RESUMEN
INTRODUCTION: Often groin recurrences after varicose vein surgery are diagnosed and classified with the help of a duplex ultrasound scan. There are, however, no studies indicating if duplex ultrasound scans can reliably distinguish between the different forms of recurrent vessels, ie, neovascularization or a residual stump. To address this issue, we have conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins. MATERIALS AND METHODS: All patients undergoing redo-surgery for symptomatic groin recurrences after previous stripping of the greater saphenous vein (GSV) during a 1-year period (May 2006-May 2007) were included in the study. Preoperatively, all patients had a duplex-ultrasound scan examination of the groin vessels. Based on the duplex scan findings, the recurrent veins in the groin were classified as either a residual stump or neovascularization. During the redo-surgery, a specimen of the recurrent groin veins was obtained and underwent histologic evaluation. Based on histologic criteria, the recurrence was also classified as a residual stump or neovascularization. RESULTS: During the 1-year study period, 125 groin recurrences in 95 consecutive patients (74 female, 21 male, mean age 58.7 years, standard deviation [SD] 10.3 years) were included. In the 119 cases where both duplex-ultrasound scan and histological evaluation were available, a residual stump was seen at the histological examination in 80.7% of cases, a neovascularization in 10.9% of cases, and a combination of both entities in 8.4% of cases. Duplex-ultrasound scan classified the recurrent groin veins as a residual stump in 68.1% of cases, as neovascularization in 26.1%, and as a combination of both in 5.8% of cases. With histological classification as the gold-standard, duplex ultrasound scans reached a sensitivity of 77.1% and a positive predictive value of 91.4% in correctly identifying a residual stump as the cause of recurrence. For the correct classification of neovascularization, sensitivity was 61.5% and the positive predictive value 25.8%, while a combination of both was recognized with a sensitivity of 10% and a positive predictive value of 14.3%. CONCLUSION: While duplex-ultrasound scan is a reliable tool to diagnose groin recurrences after varicose vein surgery, its validity in classifying the different types of recurrent groin vessels is limited. Especially the correct identification of neovascularization which is poor with a sensitivity of 62% and a positive predictive value of 26%. Histological examination should still be regarded as the gold-standard when trying to differentiate between different types of groin recurrences.
Asunto(s)
Ingle/irrigación sanguínea , Neovascularización Patológica/diagnóstico por imagen , Vena Safena/diagnóstico por imagen , Vena Safena/cirugía , Ultrasonografía Doppler en Color , Várices/diagnóstico por imagen , Várices/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Recurrencia , Reoperación , Reproducibilidad de los Resultados , Vena Safena/patología , Sensibilidad y Especificidad , Resultado del Tratamiento , Várices/patologíaRESUMEN
BACKGROUND: We investigated exocrine pancreatic insufficiency in severely traumatised patients with enteral nutrition using the fecal elastase-1 concentration. METHODS: The fecal elastase-1 levels of critically ill patients after major trauma (n=18) were determined in a prospective study. Early enteral nutrition was started with a high molecular diet via a naso-duodenal tube, starting 24-36 hours after admission to the intensive care unit. Enteral feeding was administered continuously starting with 20 mL/h (1 kcal/mL) and advanced gradually to 80 mL/h in the next days. Stool samples from the first and second stool after beginning of the enteral nutrition were taken for determination of the fecal elastase-1. For elastase-1 analysis in a sandwich-type enzyme immunoassay (ELISA), a sample of approximately 1 g stool was taken from the first and second stool after beginning of the enteral nutrition. Elastase-1 concentration of >200 microg/g was considered as normal, whereas <100 microg/g elastase-1 was significantly low indicating a severe exocrine pancreas dysfunction. RESULTS: All patients were fed enterally without relevant feeding-associated complications and no diarrhoea occurred in any patient. In the initial stool passage, 55.6% of the patients had moderately or severely decreased elastase-1 concentrations. In the second stool passage, only 38.9% of the patients showed a decrease in the elastase-1 concentration (p<0.01). The average elastase-concentration in the first stool sample was 268.4 microg/g (median: 162.1 microg/g) and in the second sample 333.8 microg/g (median: 520.2 microg/g). CONCLUSION: The data of this study suggests that initial exocrine pancreas insufficiency may occur in severely traumatised and critically ill patients, which improves under early enteral nutrition with polymeric enteral diets. The clinical consequences of exocrine pancreatic dysfunction in the early posttraumatic situation have to be defined.
Asunto(s)
Nutrición Enteral , Insuficiencia Pancreática Exocrina/diagnóstico , Páncreas Exocrino/enzimología , Elastasa Pancreática/análisis , Heridas y Lesiones , APACHE , Adulto , Cuidados Críticos , Enfermedad Crítica , Ensayo de Inmunoadsorción Enzimática , Insuficiencia Pancreática Exocrina/enzimología , Heces/química , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Pruebas de Función Pancreática , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
We discuss a case of contained ruptured aortitis due to Clostridium septicum infection in a 71-year-old man, who had undergone a right hemicolectomy and cholecystectomy to treat an ascending colon carcinoma. Computed tomography identified a juxtarenal abdominal aneurysm with gas formation in the right psoas muscle. Emergency abdominal exploration revealed a ruptured aortitis. After in situ graft replacement of the abdominal aorta, Clostridium septicum was identified in tissue culture. Antibiotic therapy with penicillin G was administered. The postoperative course was complicated by a retroperitoneal haematoma which necessitated surgical revision. The patient was discharged 2 months afterwards. At clinical monitoring at 6 months he is still doing well.
Asunto(s)
Aortitis/microbiología , Aortitis/cirugía , Infecciones por Clostridium/complicaciones , Clostridium septicum , Neoplasias del Colon/complicaciones , Neoplasias del Colon/cirugía , Gangrena Gaseosa/complicaciones , Anciano , Antibacterianos/uso terapéutico , Aortitis/complicaciones , Aortitis/diagnóstico por imagen , Infecciones por Clostridium/cirugía , Clostridium septicum/aislamiento & purificación , Neoplasias del Colon/diagnóstico por imagen , Gangrena Gaseosa/cirugía , Hematoma/etiología , Hematoma/cirugía , Humanos , Masculino , Penicilina G/uso terapéutico , Reoperación , Espacio Retroperitoneal , Rotura Espontánea/diagnóstico por imagen , Rotura Espontánea/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Three cases of cystic adventitial disease (CDA) of the popliteal artery and the results of a literature review are described in order to identify the treatment of first choice of this rare clinical entity. Three male patients (mean age 56,3 years) presented at our Institution due to a sudden abrupt of disabling claudication of the lower limb. The eco-color-Doppler examination showed multiple hypoechoic and anechoic masses arising in the wall of the artery consistent with CAD. The magnetic resonance imaging (MRI) confirmed this finding. In 2 cases a venous interposition grafting was performed and in the remaining patient a duplex-directed punction. The 3 patients are asymptomatic at the clinical control at 9 months after treatment. As it results after a literature review, the MRI seems to be the best diagnostic tool and the vein interposition grafting the treatment of first choice. In cases of young male patients without cardiovascular risk factors and suffering of disabling claudication of recent onset the MRI guarantees a valuable diagnosis in case of ultrasonographic suspect of CAD of the popliteal artery. The surgical resection and the vein interposition grafting represent the treatment of first choice. In selected patients, a duplex-guided punction assures satisfactory clinical results. A strict ultrasonographic follow-up guarantees an early recognition of relapse.
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Quistes/diagnóstico , Quistes/cirugía , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/cirugía , Arteria Poplítea , Quistes/complicaciones , Humanos , Claudicación Intermitente/etiología , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/complicaciones , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/patología , Arteria Poplítea/cirugía , Vena Safena/trasplante , Resultado del Tratamiento , Ultrasonografía Doppler en ColorRESUMEN
The aim of the study was to determine the effect of comorbidity conditions on the early outcome and complication rates of thrombolytic treatment of lower limb ischaemia with recombinant tissue plasminogen activator (rt-PA). Clinical and procedural data of 82 patients treated for acute/subacute arterial/graft occlusion were analysed retrospectively. Early results and adverse events were recorded and evaluated statistically. Early resolution of ischemic symptoms was achieved in 67 (82%) patients with a median dose of 25.4 mg of rt-PA. Major bleeding was reported in 9 and minor bleeding in 6 cases (intracranial hemorrhage rate 1%, mortality rate 1%, major amputation rate 1%). Comorbidity conditions and patient characteristics did not statistically influence success and complication rates. Bleeding was observed in patients who received a higher dose of the thrombolytic agent (30.0 mg vs 24.3 mg). Comorbidity conditions have no effect on early outcome and adverse events after thrombolytic management of lower limb ischemia. Higher doses of rt-PA with prolonged infusion times increase the risk of occurrence of treatment-related bleeding.
Asunto(s)
Fibrinolíticos/uso terapéutico , Isquemia/tratamiento farmacológico , Extremidad Inferior/irrigación sanguínea , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoRESUMEN
The aim of the study was to define mortality and limb loss rates and to identify factors predictive of early clinical success in the management of infected vascular grafts. Clinical data of 40 patients were reviewed, evaluating comorbidity factors, laboratory findings, ischaemic symptoms, graft material and time of onset of infections. Diabetes and chronic renal insufficiency were reported in 15% of cases, malignancy in 10%, pathological C-reactive protein in 77.5% and leukocytosis in 60%. 52.5% of the patients presented with a disabling claudication, and 77.5% with an infected alloplastic graft. Early infection had developed in 57.5%. A total graft excision was performed in 72.5% of cases. Early complications were recorded in 32.5% of the patients, with a limb loss rate of 22.5% and a mortality rate of 10%. Total graft excision is the treatment of first choice in patients with an infected vascular graft. Patients presenting with critical ischaemia and early septic complications will experience poor clinical results in terms of limb loss and mortality. Pathological blood levels of C-reactive protein could help in the choice of treatment in unclear cases.