Surgical treatment of lower limb ischemia in diabetic patients – long-term results

Introduction

Lower limb ischemia may cause nonhealing ulcers, infection, amputation and even mortality in diabetic patients. In this study, we review our data of ischemic lower limb revascularization procedures in diabetic patients and present the early, mid- and long-term results.

Material and methods

From March 2004 to September 2008, 83 patients with lower limb ischemia in Fontaine class III and IV underwent distal arterial bypass procedures. Saphenous vein grafts were used for below-knee arterial bypasses in all patients. In 16 (19%) patients femoropopliteal bypasses were performed with PTFE grafts. Short-term and long-term surgical results were evaluated.

Results

Ulcer recovery was determined in 36% of patients. Graft patency was 95% and 1 death (1%) occurred in short-term follow-up. In long-term follow-up the total effectiveness rate was 74%. Graft patency was 79% and 6 deaths (7%) occurred during the follow-up.

Conclusions

Lower limb ischemia is a serious event in patients with diabetes mellitus. The consequences may include increased mortality and morbidity in this particular patient population. However, distal arterial revascularizations are considerably effective procedures to avoid amputation, to eliminate symptoms, to promote ulcer recovery and to help the patient participate in social life with acceptable short, mid- and long-term follow-up results.     

Unexpectedly ease surgery for a worrisome abdominal mass: Pedunculated GISTs

INTRODUCTIONDiscovery of abdominal masses often poses significant diagnostic difficulties. GISTs are mesenchymal masses, with specific histological features. Dimensions may vary from millimeters to giant tumours. We would like to present our case, which had an unexpectedly easy operative course which was easily handled with a simple surgical excision with a short operative duration.PRESENTATION OF CASEA 38 years old female patient was diagnosed to have an abdominal heterogen mass of 15 cm × 12 cm × 10 cm in dimension. Abdominal computed tomography revealed the solid mass between the stomach and pancreas corpus and tail, possibly orginating from the pancreas. With the preoperative diagnosis of locally invasive distal pancreas cancer the patient underwent laparotomy, following the dissection, the mass was observed to be originating from the posterior gastric Wall, extending exophytically with a peduncle of 5 cm in width, without any visual evidence for peritoneal invasion and metastasis. The tumour and the peduncle was resected with stapler device. Total operation time was 30 min. Postoperative course was uneventful. Pathologic diagnosis was gastrointestinal stromal tumour (GIST).DISCUSSIONPedunculated large GISTs are not frequent and they can enlarge as 15 cm in diameter and compress the neighbouring organs. When they were huge, it is difficult to differentiate the origin of the masses. GISTs should be considered in differential diagnosis of giant abdominal masses.CONCLUSIONWhen GISTs are huge and pedunculated, it can be difficult to differentiate the origin of the masses. This case report presents unexpectedly ease surgery for a worrysome abdominal mass.     

Effect of mucosal immunomodulation with fed cholera toxin on healing of experimental colonic anastomosis

PURPOSE: The aim of this study was to investigate in rats whether preoperative orogastric administration of low doses of cholera toxin would influence the mechanical strength of experimental colonic anastomosis on the basis of the gut mucosal immunomodulation effect of this antigen. METHODS: The cholera toxin group (n = 14) was fed 10 g of cholera toxin in phosphate-buffered saline three times before surgery at 10-day intervals, whereas the controls (n = 14) received phosphate-buffered saline only. Twenty-four hours after the last dose of cholera toxin (or placebo in control group), the animals underwent left colonic transection and anastomosis. Seven days after colonic transection-anastomosis, the bursting pressure of the anastomotic segment was recorded in situ. Perianastomotic and extra-anastomotic tissue samples were obtained for measurements of tissue transforming growth factor-beta, interleukin-6, and interferon-gamma levels with enzyme-linked immunosorbent assay. RESULTS: Cholera toxin administration resulted in a significantly higher bursting pressure than in the control group (165.78 ± 12.37 vs. 138.4 ± 7.87 mmHg; P < 0.001). Compared with the control group, the heightened mechanical strength of colonic anastomosis provided by cholera toxin was associated with significant increases in the perianastomotic tissue levels of transforming growth factor-beta (199.34 ± 24.85 vs. 70.66 ± 10.63 pg/ml; P < 0.001) and interleukin-6 (439.31 ± 95.14 vs. 289.57 ± 96.59 pg/ml; P = 0.001), whereas interferon-gamma was significantly lower (174.04 ± 44.82 vs. 219.00 ± 31.35 pg/ml; P < 0.05). This cytokine pattern induced by cholera toxin in the wound milieu was also found to be similar in the extra-anastomotic colon. CONCLUSION: The mechanical strength of uncomplicated experimental colonic anastomosis increased significantly with gut mucosal immunomodulation with repeated low preoperative doses of cholera toxin. This enhanced healing had significant positive correlation with the colonic tissue level of transforming growth factor-beta and inverse correlation with interferon-gamma. If the relevant dose regimen is identified and its safety is assured in humans, gut mucosal immunomodulation might provide an efficient, safe, and inexpensive tool to improve surgical outcome in colorectal surgery, particularly in high-risk situations.     

Gluteal region morphology: the effect of the weight gain and aging

The gluteal region is an important secondary sexual character itself and it has its place in the concept of the beauty in all communities. Interestingly, as far as we know, there is not any previous study addressing gluteal region morphology in an objective way in the aesthetic surgery literature. The aim of this study was to define the changes of the gluteal region morphology with aging and weight gain. Beside body weight, a total of five distances between predetermined anatomic points in gluteal region were measured on randomly selected 115 female volunteers, with their age ranging from 17 to 48 years (mean 22.7). All the records were analyzed by a correlation matrix using computer-based SPSS 7.5 program. As women grow older, the width of the gluteal region decreases and the gluteal sulcus elongates laterally and inferiorly. Contrary to aging, with weight gain the gluteal region becomes wider as the gluteal sulcus gets shorter. Although the subject does not sound new, our study is the first, documenting the changes in morphology of the gluteal region in relation to weight gain and aging in an objective way.     

The effect of temporary hemiepiphyseal stapling on the growth plate: a radiologic and immunohistochemical study in rabbits

The purpose of this study was to investigate the effect of temporary hemiepiphyseal stapling on the bone geometry and proliferative activity of the physis in immature rabbits. Proximal medial epiphyseal stapling of the right tibia was performed in 46 6-week-old New Zealand white rabbits. The rabbits were assigned randomly into two groups. In group 1, the staples were inserted extraperiosteally and the rabbits were killed at the end of 3 weeks. In group 2, the staples were fixed subperiosteally (group IIA) or extraperiosteally (group IIB), the staples were removed at the end of 3 weeks, and the rabbits were killed at the end of 6 weeks. The articular line-diaphysis angle (ALDA) was significantly increased with 3 weeks of stapling. After the removal of staples, while ALDA continued to worsen in group IIA, it improved in group IIB. Bone was observed to bridge the physis in group IIA. However, the proliferative activity of the physis continued. Temporary hemiepiphyseal stapling is a safe and effective method for control of physeal growth of long bones before skeletal maturity. However, it is of paramount importance not to disturb the periosteum during stapling.     

Radiological outcome of proximal femoral varus osteotomy for the treatment of lateral pillar group-C Legg-Calvé-Perthes disease

Results from 26 hips of 24 Legg-Calvé-Perthes disease patients were evaluated retrospectively. There were 22 male and two female patients in the study group. The mean age of the patients was 8.3 years and the mean follow-up was 13.03 years. All the patients were older than 6 years of age and all of them had lateral pillar group C hips. The patients were treated with intertrochanteric uniplanar varus osteotomy. All the patients were mature at the time of the last evaluation. Radiological end results were evaluated according to Stulberg's classification. Six hips healed with spherical congruency (Stulberg class 1 or 2), 19 with aspherical congruency (Stulberg class 3 or 4) and one with aspherical incongruency (Stulberg class 5). Six of 14 hips treated before 9 years of age healed with spherical congruency but all hips treated after 9 years of age healed with Stulberg class 3, 4 or 5 results. Trochanteric overgrowth was evident in 20 hips. The results of this radiological outcome study showed that Herring class C hips treated with proximal femoral varus osteotomy had a poor outcome, especially after 9 years of age in this group of patients.     

Traumatic Injuries to the Subclavian and Axillary Arteries: A 13-Year Review

Purpose By reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.Methods We retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.Results Arterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.Conclusion Successful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.This work was presented at the 5th European Congress of Trauma and Emergency Surgery. October 1–5, 2002 in Istanbul, Turkey