Multivisceral transplantation for diffuse portomesenteric thrombosis in a patient with life-threatening esophagogastroduodenal bleeding

Portal vein thrombosis is the most common cause of portal hypertension in noncirrhotic patients. Variceal bleeding is difficult to treat in these patients, especially those with prehepatic diffuse portal mesenteric thrombosis. In a patient with refractory esophagogastroduodenal variceal bleeding as a result of diffuse portomesenteric thrombosis and portal hypertension, life-threatening bleeding was unresponsive to endoscopic therapy and other surgical procedures. A multivisceral transplant was performed. It was curative and also lifesaving. There is only one report in the literature mentioning multivisceral transplantation for a patient with life-threatening esophagogastroduodenal bleeding; however that patient had protein C deficiency. Our patient had normal liver and intestinal function tests and no signs of hypercoagulable disease. We believe that multivisceral transplantation should be considered as a treatment option for patients with diffuse mesenteric thrombosis, even in the absence of liver and intestinal failure, when other treatment options for variceal bleeding have failed, particularly in a younger patient with a relatively good nutritional status before transplantation.     

Fenestrated endovascular grafting: The renal side of the story

BACKGROUND: Fenestrated endovascular aneurysm repair uses the visceral aortic segment, in the setting of a suboptimal proximal neck, for sealing and fixation. This technique requires the placement of visceral stents and might be hampered by the deleterious effects of such interventions. This study was performed to define outcomes related to renal events. MATERIALS AND METHODS: Consecutive clinical records and radiographic studies of patients treated primarily with an endovascular approach with a fenestrated endograft were reviewed. The population was divided into groups with and without baseline renal dysfunction based on the National Kidney Foundation definition of chronic kidney disease. Morphologic measurements and the detection of postoperative renal events such as renal artery stenosis or occlusion, need for dialysis, deterioration of renal function by using estimated glomerular filtration rate (GFR), and secondary interventions related to the renal arteries were assessed. Preoperative and postprocedural factors predictive for the development of renal dysfunction were assessed by using a Fisher exact test, t test, and logistic regression. RESULTS: A total of 72 patients were treated between 2001 and 2004 with a mean age, aneurysm size, and follow-up of 75 years, 6.2 cm, and 6 months (range, 1 to 24 months), respectively. No ruptures and five deaths (two procedure-related) were observed. There were 23 patients with baseline renal insufficiency and 49 patients without insufficiency. Twenty-four patients had deterioration in GFR >30% during the follow-up period, and 17 patients experienced 19 renal-related events (more common in patients with baseline insufficiency, 39% vs 16.3%; P = .04; relative risk, 2.4). Four patients required dialysis (two permanent), and all had preoperative renal dysfunction ( P = .002); similarly, death was also more common in this group (17.4% vs 2%; P = .02; relative risk, 8.52). Renal events in most patients occurred within the first postoperative month (59%). However, mean GFR stabilized after 6 months. CONCLUSION: Aneurysm repair with fenestrated endovascular grafts is associated with a significant risk for adverse renal events (16% in those without renal dysfunction, although none developed a creatinine >2 mg/dL, and 39% for patients with preoperative renal dysfunction). These patients must be meticulously followed, particularly within the first month after such a procedure. When renal artery restenosis is suspected or diagnosed, aggressive approach might be warranted to limit the extent of late renal dysfunction.     

Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results

PURPOSE: This prospective study was designed to assess the technical success and outcome after patients with thoracic aortic pathology at high risk for conventional therapy were treated with the Zenith TX1 and TX2 endovascular graft. METHODS: Between 2001 and 2004, patients at high risk for conventional surgical therapy presenting with chronic aortic dissections, thoracic aneurysms, or aortobronchial or aortoesophageal fistulas were treated with a single- or multiple-piece endovascular grafts. Surgical modification of proximal or distal fixation sites was performed when necessary to establish adequate regions for device landing zones. Follow-up studies included radiographic evaluation before discharge and at 1, 6, 12, and 24 months. Aortic morphologic characteristics were determined by using three-dimensional imaging studies and centerline of flow measurements. Statistical analyses were performed with Kaplan Meier analysis to assess survival, factors predictive of poor outcome, and morphologic changes, including sac shrinkage. RESULTS: A total of 100 patients (42% women) were treated, including 81 aneurysms, 15 aortic dissections (with aneurysms), 2 patients with fistulous connections (1 aortobronchial and 1 aortoesophageal), 1 subclavian artery aneurysm, and 1 aortic rupture. Mean follow-up and aneurysm size were 14 months and 62 mm, respectively. Most patients (55%) had undergone prior aortic aneurysm repair. Surgical modifications were required to create adequate implantation sites in 29% patients, including 14 elephant trunk/arch reconstructions, 18 carotid-subclavian bypasses, and 4 visceral vessel bypasses. Iliac conduits were required in 19 patients. Overall mortality was 17%, and aneurysm-related mortality was 14% at 1 year. Sac regression (>5 mm maximum diameter decrease) was observed in 52% and 56% at 12 and 24 months. Growth was noted in one patient (1.6%) at 12 months. Endoleaks were detected in eight patients (8.5%) at 30 days and three patients (6%) at 12 months. Secondary interventions were required in 15 patients. Migration (>10 mm) of the proximal or distal stent was noted in three patients (6%) (two proximal and one distal), none of which required treatment or resulted in an adverse event. CONCLUSIONS: Acceptable intermediate-term outcomes have been achieved in the treatment of high-risk patients in the setting of both favorable and challenging anatomic situations with these devices. The complexity of the patient population, in contrast to endovascular infrarenal repair, attests to the differences in the pathophysiology aortic disease in the anatomic beds.     

Disease Progression in the Contralateral Carotid Artery after Endarterectomy

Our objectives were to establish the incidence and progression of stenotic lesions in the contralateral carotid artery (CCA) after endarterectomy, to identify subpopulations of patients at risk of contralateral disease progression, and to evaluate the efficacy of duplex scanning surveillance at detecting these lesions. We performed a prospective study on 180 patients in whom the CCA to the operated artery was healthy or showed <70% stenosis. All patients had completed a clinical and hemodynamic follow-up program, including duplex scanning of both carotids, with sessions 3 and 6 months after surgery and then every semester until 2 years. Thereafter, examinations were scheduled according to the severity of stenosis. Mean follow-up time was 26.2 months (range 1.6-67.6). Disease progression was observed in 26 lesions (15%), nine of which (5.5%) progressed to severe stenosis (SS). Kaplan-Meier event-free rates of any disease progression were 89%, 88%, 82%, and 79% for 1, 2, 3, and 4 years, respectively. Event-free rates of progression to SS were 98%, 96%, 93%, and 90.6%, respectively, for 1, 2, 3, and 4 years. The risk of progression to SS was five times higher for stenoses that were moderate at the start of the study (p = 0.025). Severe contralateral stenoses were more common and appeared later during follow-up than ipsilateral restenoses. Progression of contralateral stenotic lesions is not uncommon and is essentially related to the presence of a moderate lesion at the start of follow-up. Indeed, moderate stenosis is a risk factor for progression to SS, which appears later and more frequently than ipsilateral restenosis. It therefore seems that patients with a moderate contralateral lesion would benefit from long-term duplex ultrasound surveillance.     

Changes of the extracellular matrix as a risk factor for anastomotic leakage after large bowel surgery

BACKGROUND: Despite improved surgical techniques, anastomotic leakage remains as a serious complication in colorectal surgery, producing increased morbidity and mortality. This prospective study was initiated to test the hypothesis that preexisting disorders in the extracellular matrix (ECM) may be a factor influencing the onset of anastomotic wound healing complications. METHODS: In this prospective study of 119 patients with colorectal anastomoses, 30 clinical parameters with possible influence on anastomotic complications were evaluated. From all patients, samples of macroscopically intact colonic tissue were obtained at the index operation. Crosspolarization microscopy was performed to analyze the collagen type I/III ratio, and immunohistochemical studies were done to determine the expression of matrix metalloproteinase (MMP) 1, 2, 9, and 13. The patients with uncomplicated postoperative healing were compared with those developing anastomotic leakage. RESULTS: Patients with impaired anastomotic healing exhibited a significantly lower collagen type I/III ratio compared with the controls. Significantly higher expression of MMP-1 and MMP-2 in the mucosal layers and of MMP-2 and MMP-9 in the submucosal layers was found in the normal bowel wall of the leakage group. These findings were statistically independent from the clinical parameters. CONCLUSION: The present study confirms the hypothesis that disturbances of the ECM play a role in the pathogenesis of anastomotic leakage after large bowel surgery.     

New concepts in feminizing genitoplasty--is the Fortunoff flap obsolete?

PURPOSE: We retrospectively evaluated the results of an original technique that combines mobilization of the urogenital sinus with the creation of urogenital flaps to enlarge the vaginal introitus for 1-stage feminizing genitoplasty in children with urogenital sinus anomalies, thus, avoiding the use of posteriorly based perineal flaps. MATERIALS AND METHODS: A total of 11 patients with urogenital sinus anomalies have undergone a modified Fortunoff technique combining total urogenital mobilization with the creation of urogenital sinus flaps by a single surgeon (RG) since 1998. Patient age at surgery ranged from 3 months to 13 years (mean 3.8 years). Diagnoses included congenital adrenal hyperplasia in 7 patients, cloacal malformation in 2 and urogenital sinus malformation in 2. Eight patients underwent a perineal approach and 3 underwent a posterior sagittal approach. RESULTS: Followup ranged from 3 months to 5 years (mean 2.5 years). The cosmetic appearance was considered superior to that achieved with previous techniques. The vagina had a more physiological position in all patients except 1, and no patient had development of vaginal stenosis. One patient had development of a mild mid urethral stricture that required a single dilation using anesthesia. In this patient cystourethroscopy performed 3 years later was normal. CONCLUSIONS: We believe that the redundant urogenital sinus tissue must not be discarded, but rather incorporated into the reconstruction of the posterior vaginal wall, thus, avoiding the use of perineal skin flaps. This modification allows placement of the vaginal opening in a more physiological position with a better cosmetic appearance than previous techniques.