Four years' experience of limb replantation in Saudi Arabia: a clinical review

This is a review of 70 patients with traumatic limb and digit amputations treated at King Khalid University Hospital, Riyadh in Saudi Arabia from April 1984 to April 1988. Out of 70 cases 34 were not suitable for replantation. In the remaining 36 patients replantation or revascularization was attempted on 46 units. The data are discussed and compared with other published series. Our net survival rate was 67.4 per cent. The survival rate improved from 62.8 per cent in the first 2 years to 81.8 per cent in the subsequent 2 years. The average hospital stay (34 days) was much longer than that reported from developed countries. The increased emergency workload due to a high incidence of referral of unsuitable cases and the longer hospital stay should be taken into account while establishing a replant service in a developing country. Eighteen cases were followed up for more than 1 year; of these, 61 per cent had good (grade I or grade II) functional recovery. The survival rate and functional recovery improved with increased experience and this is a strong argument in favour of centralizing the replant services.     

Four years' experience with fibrin sealant in thoracic and cardiovascular surgery

A single-donor fibrin sealant system was used in 689 thoracic and cardiovascular surgical procedures over the 4-year period between April 1, 1985, and March 31, 1989. An excellent overall success rate (646/689, 94% effective) was achieved with specific applications, including reduction of leakage of air (29/33, 88% effective), blood (595/634, 94% effective), and fluid (14/14, 100% effective), as well as positioning of anatomical structures such as coronary bypass grafts (8/8, 100% effective). Application methods included use of spray bottles (477/497, 96% effective), syringes (165/186, 89% effective), and a Silastic cannula through the flexible fiber-optic bronchoscope (4/6, 67% effective). The system was used in a wide variety of cardiac, pulmonary, esophageal, and vascular procedures to seal staple lines, suture lines, anastomoses, conduits, fistulas, and raw surfaces. No complications with this single-donor system secondary to blood-borne disease have been documented. Overall infection occurred at a nominal rate (16/689, 2%). Thus, fibrin sealant has been a useful tool to control the leakage of air, blood, and fluid during a wide variety of thoracic and cardiovascular procedures and may be of benefit to other surgeons.     

The first two years' experience with major trauma at a pediatric trauma center

We reviewed the records of 233 patients with major trauma admitted to The Children's Hospital of Alabama during the first 2 years of operation of its Pediatric Trauma Center. The male-to-female ratio was 1.7:1. The highest incidence of trauma occurred in the spring (88 patients, 38%) and the lowest in the winter (36 patients, 15%). Most children (184, 79%) were injured between noon and midnight. Blunt mechanisms of injury accounted for 206 patients (88%), penetrating for 17 (7%), and burns for ten (4%). The distribution of injuries by organ system was head/neurologic, 185 patients (79%); musculoskeletal, 83 (36%); thoracic, 57 (24%); abdominal, 29 (12%); major soft-tissue, 26 (11%), genitourinary, 11 (5%); and vascular, 11 (5%). Surgery was required at some point during the hospitalization in 89 patients (38%). Seventy-two patients (31%) experienced 115 complications. The mean length of time spent for resuscitation and stabilization in the trauma room was 49 min. The mean ICU stay was 3.2 days. Total length of hospitalization averaged 11.2 days. Twenty-six patients (11%) died. The Pediatric Trauma Score and the Pediatric Coma Score were found to be predictive of outcome. The organization and function of the trauma team is described, and public health concerns are discussed.     

Four years' experience with South Africa's first mobile accident unit

The mobile accident unit manned by medical staff is not a new concept, yet for a variety of reasons it has not been widely used. The first such service in South Africa was initiated by the author, and 4 years of successful duty have now been completed. Facts relating to our experience in this period are presented to illustrate the need for and the viability of such units. These facts and figures have been divided into 3 sections: incidents, patients and injuries, and treatment. The article is concluded with a discussion of the wider implications of using such a unit.     

Four years' experience with a miniaturized extracorporeal circulation system and its influence on clinical outcome

It has been suggested that the morbidity associated with cardiopulmonary bypass can be attributed in part to the blood-material and blood-air interactions in the extracorporeal circulation (ECC). A recently introduced minimized ECC-system (MECC System) should be able to reduce these negative effects associated with ECC. A retrospective analysis was performed comprising 485 patients who were operated on for elective coronary artery bypass grafting (CABG) using the MECC System with intermittent antegrade warm blood cardioplegia (group 1) from January 2000 to February 2004. A control group consisted of 485 patients (group 2) undergoing elective CABG in the same period using a conventional ECC and cold crystalloid cardioplegia. There were no significant differences between the two groups in terms of the duration of intubation following surgery, the length of intensive care unit-stay and the total hospital stay. Although the 30-day mortality was similar between the two groups, the incidence of postoperative complications and the perioperative use of blood products were significantly higher in the control group compared to the MECC group. The MECC System may serve as an alternative and less invasive approach to conventional ECC.     

Infective endocarditis in maintenance hemodialysis patients: fifteen years' experience in one medical center

BACKGROUND: Infective endocarditis (IE) is a serious infectious condition, with high morbidity and mortality in hemodialysis (HD) patients. This study was undertaken to determine the IE risk factors in maintenance HD patients, and the mortality risk factors. METHODS: We retrospectively reviewed all IE cases of maintenance HD patients at our center over the past 15 yrs (the study group). Regular HD patients without IE in the same period were used as the control group. The basic data of the two groups were analyzed to determine IE risk factors in HD patients. The in-hospital parameters of survival and mortality in the study group patients were used for mortality risk factors analysis. RESULTS: There were 18 definite, and two possible, IE diagnoses in the study group and no cases in the 268 controls. There was no significant difference in age, sex, diabetes, hypertension, underlying malignancy, previous cerebral vascular accident (CVA) history, and calcium multiplied by phosphate product. There was a significant difference between the two groups (study group vs. controls) in pacemaker implant history (15 vs. 1.1%, p<0.01), previous heart surgery history (15 vs. 0.4%, p<0.01), congestive heart failure (CHF) (50 vs. 10.4%, p<0.05), duration on maintenance HD (12.9+/-19.1 vs. 57.9+/-42.3 months, p<0.001), serum albumin at the time of admission (2.91+/-0.40 vs. 3.96+/-0.52 g/dL, p<0.001). There were more patients dialyzed via non-cuffed dual-lumen catheters in the study group (55 vs. 0%, p<0.001), and fewer patients dialyzed via arteriovenous fistula (AVF) (25 vs. 87.7%, p<0.001). The mortality in HD patients with IE was high (60%), especially in patients with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (100%). The most common pathogen was S. aureus (n=12). MRSA was more common than methicillin-susceptible S. aureus (MSSA) (67 vs. 33%). Univariant analysis of in-hospital clinical parameters for mortality revealed no significant difference in age, diabetes, dual-lumen catheter implantation, serum albumin, time to diagnosis, and time to antibiotic use. Borderline statistical significance was noted in serum C-reactive protein (CRP) (p=0.051), and blood glucose level (p=0.056). There were more IE cases due to MRSA in the mortality group than in the survival group (8 vs. 0 cases, p=0.013), but fewer cases due to MSSA (0 vs. 4 cases, p=0.050). CONCLUSIONS: IE should be considered in HD patients with the following risk factors, which include previous heart surgery or pacemaker implantation, shorter HD duration, and especially for patients dialyzed via dual-lumen catheters. The in-hospital clinical parameters including CRP and blood sugar level can offer information concerning prognosis. Since MRSA has increased in recent years and is associated with high mortality, strategies for prevention and treatment require development.     

Urological complications of live related donor renal transplantation: 13 years' experience at a single center

BACKGROUND: This study is a retrospective analysis of urological complications and their treatment in our series of live-donor renal transplantation. MATERIAL AND METHODS: The series comprised of 500 patients. All underwent extravesical ureteroneocystostomy and all except a few initial patients were stented. RESULTS: There were 92 complications in 82 patients (18.4%). Urinary leakage occurred in 1.2%. There were no intrinsic ureteric obstructions. Extrinsic ureteric obstruction occurred in 0.8% of cases. The incidence of UTI was 15.4% and of urethral strictures 1%. CONCLUSION: The technique of stented extravesical ureteroneocystomy has led to an extremely low rate of urological complications in our series, over a long time and in a substantial number of patients.     

Seven years' single center experience of Powerlink unibody bifurcated endograft for endovascular aortic aneurysm repair

AIM: To assess the 7-year results of endovascular aortic aneurysm repair using the Powerlink unibody bifurcated endovascular stent-graft in our single center. METHODS: A prospective, nonrandomized trial was conducted in our unit within 7 years. Endovascular aortic aneurysm repair (EVAR) was planned, performed and followed-up by a fixed endovascular specialized group, including 2 vascular surgeons and 1 interventional radiologist. All the relative data were input into the SPSS statistical analysis software. All patients received abdomen X-ray plain films and CTs or duplex before discharge and 1 month, 6 months, 1 year after discharge, and then annually. RESULTS: From February 1999 to September 2006, a total of 378 abdominal aortic aneurysms (AAAs) patients were intended to treat with Powerlink device, 372 cases were implanted successfully, the technical success rate was 98.4%. The average operation time was 66 min (range, 35-150 min). The late 210 cases (56.5%) were implanted sitting on the aortic bifurcation, the other 162 early cases (43.5%) were not implanted sitting on the aortic bifurcation, proximal cuff was implanted in 209 cases (56.2%), and distal limb extension was used in 42 cases (11.3%), 22 cases (5.9%) received Palmaz stent. One hundred and ninety- four cases (52.2%) had infrarenal fixation, 178 cases (47.8%) had suprarenal fixation. Intraoperative complications included immediate conversion in 6 cases (1.6%), primary proximal type I endoleak in 8 cases (2.2%), primary distal type I endoleak in 2 cases (0.5%), type II endoleak occurred in 20 cases (5.4%). Mean follow-up was 26.7 months (range 1 month 7 years). Postoperative complications included secondary type I endoleaks in 10 cases (2.7%), secondary type II endoleaks in 9 cases (2.4%), limb occlusion in 8 cases and limb stenosis in 5 cases, endograft limb kinking/twisting in 2 cases, partial renal infarction in 9 cases (2.4%). A total of 7 cases (1.9%) had distal migration and all 7 cases were not implanted sitting on the aortic bifurcation. Post-EVAR conversion occurred in 6 cases (1.6%). There were a total of 18 deaths (4.8/%) and 6 deaths (1.6%) within 30 days. CONCLUSIONS: The Powerlink device is safe and effective in preventing AAA rupture in mid-term. It proved simple and easy for size choice. The unique design of this device may confer some advantages in terms of durability. The distinct anatomic fixation of stent-graft sitting on the aortic bifurcation simplifies the deployment procedures and minimizes the potential of distal migration. Prospective longer follow-up in multicenter randomized controlled larger series is necessary to confirm the encouraging outcomes.