Case report of a hybrid endovascular approach to an abdominal aortic dissection with retrograde thoracic extension and infrarenal aneurysm

Spontaneous abdominal aortic dissection (AAD) with retrograde thoracic extension is an extremely rare occurrence with a high mortality. Abdominal aortic dissection can be associated with an abdominal aortic aneurysm (AAA) and the presence of an AAD with an AAA mandates surgical intervention because of a high rate of rupture. We present the case of a 53-year-old woman with a spontaneous AAD that extended retrograde into the thoracic aorta with a concomitant supraceliac intimal tear and an infrarenal AAA repaired electively with a hybrid approach using a supraceliac stent graft and an open infrarenal aortobiiliac graft. This hybrid approach provided an excellent outcome of this rare and complex vascular pathology.     

Usefulness of performing a pancreaticojejunostomy with an internal stent after a pancreatoduodenectomy

PURPOSE: In pancreaticojejunostomy (PJ), the occurrence of an injury during the removal of a stented tube is sometimes related to pancreatitis or late-onset stenosis of the pancreatic duct. In this study, we compare the outcomes of a PJ with an external stent versus an internal stent in a randomized study. METHODS: We compared the complications including pancreatic fistula, mortality, and postoperative hospital stay of 43 patients who had PJ with an external stent (group E) or PJ with an internal stent (group I) after a pancreaticoduodenectomy (PD). RESULTS: Pancreatic fistula occurred in 8 patients (36.4%) in group E, while it only was seen in 7 patients (33.3%) in group I. Pancreatitis was recognized in 3 patients in group E, while there was no patient in whom an obstruction due to an internal stent was suspected. CONCLUSION: Pancreaticojejunostomy with an internal stent is therefore considered to be an effective treatment alternative after PD, with an acceptable morbidity and no mortality.     

Repair of a large "coup de sabre" with soft-tissue expansion and artificial bone graft

The authors present a case of a "coup de sabre"--a linear form of scleroderma--in an 18-year-old woman treated by means of an expanded forehead and scalp flap, a hydroxyapatite implant, and an autologous iliac bone graft. Hydroxyapatite was implanted to augment a depressive bony deformity. The nasal deformity was repaired with an expanded forehead flap and an autologous iliac bone graft. This is the first reported case in which a deformity of scleroderma was treated with a combination of an expanded skin flap and a hydroxyapatite implant.     

Extraluminal use of the Arndt pediatric endobron-chial blocker in an infant: a case report

PURPOSE: Attaining lung isolation in the infant undergoing thoracic anesthesia can be challenging for the anesthesiologist. We describe a novel approach to performing lung isolation in an infant undergoing thoracotomy for lobectomy using an Arndt pediatric endobronchial blocker via an extraluminal technique. CLINICAL FEATURES: Lung isolation in an infant was achieved through the use of an Arndt pediatric endobronchial blocker placed externally to an endotracheal tube. The blocker's placement was facilitated through the use of a pediatric fibreoptic brochoscope placed through the guidewire of the extraluminally placed bronchial blocker. CONCLUSION: This novel technique may provide an easier and more reliable method of attaining single lung ventilation in infants and small children.     

Superdrainage of the ileocolic vein to the internal jugular vein interposed by an inferior mesenteric vein graft in replacing the esophagus with the right hemicolon

The fear of serious complications, such as a necrotic conduit caused by an impaired blood circulation can arise when replacing the esophagus with an intestinal conduit. The aim of this paper is to present effective superdrainage of an intestinal conduit using an inferior mesenteric vein (IMV) interposition graft. In 2008, we performed superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft in replacing the esophagus with the right hemicolon for advanced thoracic esophageal cancer in three patients with a synchronous gastric cancer or a previous gastrectomy. No leakage at the enteric anastomoses occurred. Neither ischemic lesions in these intestinal conduits nor complications caused by harvesting an IMV graft were observed. Superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft effectively improves the blood circulation in intestinal conduits brought up to the neck as an esophageal replacement.     

Gangrene of the upper extremity in diabetic patients

Twenty-two patients who had diabetes mellitus and had needed an amputation for gangrene in an upper extremity at an average age of fifty-one years were identified and followed. The five patients who were still living at the latest follow-up had been followed for an average of 50.6 months. The other seventeen patients survived for an average of only 20.6 months after the amputation. All of the patients were in poor health; eighteen had needed an amputation in a lower extremity, and sixteen received hemodialysis. The results of amputation in an upper extremity were unsatisfactory; the site of the initial amputation healed in only two of the twenty-two patients. In the remaining twenty patients, a total of sixty-three additional operations were performed on an upper extremity, and five of the twenty patients died before the wound had healed.     

The recognition of lesions on chest radiographs.

An approach to the recognition of lesions on chest radiographs is outlined. Four basic groups of abnormalities by means of which lesions can be recognized are mentioned and are briefly described, namely an opacity, an area of increased translucency, a combination of an opacity and an area of increased translucency, and, especially, an alteration in normal radiological anatomy.     

Endovascular Treatment of a Ureteroiliac Fistula Associated with Ureteral Double J-Stenting and an Aortic-Bifemoral Stent Graft for an Inflammatory Abdominal Aortic Aneurysm

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.     

Major intra-abdominal complications following extracorporeal shockwave lithotripsy (ESWL) in a patient with Ehlers-Danlos syndrome

A retroperitoneal bleeding is an unusual complication of extracorporeal shockwave lithotripsy (ESWL), which can be treated in a conservative way most of the time. However, an intra-abdominal bleeding after ESWL is extremely rare, which can cause life-threatening situations and requires an immediate intervention. Probably, only patients with a certain tissue fragility or connective tissue disorder are at risk to develop such an intra-abdominal bleeding. We present a case of a serious intra-abdominal bleeding due to a rupture of the vena mesenterica superior in an Ehlers-Danlos patient, evoked by an ESWL.     

Aortic dissection late after aortic valve replacement

We experienced 3 cases of an aortic dissection occurring late after an aortic valve replacement, and sucessfully treated by an aortic root replacement. An aortic dissection involving the ascending aorta can develop late after an aortic valve replacement, and such an occurrence is associated with a high mortality and morbidity. The development of effective surgical strategies at the initial aortic valve surgery, strict control of blood pressure after aortic valve replacement, serial evaluations of aortic size, and the prophylactic replacement of the ascending aorta for patients with aortic dilatation after aortic valve replacement, all play clinically important roles in preventing an aortic dissection after aortic valve replacement. When an aortic dissection occurs in patients with a previous aortic valve replacement, an aortic root replacement should be performed in order to avoid leaving the fragile diseased aortic wall including the sinus of Valsalva.     

Endovascular repair of an abdominal aortic aneurysm in the presence of a hydronephrotic horseshoe kidney

The aim of this paper is to report an unusual case of a patient with an abdominal aortic aneurysm (AAA) and a hydronephrotic horseshoe kidney (HSK) that was repaired by endovascular means. An 81-year-old male patient with a known HSK was found to have hydronephrosis and an AAA. The patient's aneurysm was treated with an endovascular stent graft which required the covering of accessory renal arteries. He had an uneventful recovery with complete resolution of the hydronephrosis evident on a computed tomography scan performed seven months after the surgery. In conclusion, endovascular aneurysm repair is a feasible therapeutic option for an AAA coexisting with an HSK and may be considered as a valid alternative to open repair when concomitant hydronephrosis is present.     

Arachnoid cyst associated with pyloric stenosis in a young boy

An unusual association between an arachnoid cyst and a decompensated pyloric stenosis in a three years-old boy is presented. The little patient was admitted into hospital with haematemesis, melena, influenced generally condition and acute posthemorrhagic anaemia following aspirin intake for hypertermia. Specific intensive care was successful and the little patient was discharged but without an upper digestive endoscopy(parents refusal, technical reasons). After one week he returned with progressive worsening vomitings and an intracranial hypertension was suspected. CT documented an arachnoid cyst in the right middle cranial fossa and the patient is directed to the Neurosurgical Clinic where a cyst fenestration was done. Subsequent to operation the vomitings reinstaled with severe dehydration and an upper GI series showed a decompensated pyloric stenosis. He was operated on underwenting an antrectomy. Finally the child recovered with good short and long-term evolution. The coincidental presence of an intracranial congenital mass and a complicated aspirin-induced peptic ulcer in this young patient, misleaded us and in the lack of an early endoscopy an intempestive neurosurgical operation was initially done.     

Anesthesia in a child with newly diagnosed Hypertrophic Cardiomyopathy

We report the initial resuscitation and subsequent management of a child with newly diagnosed Hypertrophic Cardiomyopathy (HCM), which presented as an out of hospital cardiac arrest. HCM is an autosomal dominant condition that is uncommonly encountered in the pediatric setting and is an important cause of sudden death. Here, we describe the safe use of an anesthetic technique for insertion of an implantable cardioverter-defibrillator that ensured strict hemodynamic stability and modest bradycardia.     

Abdominal incisional hernia occurring after an esophagectomy reconstructed with a gastric tube through an antesternal route: Report of a case

A Japanese man, who had undergone a subtotal esophagectomy reconstructed with a gastric tube through an antesternal route for esophageal carcinoma 16 years previously, was admitted to our hospital because of an abdominal incisional hernia. The abdominal incisional hernia was in his upper abdomen and was difficult to push back into the intraabdominal cavity by hand. The hernia was successfully repaired by operation. We thus conclude that an abdominal incisional hernia is a rare but important late-phase complication occurring after an esophagectomy reconstructed with either an antesternal or retrosternal route, and an operation should be the treatment of choice.     

Femoral venous catheter: an unusual complication

We report an erratic course of a venous femoral catheter which was in the abdominal cavity in a patient with an haemoperitoneum and an hepatic injury. This complication led to an inefficiency of the transfusion and a worsening of the haemoperitoneum.     

Voiding dysfunction after abdominoplasty—an unusual complication

Abdominoplasty is an electively undertaken aesthetic operation mostly performed on patients after massive weight reduction. Previous case reports have demonstrated an improvement of incontinence symptoms after abdominoplasty. We report a case where urinary dysfunction occurred after refashioning of an abdominoplasty. The stress urinary incontinence got worse but what was of greater concern to her was a noticeable change of her urinary stream in an upward direction. A urethrolysis combined with an insertion of a tension-free vaginal tape and an anterior colporrhaphy was performed. After the operation, stress urinary incontinence improved and she reported that her urine stream reverted towards a normal direction.     

Perioperative Addisonian crisis

An Addisonian crisis marks an acute adrenocortical failure which can be caused by decompensation of a chronic insufficiency due to stress, an infarct or bleeding of the adrenal cortex and also abrupt termination of a long-term glucocorticoid medication. This article reports the case of a 25-year-old patient with Crohn's disease who suffered an Addisonian crisis with hypotension, hyponatriemia and hypoglycemia during an emergency laparotomy after he had terminated prednisolone medication on his own authority. This necessitated an aggressive volume therapy in addition to an initial therapy with 100 mg hydrocortisone, 8 g glucose and a continuous administration of catecholamines. Under this treatment regimen hemodynamic stabilization was achieved. Reduction of the administration of hydrocortisone after 3 days resulted in cardiovascular insufficiency which required an escalation of the hydrocortisone substitution.     

Colloid carcinoma arising in an anal fistula: case report with a brief review of the literature.

Malignant change in an anal fistula is an extremely rare but an important and dangerous complication. Less than 75 cases have been described in the English and Scandinavian literature. We now report a case of colloid carcinoma arising in an anal fistula because of its rarity and other interesting features.     

Türkischer Honig

Several differential diagnoses show signs and symptoms of an acute coronary syndrome – an uncommon one is an intoxication with pontic honey. In this case a male patient of Turkish origin had an accidental intoxication. He describes strongest chest pain; the ECG shows a bradyarrhythmia. After excluding an acute coronary syndrome the patient is monitored in the ICU and was treated symptomatically. Within 24 hours, all symptoms disappeared completely.