[Treatment of traumatic false aneurysm of the thoracic aorta with stent graft].

UNLABELLED: The treatment of traumatic false aneurysm of the thoracic aorta by endovascular stent graft may have advantages over conventional surgery. This is a case study of two women suffering from false aneurysm of the thoracic aorta caused in one by a knife injury and in the other by a car accident. After the patients became hemodynamically stable, a commercially available endothelial stent graft (Talent, Gor) was deployed. Recovery was rapid in the first patient. The second patient required emergency laparotomy for venous bleeding one day after stent placement; she died two weeks later, mainly from organ failure. CONCLUSIONS: Endovascular techniques can be used in selected cases to treat thoracic false aneurysms thereby avoiding the complexity and morbidity of conventional surgery.

[Surgery of the carotid body tumors].

Carotid body tumor is a rare tumor of obscure origin, usually benign, and commonly present as a non-painful cervical mass. Resection is the treatment of choice. When the tumor is very adherent to the carotid artery, it may be necessary to also resect the artery and to reconstruct the arterial continuity using a saphenous or synthetic interposition graft. The most common complication of surgery is damage to the cranial nerves in the vicinity of the artery. We present 8 patients with carotid body tumor who underwent surgery in our department in 1996-1999. Two had a large tumor penetrating the intima which mandated resection of the involved carotid artery and a saphenous interposition graft reconstruction. Our experience with resection of carotid body tumors is detailed, with emphasis on precautions taken to prevent damage to the adjacent cranial nerves.

Saphenous vein harvesting for coronary artery bypass grafting. Retrospective analysis of possible causes of major wound complications in patients with peripheral arterial disease.

OBJECTIVES: to retrospectively evaluate the possible reasons for major wound complications at the saphenous vein harvesting site in patients with peripheral arterial disease (PAD). DESIGN: retrospective study. MATERIALS AND METHOD: fifteen consecutive patients admitted to the vascular department for impaired healing at the saphenous vein harvesting site after successful coronary bypass artery grafting (CABG) (Group A) were evaluated for medical, perioperative, laboratory and pathological factors and outcome. Findings were compared with those in 15 matched controls followed in the outpatient clinic after CABG (Group B). RESULTS: absence of pedal pulses in the affected leg was noted in 13 patients in group A and 3 patients in group B. Ankle brachial index ranged from 0.4--0.7 in group A and 1.7--1.1 in group B; corresponding ankle pressures were 40--100 mmHg (mean 60 mmHg) and 80--160 mmHg (mean 110 mmHg). All patients in group A had PAD, whereas none did in group B, and all patients in group A required intervention to save the leg. Wound healing was noted in 11 group A patients; four patients underwent below-knee amputation. CONCLUSION: saphenous vein harvesting from limbs with severe PAD can lead to significant morbidity, including limb loss. In patients lacking a palpable pedal pulse, we recommend harvesting only the proximal saphenous vein.

Experimental acute necrotising pancreatitis: evaluation and characterisation of a model of intraparenchymal injection of sodium taurocholate in rats.

OBJECTIVES: To evaluate a simple model that produces progressive dose dependent pancreatitis, by intraparenchymal injection of sodium taurocholate. DESIGN: Open laboratory study. SETTING: Teaching hospital, Israel. MATERIALS: Forty eight Wistar rats. INTERVENTIONS: Sodium taurocholate was injected, 0.3 ml/100 g body weight, in concentrations of 5% and 10% into the pancreatic parenchyma of 32 Wistar rats, resulting in two distinct groups of severity. In 16 sham controls, saline was injected into the pancreas in similar fashion. Blood samples were withdrawn before, and 6, 24, 48, and 72 hours after induction of pancreatitis. RESULTS: Six hours after taurocholate injection, there was a sharp increase in the plasma activities of amylase, lipase, and lactate dehydrogenase (LDH). After 24 hours plasma activities of amylase and lipase decreased to near normal values while LDH remained slightly increased for 48 hours and decreased only after 72 hours. At 6 hours after the injection, interleukin-6 (IL-6) concentrations had increased slightly in the 5% group and decreased to the baseline values at 24 hours. In the 10% group, the increase in IL-6 values was significantly greater than in the 5% group (p = 0.04), and correlated well with severity of pancreatitis as defined by histology (p = 0.01) and mortality (p = 0.037). Twenty four hours after injection of taurocholate, morphological changes comprising diffuse necrosis of the pancreas, fat necrosis, and intestinal dilatation secondary to paralytic ileus were severe. Histopathological examination of the pancreas showed good correlation with the clinical findings and with mortality. No morphological changes were detected when saline was injected into the pancreas (sham control), and only mild rises of IL-6, lipase, amylase, and LDH activities were seen at 6 hours after injection. The mortality, after 10 days, was 80% in the 10% taurocholate group, 30% in the 5% taurocholate group, and 0 in the sham control group (p < 0.05). CONCLUSION: The intraparenchymal injection of taurocholate is easy to perform and highly reproducible. The histopathological injury is dose-dependent, as is the mortality. We conclude that this model is valuable for the study of new treatments for pancreatitis.

[Laparoscopic cholecystectomy in acute cholecystitis].

We performed 417 laparoscopic cholecystectomies, including 58 for acute cholecystitis, between September 1991 and April 1995,. All operations were successful, with no mortality or complications. In about 10%, the laparoscopic approach failed and we converted to open cholecystectomy. Average post-operative hospitalization was 24 hours. We also performed primary open cholecystectomies in 55 patients with acute cholecystitis, because of limitations of operating room and staff availability for unscheduled laparoscopic surgery. In these patients, hospital stay was longer and rate of complications higher. In our opinion laparoscopic cholecystectomy is safe and the preferred approach in acute cholecystitis.

Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation?

Blast injuries are rare, and although blast-induced perforations of the bowel have been described in the past, the entity of a delayed perforation caused by an evolving injury has not been reported. We report three men injured by the explosion of a terrorist bombing in open air. They suffered primary blast injuries, which resulted in isolated perforations of the terminal ileum. They were operated at different times after the blast event. The resected specimens were examined under light microscopy. One patient was operated immediately, and had three perforations in the terminal ileum. In the other two patients, abdominal complaints appeared only 24 and 48 hours later. These two patients were found to have hematomas in the wall of the terminal ileum, and small perforations therein, with almost no contamination of the peritoneal cavity. On histological examination, there were small perforations with disruption of all intestinal layers. In the vicinity of the perforations, the mucosa was necrotic and disorganized. The submucosa showed edema and vascular thrombi, and at several points mucus was shown dissecting through the muscularis propria, thus creating minute microperforations. Because of the findings in these patients, we suggest a mechanism of evolving damage to the bowel wall and delayed perforation rather than delayed diagnosis, after blast injuries. We suggest that patients exposed to a significant blast should be watched carefully for at least 48 hours.

Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies.

OBJECTIVES: To describe the surgical technique of endoscopic transthoracic sympathectomy for the treatment of palmar hyperhidrosis and to identify associated complications. DESIGN: Prospective clinical study. SETTING: University referral center. PATIENTS: A consecutive series of 150 patients with primary palmar hyperhidrosis. INTERVENTION: The surgical procedure is performed under general anesthesia. A trocar and endoscope are inserted into the chest cavity. The sympathetic chain and the second, third, and fourth ganglia are then identified, cauterized, and cut. After reinflation of the lung, the procedure is repeated on the other side. RESULTS: Two hundred ninety sympathectomies were performed with a 98% success rate. Complications of the procedure included pneumothorax in seven patients (2.4%), hemothorax in three (1.0%), and temporary Horner's syndrome in two (0.7%). Severe postoperative pain during the first 2 to 4 hours required treatment. Of 60 patients who were followed up for 12 months, 50% developed compensatory sweating and 8.3% developed rebound sweating. Hyperhidrosis recurred in three patients. CONCLUSION: Endoscopic transthoracic sympathectomy is an effective form of treatment for palmar primary hyperhidrosis, is associated with a low morbidity, and can be performed as an ambulatory procedure.

The role of isosorbide dinitrate in the treatment of perioperative hypertension.

Intravenous nitroglycerin (NTG) has recently been found to be useful for the control of blood pressure during the perioperative period, especially during coronary artery bypass procedures. The objective of this study was to determine whether intravenous isosorbide dinitrate (ISDN) could play a similar role. Sixty-seven patients undergoing coronary artery bypass grafting at three centers were randomly assigned to an ISDN or NTG treatment group. The hemodynamic performance of all patients was assessed by the methods commonly used for cardiac patients (ECG, arterial line, thermodilution pulmonary artery catheter). One of the two nitrates was infused whenever the systolic blood pressure or the pulmonary capillary wedge pressure exceeded predetermined values. Treatment by either agent was considered successful if the elevated values returned to normal. NTG reduced the blood pressure in a higher percentage of hypertensive events. The rates of success were 84% for NTG vs 72% for ISDN in the prebypass phase, 93% vs 64% in the postbypass phase, and 71% vs 54% in the postoperative phase. Increased ISDN effectiveness may be attained with the use of a bolus administration before continuous infusion or with the use of a rapid rate of infusion.