Serious lower extremity venous injury management with ligation: prospective overview of 63 patients

Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0-3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n=18 superficial, n=1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.     

The effects of different hernia repair methods on postoperative pain medication and CRP levels

Although tension-free techniques of hernia repair using synthetic meshes have yielded encouraging results, the best method of inguinal hernia repair is still unclear. The aim of this study was to compare the responses of inflammatory mediators and postoperative pain relief following laparoscopic total extraperitoneal (TEP) hernioplasty, open tension-free mesh hernioplasty (Lichtenstein), posterior preperitoneal mesh hernioplasty (Nyhus procedure), and Bassini procedure. Patients with primary inguinal hernia were randomized in the operating room to undergo one of these repair techniques. Group I comprised 24 patients treated by Lichtenstein procedure; Group II comprised 21 patients treated by Nyhus procedure; Group III comprised 19 patients treated by Bassini procedure; and Group IV comprised 20 patients treated by laparoscopic TEP mesh hernioplasty. Postoperative pain levels following hernia repair were compared by measuring the use of patient-controlled analgesia (PCA) during the 24 hours after surgery. Serum samples withdrawn before surgery and 48 hours after surgery were assayed for C-reactive protein (CRP) content. Patient characteristics, operating time, and operative and early complications were noted. Serum CRP levels rose markedly following Nyhus (184.5 +/- 41.6 mg/L), Lichtenstein (138.4 +/- 72.5 mg/L), and Bassini repair (137.2 +/- 55.9 mg/L) compared with that of patients who underwent TEP mesh hernioplasty (55.5 +/- 41.2 mg/L). There were also significant differences in the postoperative need for analgesics via PCA among patients undergoing Nyhus (382.9 +/- 189.1 mg), Bassini (303.2 +/- 173.7 mg), and Lichtenstein (253.9 +/- 129.3) procedures compared with 196.6 +/- 148.8 mg for the TEP mesh hernioplasty group. Patients in the Lichtenstein group also had significantly less need of analgesics than those in the Nyhus and Bassini groups. In conclusion, TEP mesh hernioplasty is less traumatic and yields less postoperative pain than the Nyhus, Lichtenstein, and Bassini procedures.     

Laparoscopic versus open resection of colorectal liver metastasis

Background

Findings have shown laparoscopic liver resection (LLR) to be feasible and safe, but the data in the literature regarding oncologic outcomes are scant. This study aimed to compare the perioperative and short-term oncologic outcomes between LLR and open resection of colorectal liver metastasis (CLM).

Methods

Between January 2006 and April 2012, 40 patients underwent LLR of CLM. These patients were compared with a consecutive matched group of 40 patients who underwent open resection within the same period. Data were obtained from a prospective institutional review board (IRB)-approved database. Statistical analysis was performed using t test, Chi-square, and Kaplan–Meier survival.

Results

The groups were similar in terms of age, gender, tumor size, number of tumors, and type of resections performed. The operative time was similar in the two groups, but the estimated blood loss was less in the LLR group than in the open resection group. The length of stay was shorter in the LLR group (3.7 vs 6.5 days; p < 0.001). The 2-year overall survival rate was 89 % for LLR and 81 % for open resection. The median disease-free survival time was 23 months in each group.

Conclusions

The findings suggest that LLR is associated with less blood loss and a shorter hospital stay than open resection for CLM. According to our short-term results, LLR is equivalent to open resection in terms of oncologic outcomes.     

Duodenal Ulcer Perforation and Pneumothorax: a Case Report

Pneumothorax and pneumomediastinum are rarely observed as a complication of perforated peptic ulcer, which is a common cause of acute abdomen. We report a case of a 30-year-old male patient with abdominal pain and respiratory distress. Resulting from physical examination and laboratory data of the patient, acute abdomen and pneumothorax were diagnosed simultaneously. Laparotomy revealed duodenal ulcer perforation and a simple patch closure was performed. No complications were observed during the postoperative course of the patient.     

Vascular reconstruction in Buerger's disease: is it feasible?

Purpose: Thromboangiitis obliterans (Buerger's disease) is a clinical syndrome characterized by segmental occlusions of the distal vessels. Although a cessation of using nicotine products usually helps, nevertheless a surgical revascularization may be needed in cases of stage III and IV limbs. Because of the distal and segmental nature of the disease, these procedures are rarely feasible. This article focuses on the feasibility of performing a vascular reconstruction in thromboangiitis obliterans. Methods: Thirty-six of 94 patients (38.3%) who were followed by the Peripheral Vascular Unit of Istanbul Medical Faculty were selected for revascularization and 27 of 36 (81%) patients underwent revascularization procedures. Results: During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively. The limb salvage rate was 92.5%. Conclusions: Since patients affected by Buerger's disease consist a group of young population who are still in their productive stages, every effort should be taken to obtain a limb salvage in the ischemic period. Although the patency rates do not seem promising, the limb salvation rate was quite satisfactory. Received: October 29, 2001 / Accepted: July 2, 2002 Reprint requests to: Ş. Dilege     

The effects of one- and two-stage orchiopexy on postoperative serum testosterone levels and testicular volume in adult patients with bilateral nonpalpable testes

In this study, we investigated the effects of one- and two-staged orchiopexy on testicular volume and serum testosterone levels in cases with high, abdominally localized, bilateral nonpalpable testes. Between March 1996 and April 2001, orchiopexy was performed on 46 testes in 23 patients with bilateral nonpalpable testes. In 15 of the 23 patients, a two-stage Fowler-Stephens orchiopexy was performed, and in 8 of the 23 patients, a one-stage laparoscopic orchiopexy was performed. For one patient who lacked both testes, bilateral prosthetic testes were inserted. The patients' ages were between 20 and 23 years (average, 21 years). In the first stage of the two-stage orchiopexy, the spermatic artery was ligated laparoscopically. Six months later, open surgery orchiopexy was performed. Patients were followed for 2 to 16 months (average, 10 months) and were evaluated for testicular atrophy, serum testosterone levels, and complications. In all the patients, the preoperative secondary sexual characteristics and serum testosterone levels were normal. Among the postoperative controls, evaluated at months 3 and 6, one patient's testes were found at the pubic area. Testicular atrophy was not observed in any of the patients, and the serum testosterone levels were in the normal range. In the two-stage orchiopexy group, 5 (33%) of the 15 patients had an average 30% volume decrease, and in the one-stage group, 2 (25%) of the 8 patients had an average 40% volume decrease. In this study, it was shown that either two-stage Fowler-Stephens orchiopexy or laparoscopic orchiopexy can be successfully performed in patients with bilateral abdominal testes, and that the testes can be fixed to their palpable original positions without interfering with the secretion of testosterone. Although the results are similar, our experience suggests that single-stage laparoscopic orchiopexy is the preferable method.     

Effects of ACE inhibition and angiotensin II receptor blockade on glomerular basement membrane protein excretion and charge selectivity in type 2 diabetic patients.

Angiotensin-converting enzyme (ACE) inhibitors may reduce urinary albumin excretion (UAE) by decreasing glomerular pressure and increasing glomerular charge selectivity through preservation of glycosaminoglycans. The effect of Angiotensin II antagonism on glomerular charge selectivity remains to be determined. The aim of this study was to compare the effects of an AT1 blocker losartan and an ACE inhibitor (ACE-I) enalapril on UAE, extracellular matrix proteins, glycosaminoglycan excretion (UGAG) and red blood cell anionic charge (RBCCh) which are the indirect markers of glomerular basement membrane anionic content in hypertensive Type 2 diabetic patients. Twenty-four patients were randomised into two groups and received either enalapril (520 mg/d) or losartan (50100 mg/d). All parameters were measured at baseline and after six months of treatment. At the end of six months, systolic and diastolic blood pressures (BP), UAE rates, UGAG excretion and RBCCh were significantly and equally reduced in both treatment groups compared with baseline. RBCCh was negatively correlated with UAE (r=-0.57, p<0.0001) and UGAG excretion (r=-0.57, p<0.0001); UAE was correlated with UGAG excretion (r=0.58, p<0.0001). In conclusion, enalapril and losartan treatment were equally effective in reducing BP, UAE as well as UGAG excretion and preserving RBCCh in hypertensive Type 2 diabetic patients. ACE inhibition and AT1-receptor blockade may have favourable effects on preserving glomerular anionic content in hypertensive diabetic patients.     

Association of intracerebral venous angioma and true arteriovenous malformation: a rare, distinct entity

We report a mixed cerebrovascular malformation in which a true arteriovenous malformation drained into associated venous angiomas. We describe the MRI and angiographic appearances and review the literature on mixed vascular malformations.     

Congenital generalized infantile myofibromatosis and neonatal hemochromatosis. An autopsy case report

An autopsy case of congenital infantile myofibromatosis and neonatal hemochromatosis is reported. A thirty-six-hour-old baby girl had multiple subcutaneous nodules in addition to multiple visceral involvement of heart, lungs, pharynx, larynx, stomach, small bowel, large bowel, pancreas, kidneys, spleen, thyroid, adrenal glands, lymph nodes, peripheral nerves, meninges and soft tissues. In these tumoral nodules, three types of histological patterns were observed: 1-hemangiopericytoma-like, 2-mixed, and 3-pure spindle cell. Tumor cells were immunohistochemically positive for actin, and negative for desmin, muscle-specific antigen, and estrogen, related protein. The histological and immunohistochemical findings of the case suggested that a close relationship may exist between infantile myofibromatosis and infantile hemangiopericytoma. In addition to infantile myofibromatosis, neonatal hemochromatosis characterized by iron deposition in parenchymatous organs such as liver, pancreas, lungs, thyroid, and adrenal glands was another important characteristic of the case.