus, laboratory animals such as the rat are preferably used as a substitute. In an attempt to minimize the use of living animals without jeopardizing a realistic training setting, we developed a pulsatile perfused porcine coronary artery model for microsurgical education. The training model consists of a membrane pump that generates a pulsatile flow within a coronary artery of a porcine heart. The pump is commercially available with a dimension of approximately 130 × 100 × 60 mm and a weight of 190 g. The pump is energized by 220 B and the motor is run on a transformed power of approximately 12 V (range, 1.5–12 V). Different fluids from simple saline solution to theoretically whole blood can be used for perfusion. The membrane pump proved to be very reliable during microvascular training because of its convenient size and wide range of feed rate providing a very realistic training setting. A maximum fluid output of 850 mL/min can be achieved. The pump has a high acceptance in microsurgical trainees evaluated by questionnaires during several microsurgical courses. The pulsatile perfused porcine coronary artery system for microsurgical training enables the trainee to work under the most realistic training settings. It proved to be a valuable tool during microsurgical education, reducing the costs and sparing living laboratory animals. Thus, we can recommend this system to anyone who is involved in training and teaching microsurgical skills.

Restoration of the gluteal fold by a deepithelialized skin flap: Preliminary observations

BackgroundThe gluteal fold represents an important aspect of the gluteal region. Destruction of this anatomic landmark as a consequence of trauma or tissue harvest can result in an aesthetically disturbing disfigurement. A technique for reconstruction of the gluteal fold and preliminary results are presented.MethodsThe newly formed gluteal fold is created by fixation of a deepithelialized skin flap to the periosteum of the tuber ischiadicum.ResultsThe operative procedure is quick and easy to apply. The method is used mainly for patients with a distorted gluteal fold after tissue harvest for breast reconstruction. However, it also can be used after trauma such as that associated with burn injuries. In all patients, reconstruction of the gluteal fold yielded aesthetically pleasing and reliable results with high patient satisfaction.ConclusionsThe authors present a simple and effective technique for reconstruction of the gluteal fold by a deepithelialized skin flap. The technique is applicable for patients who have lost their natural gluteal sulcus, with a resultant altered buttock shape, after trauma or other causes.

Mycobacterium chelonae Skin Infection in Kidney-Pancreas Recipient

To the Editor: Mycobacterium chelonae is rapid growing and is ubiquitous in the environment, including soil, water, domestic and wild animals, and milk and fruit products. It can be associated with infections of the soft tissue, lung, bone, joint, central nervous system, and eye. M. chelonae infections in an immunocompromised host are disseminated in >50% of those infected; chronic use of steroids, even in low doses, seems to be the most important predictive factor for disseminated disease (1,2). In immunocompetent hosts, nontuberculous mycobacteria can colonize body surfaces and be secreted for prolonged periods without causing disease. In hematopoietic stem cell and solid organ transplant recipients, infections with nontuberculous mycobacteria are common and may be a source of illness and death (3). We describe a case of localized cutaneous M. chelonae infection after a dog bite in a kidney-pancreas transplant recipient.

Management of a traumatically avulsed skin-flap on the dorsum of the foot

BackgroundIt is common for traumatologists to see avulsion injuries with resulting composite skin flaps. Simply reattaching the avulsed flap by suturing it back into its bed may result in ischemic necrosis of the distal portion of the flap.Case reportThe authors present a case in which an extensive avulsion injury of the dorsum of the foot with amputation of the fourth and fifth toe was treated by defatting the avulsed flap and reattachment as a full-thickness graft. Healing was uneventful and no skin necrosis was encountered. At 1-year follow-up there was a stable skin situation at the dorsum of the foot. The patient has no difficulties with wearing shoes. However, there is diminished sensibility.ConclusionsIndications for this type of surgical technique include all types of avulsion or degloving injuries that create composite skin flaps prone to undergo ischemic necrosis if simply reattached. This quick and easy method should be in the armamentarium of each surgeon possibly dealing with this type of injury.

Purpura fulminans due to E. coli septicemia.

A 26-year-old man presented with a fulminant liver failure due to Wilson’s disease and was scheduled for orthopic liver transplantation. One day prior to surgery blood culture were positive for E. coli and an antibiotic regimen consisting of ceftazidim and flucloxacillin was initiated. During the postoperative course he developed extensive skin necrosis on both legs (Fig. 1, 2). Although a septic shock associated with disseminated intravascular coagulation (DIC) with formation of microthrombi in the microcirculation seemed most likely as underlying cause, surprisingly platelet count (154 G/l) and coagulation parameters were within normal range and thus, no signs of DIC were present. Furthermore, a heparin-induced thrombocytopenia (HIT) could not be confirmed and no vasoconstrictor agents were administered intraoperatively. The patient received postoperatively cyclosporin A, mycophenolatmofetil and prednisolone for immunosuppression and dalteparin for thromboembolic prophylaxis. Two weeks after the transplantation the lesions were initially debrided and after another 14 days were covered with split-thickness skin grafts. The patient was discharged on the 57th postoperative day in good condition with stable liver function and well-healed skin grafts on both legs. Most cases of purpura fulminans are caused by meningococcal septicemia. However, other bacteria have been implicated as well, such as Streptococcus pneumoniae, Mycobacterium tuberculosis, and – as in our case – E. coli [1, 2]. Critically ill patients receiving massive vasoconstrictor therapy during septic shock are at a special risk and in most instances a severe DIC is present. As our case illustrates also hemodynamically stable patients without additional risk factors and without overt DIC can develop purpura fulminans.

Giant lipoma of the thenar

A 47-year old female farmer came to our clinic because of problems with carrying out daily errands due to a progressive swelling of her right thumb. On clinical examination, we found a giant subcutaneous tumour (Fig. 1). Due to absence of any trauma, lipoma was the most likely diagnosis. Preoperative plain x-ray showed bony erosion of the right first metacarpal. During operation under general anaesthesia, a giant lipoma was found displacing thenar muscles and eroding the first metacarpal due to pressure (Fig. 2). Postoperative healing was uneventful and the patient returned to work 2 weeks after the operation. Intramuscular lipoma of the thenar is a rare condition and has been described infrquently in the literature so far [1, 2]. Differential diagnosis should include posttraumatic hematoma or other tumours of surrounding structures such as lipofibroma of the median nerve [3].

Finger amputation by a sausage packing machine.

A 21-year-old man was brought to the emergency room after having injured his left hand while operating a commercial sausage packing machine. Besides the injuries to his hand he was in good medical condition. In a previous, similar accident he had lost his index finger and sustained subtotal amputation of his middle finger. On examination, complete amputation of the distal phalanx of the middle finger along with a laceration to the nail of the thumb were present. Interestingly, the packing machine had obviously “packed” the distal part of the middle finger, attaching the metal clip typically seen on the ends of sausages to the flexor digitorum profundus tendon (Fig. 1). Luckily, the flexor tendon was not entirely torn out [1]. The amputated distal phalanx was almost completely destroyed and, because of the previous subtotal amputation, replantation was not an option. A decision was made in favor of shortening the finger stump to facilitate closure. The flexor digitorum profundus tendon was shortened and closure was achieved with a local skin flap and a full-thickness skin graft harvested from the amputated distal phalanx (Fig. 2). The laceration to the nail bed of the thumb was managed by simple wound closure. The patient left the hospital on the same day. He went back to work three weeks after the accident. Georg M. Huemer, Harald Schoffl, and Karin M. Dunst