Successful treatment of massive thrombosis of the vena cava inferior with nephrotic syndrome and chronic bilateral pulmonary artery thromboembolism in a patient with genetic thrombophilia

A case is reported of a 23-year-old male patient who developed, after severe blunt injury of the lumbar region, massive thrombosis of the vena cava inferior (VCI), both renal veins, bilateral pulmonary artery thromboembolism (PATE), nephrotic syndrome (NS). In spite of anticoagulant therapy, the condition of the patient progressively aggravated for 1.5 year: thrombosis involved the ileac and femoral arteries on the right, thrombus floated in the right atrium with PATE recurrent episodes, pulmonary hypertension reached 120 mm Hg with formation of decompensated cor pulmnonale, proteinuria and hypoalbuminemia deteriorated, anasarca edema developed Multigenic thrombophilia was diagnosed (1 homozygous and 5 heterozygous mutations). A radical one-stage operation was successful: thromboectomy from the VCI, right ileac and left renal veins, thrombendarterectomy from the pulmonary arteries, suture of the interatrial septum defect, installation of cava-filter After the operation pulmonary pressure lowered to 40-45 mm Hg, right heart volume normalized, immunosuppressive therapy with prednisolone and cyclosporine led to nephropathy remission. The discussion covers mechanisms and factors (including genetic) of thrombosis progression, correlations between intravascular thrombosis, NS and chronic glomerulonephritis (possible NS development due to bilateral thrombosis of the renal veins and nephropathy role in thrombosis progression), approaches to conservative and surgical treatment of such patients. Global experience in conduction of pulmonary thrombendarterectomy and thrombectomy from VCI is reviewed (one-stage operations were not described earlier).     

Surgical treatment of major duodenal papilla neoplasm

Immediate and long-term results of pancreatoduodenal resections in 33 patients undergone surgery for adenocarcinoma of bile papilla from 1984 to 2003 were studied. Majority of patients had II and III stages of diseases. Correct diagnosis before surgery was made in 27 (81.8%) patients. Morphologic study revealed metastasis in 11 patients. Lethality was 9.1%, moreover last 18 pancreatoduodenal resections had no lethal outcomes. Long-term results were studied in 25 (83.3%) patients: 1-year survival was 90.4%, 3, 5 and 10 years survived 71.4, 61.2 and 51% patients respectively. Only metastatic lesion of lymph nodes and later stage of disease had negative influence on long-term results. Such factors as gender, diameter of carcinoma, lymphadenectomy and pylorus-saving variant of surgery did not influence on long-term results. It is concluded that pancreatoduodenal resection must be surgery of choice in the treatment of resected cancer of bile papilla.     

Problems of hemostasis and hermetic properties in liver resections with application of fibrin-collagen substance

Forty-seven patients with various diseases of the liver were treated from 1992 to 2002. Patients had undergone liver resections of different scope. In 20 patients (study group) wound covering "Tachokomb" was used for final hemostasis and high hermetic properties of wound surface. Conventional suturing of the vessels and bile ducts was performed in 27 patients of the control group. Reliable hemostasis of the hepatic stump after anatomic resection was achieved in all the patients of the study group. Application of wound covering decreased time of final hemostasis, severity of hemorrhage and blood transfusion during surgery. Biliary complications after surgery were seen more often. Application of combined glue composition failed to reduce significantly rate of biliary complications after surgery, their rate increased proportionally to extension of liver resection.