Letter to Editor
in these cases. When a plaster slab is used, wound inspection is a major problem and if there is a significant oozing from the drains, the plaster becomes messy and change of plaster is a very cumbersome procedure. This sling can be only used in those patients who have no shoulder abduction. Thus, this new type of immobilisation can be used universally in all patients who are operated with FFMTs with global brachial plexus palsy.
Bipin A. Gangurde, Mukund R. Thatte, Nitin Mokal, Samir Kumta Department of Hand, Microsurgery, Plastic Surgery, Sushrusha Hospital, Dadar, Mumbai, Maharashtra, India Address for correspondence: Dr. Samir Kumta, 1, Vikas, Vinaya Society, B. Keer Lane, Mahim, Mumbai - 400 016, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg 1976;58:407-11. 2. Lin SH, Chuang DC, Hattori Y, Chen HC. Traumatic major muscle loss in the upper extremity: Reconstruction using functioning free muscle transplantation. J Reconstr Microsurg 2004;20:227-35. 3. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg Am 1978;3:416-26. 4. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg Am 1984;9A:32-9. 5. Berger A, Hierner R. Free functional gracilis muscle transplantation for reconstruction of active elbow flexion in posttraumatic brachial plexus lesions. Oper Orthop Traumatol 2009;21:141-56. 6. Doi K, Sakai K, Fuchigami Y, Kawai S. Reconstruction of irreparable brachial plexus injuries with reinnervated free-muscle transfer: Case report. J Neurosurg 1996;85:174-7. 7. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg Am 1995;20:408-14. 8. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004;16:E8. 9. Gilchrist DK. A stockinette-Velpeau for immobilization of the shoulder-girdle. J Bone Joint Surg Am 1967;49:750-1.
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Successful thrombolytic therapy for massive pulmonary embolism following abdominoplasty Sir, Massive pulmonary embolism is a rare, but life threatening complication, which can occur after abdominoplasty.[1,2] Post-operative pulmonary embolism often possess a dilemma in management due to its attended bleeding risk. A 59-year-old hypertensive female patient, who underwent suction assisted abdominoplasty and ventral hernia repair developed breathlessness on the 5th postoperative day. Considering low saturation and significant symptoms despite bronchodilators, cardiac evaluation was performed. Echocardiogram revealed dilated right atrium and right ventricle (RV), suggestive of pulmonary embolism. Computed tomography scan confirmed massive pulmonary embolism. The only immediately available treatment option was to give thrombolytic drug. The risk of bleeding complication was anticipated. Considering the mortality rate of untreated pulmonary embolism is as high as 30%, weight adjusted thrombolytic drug tenectaplase (40 mg) was given. Her symptoms relieved within 2 h, but after 6 h she had significant bleeding from wound margins with hypotension. It was managed by manual compression, tight banding, intravenous fluids and dopamine. 2 units of blood transfusion were also needed. She was discharged 1 week later on oral anticoagulants for next 3 months. On 1-year follow-up her echocardiogram was normal. The reason for increased incidence of pulmonary embolism following this surgery is found to be secondary to elevation of intra-abdominal pressure. This abdominal compartment syndrome is directly related to the severity of plication of rectus fascia. When the intra-abdominal pressure increases by more than 20 mm of Hg, it impedes the venous return from the lower limbs and predispose to deep vein thrombosis.[3,4] Perioperative pulmonary embolism, if associated with hypotension and RV dilatation often needs thrombolysis despite bleeding risk.
DOI: 10.4103/0970-0358.122035
Jayakrishnan Kolady, Rennis Davis1, Rupesh George2, Biju Jacob1 Departments of Plastic Surgery, 1Medicine and 2Cardiology,
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
600
Letter to Editor Amala Institute of Medical Sciences, Thrissur, Kerala, India Address for correspondence: Dr. Rupesh George, Department of Cardiology, Amala Institute of Medical Sciences, Thrissur - 680 555, Kerala, India. E-mail: [email protected]
REFERENCES 1.
Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg 1977;59:513-7. 2. Pitanguy I. Evaluation of body contouring surgery today: A 30year perspective. Plast Reconstr Surg 2000;105:1499-514;1515. 3. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: The physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:745-53. 4. Sugrue M. Intra-abdominal pressure: Time for clinical practice guidelines? Intensive Care Med 2002;28:389-91.
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EDITOR’S COMMENT
Website: www.ijps.org
Tenecteplase is the 527 amino acid protein produced by recombinant DNA technology. Tenecteplase is a modified form of human tissue plasminogen activator that binds
601
to fibrin and converts plasminogen to plasmin. In the presence of fibrin, in vitro studies demonstrate that Tenecteplase conversion of plasminogen to plasmin is increased relative to its conversion in the absence of fibrin. This fibrin specificity decreases systemic activation of plasminogen and the resulting degradation of circulating fibrinogen as compared to a molecule lacking this property. Following administration of the drug there are decreases in circulating fibrinogen and plasminogen. Whereas streptokinase is given slowly in 30 to 60 minutes tenectaplase can be given as a bolus over 5 to 10 seconds and has a quicker onset of action. However in the Indian market the drug is five times costlier than streptokinase.
DOI: 10.4103/0970-0358.122036
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Copyright of Indian Journal of Plastic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
in these cases. When a plaster slab is used, wound inspection is a major problem and if there is a significant oozing from the drains, the plaster becomes messy and change of plaster is a very cumbersome procedure. This sling can be only used in those patients who have no shoulder abduction. Thus, this new type of immobilisation can be used universally in all patients who are operated with FFMTs with global brachial plexus palsy.
Bipin A. Gangurde, Mukund R. Thatte, Nitin Mokal, Samir Kumta Department of Hand, Microsurgery, Plastic Surgery, Sushrusha Hospital, Dadar, Mumbai, Maharashtra, India Address for correspondence: Dr. Samir Kumta, 1, Vikas, Vinaya Society, B. Keer Lane, Mahim, Mumbai - 400 016, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg 1976;58:407-11. 2. Lin SH, Chuang DC, Hattori Y, Chen HC. Traumatic major muscle loss in the upper extremity: Reconstruction using functioning free muscle transplantation. J Reconstr Microsurg 2004;20:227-35. 3. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg Am 1978;3:416-26. 4. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg Am 1984;9A:32-9. 5. Berger A, Hierner R. Free functional gracilis muscle transplantation for reconstruction of active elbow flexion in posttraumatic brachial plexus lesions. Oper Orthop Traumatol 2009;21:141-56. 6. Doi K, Sakai K, Fuchigami Y, Kawai S. Reconstruction of irreparable brachial plexus injuries with reinnervated free-muscle transfer: Case report. J Neurosurg 1996;85:174-7. 7. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg Am 1995;20:408-14. 8. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004;16:E8. 9. Gilchrist DK. A stockinette-Velpeau for immobilization of the shoulder-girdle. J Bone Joint Surg Am 1967;49:750-1.
Access this article online Quick Response Code:
Website: www.ijps.org
Successful thrombolytic therapy for massive pulmonary embolism following abdominoplasty Sir, Massive pulmonary embolism is a rare, but life threatening complication, which can occur after abdominoplasty.[1,2] Post-operative pulmonary embolism often possess a dilemma in management due to its attended bleeding risk. A 59-year-old hypertensive female patient, who underwent suction assisted abdominoplasty and ventral hernia repair developed breathlessness on the 5th postoperative day. Considering low saturation and significant symptoms despite bronchodilators, cardiac evaluation was performed. Echocardiogram revealed dilated right atrium and right ventricle (RV), suggestive of pulmonary embolism. Computed tomography scan confirmed massive pulmonary embolism. The only immediately available treatment option was to give thrombolytic drug. The risk of bleeding complication was anticipated. Considering the mortality rate of untreated pulmonary embolism is as high as 30%, weight adjusted thrombolytic drug tenectaplase (40 mg) was given. Her symptoms relieved within 2 h, but after 6 h she had significant bleeding from wound margins with hypotension. It was managed by manual compression, tight banding, intravenous fluids and dopamine. 2 units of blood transfusion were also needed. She was discharged 1 week later on oral anticoagulants for next 3 months. On 1-year follow-up her echocardiogram was normal. The reason for increased incidence of pulmonary embolism following this surgery is found to be secondary to elevation of intra-abdominal pressure. This abdominal compartment syndrome is directly related to the severity of plication of rectus fascia. When the intra-abdominal pressure increases by more than 20 mm of Hg, it impedes the venous return from the lower limbs and predispose to deep vein thrombosis.[3,4] Perioperative pulmonary embolism, if associated with hypotension and RV dilatation often needs thrombolysis despite bleeding risk.
DOI: 10.4103/0970-0358.122035
Jayakrishnan Kolady, Rennis Davis1, Rupesh George2, Biju Jacob1 Departments of Plastic Surgery, 1Medicine and 2Cardiology,
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
600
Letter to Editor Amala Institute of Medical Sciences, Thrissur, Kerala, India Address for correspondence: Dr. Rupesh George, Department of Cardiology, Amala Institute of Medical Sciences, Thrissur - 680 555, Kerala, India. E-mail: [email protected]
REFERENCES 1.
Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg 1977;59:513-7. 2. Pitanguy I. Evaluation of body contouring surgery today: A 30year perspective. Plast Reconstr Surg 2000;105:1499-514;1515. 3. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: The physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:745-53. 4. Sugrue M. Intra-abdominal pressure: Time for clinical practice guidelines? Intensive Care Med 2002;28:389-91.
Access this article online Quick Response Code:
EDITOR’S COMMENT
Website: www.ijps.org
Tenecteplase is the 527 amino acid protein produced by recombinant DNA technology. Tenecteplase is a modified form of human tissue plasminogen activator that binds
601
to fibrin and converts plasminogen to plasmin. In the presence of fibrin, in vitro studies demonstrate that Tenecteplase conversion of plasminogen to plasmin is increased relative to its conversion in the absence of fibrin. This fibrin specificity decreases systemic activation of plasminogen and the resulting degradation of circulating fibrinogen as compared to a molecule lacking this property. Following administration of the drug there are decreases in circulating fibrinogen and plasminogen. Whereas streptokinase is given slowly in 30 to 60 minutes tenectaplase can be given as a bolus over 5 to 10 seconds and has a quicker onset of action. However in the Indian market the drug is five times costlier than streptokinase.
DOI: 10.4103/0970-0358.122036
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Copyright of Indian Journal of Plastic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
