Part of the book: Technical Problems in Patients on Hemodialysis
Part of the book: Hemodialysis
Patients with severe injury or vasculopathy of the extremities often require resurfacing of tissue defects as well as preservation of functional blood flow to distal areas. In conventional free flap transfer, the recipient vessel is sacrificed to facilitate pedicle anastomosis. On the other hand, a flow‐through flap can provide blood flow to distal tissues. In this chapter, we present cases of successful salvage and reconstruction of the extremities using free flow‐through flaps and highlight their advantages and applications. Free flow‐through flap use should be a good option in the following cases: (1) Gustilo‐Anderson IIIC type open fracture, (2) chronic ulcer resurfacing in the less vascularized extremities, and (3) additional blood supply for an ischemic flap. This flap facilitates not only the reconstruction of soft tissue defects, but also restores the functional vascular anatomy and maintains the original blood flow by interposing the T‐portion of the vessel. This technique enables both vascular and soft tissue reconstructions simultaneously with minimal donor site problems. The anterolateral thigh flap is recommended as a free flow‐through‐type flap due to its advantages, including the variety of flap sizes, adequate calibers of the vascular pedicle, and the lack of a need for position changing.
Part of the book: Issues in Flap Surgery
Background: The wound treatment has progressed owing to the development of new medicine, instruments. Following these trends, can the bone-exposing wounds of severe open fractures be resurfaced without using flaps but only skin grafting? We evaluated a new medicine and instrument, for the resurfacing of bone-exposing complex wounds of Gustilo-Anderson IIIB and C fractures. Patients and methods: Patients with Gustilo-Anderson IIIB (five cases) and C (two cases) open fractures who underwent open reduction and external fixation were evaluated. Bone-exposing wounds were resurfaced with artificial dermis, and basic fibroblast growth factor was sprayed. We investigated the course and outcome. Result: In all of seven cases, abundant granulation tissue did not develop on the bone-exposing wound surface during 2–5 weeks, and 4 patients developed osteomyelitis. Subsequently, all cases required flap surgery to resurface the wound. All patients could walk; however, required a longer period for the complete union of bones. Conclusion: This study showed that it was impossible to prepare a favorable wound bed on the bone when the fracture was severe. Thus, early flap surgery was a recommendable resurfacing option. Furthermore, emergent bone resurfacing with flap, while performing rigid bone fixation with an internal fixation plate, was an ideal procedure.
Part of the book: Issues in Flap Surgery
Several surgical methods are performed for the reconstruction of abdominal wall defects after abdominoperineal resection, involving re-suture and free skin grafting. In the complex surgical cases with large abdominal wall defects, the treatment of intestinal fistula and wound infection is challenging. In many cases, they also have had the problems of the control and reposition of a stoma, which has been already present due to the previous unsuccessful surgical procedures. Especially, the case of larger abdominal wall defects with intestinal fistulation, which drains digestive juice into the wound, requires repairing the abdominal wall while fashioning a stoma. This is because a ruptured digestive tract causes infection and inflammation that results in adhesion of the digestive tract, which limits the mobility of both the abdominal wall and bowel. The only method to solve this complex problem is abdominal wall reconstruction with a large vascularized flap and creation of a new stoma on it to separate the wound from drained digestive juice. We present several cases of a large abdominal wall defect, which was reconstructed successfully. Especially, surgical methods using free and perforator flaps are highlighted. These are optimal methods to reconstruct severe abdominal wall defects that involve complications.
Part of the book: Gastrointestinal Stomas
Foot ulceration in persons with diabetes is the most frequent precursor to amputation, which impairs their activities. The aim of this chapter is to describe factors that lead to amputation of a diabetic foot, and propose a management strategy to prevent major amputation. I analyzed 233 patients who were admitted at the National Nagasaki Medical Center between 2008 and 2017 with foot ulcer and/or infection. We divided them into two groups: 152 patients with diabetes mellitus (DM) and 81 without DM. We analyzed their laboratory data, and evaluated the wound severity, complications of peripheral artery disease (PAD) and renal failure, and infection. Patients with DM ulcer were significantly more likely to receive amputation. Patients with DM were significantly more likely to develop infection, and tended to undergo emergency debridement. Among the patients with DM, the amputation group (85) showed significantly higher levels of CRP and WBC, and was more likely to develop infection, PAD, and renal failure. My results suggest that risk factors leading to leg amputation are severe infection and reduction of arterial blood flow. Early debridement to reduce infectious inflammation and angioplasty following free flap transfer are recommended to preserve legs.
Part of the book: Limb Amputation