A patient with vertebrobasilar transient ischaemic attacks and provokable basilar steal.

In a 65-year-old woman with vertebrobasilar transient ischaemic attacks (TIAs) and subclavian steal, a steal phenomenon in the basilar artery could be demonstrated by transcranial Doppler sonography after provocation with postischaemic hyperaemia of the arm on the affected side. It was not possible to provoke symptoms or signs at the time. The significance of finding a steal phenomenon in the basilar artery even in a patient with a history of vertebrobasilar TIAs is discussed.

Surgical treatment of patients with a carotid artery occlusion and a contralateral stenosis.

Patients with a carotid artery occlusion and a haemodynamically significant contralateral stenosis have an increased risk of incurring a stroke. Based on the results of a series of 33 patients our conclusion is that the surgical therapy of choice should be endarterectomy of the stenotic artery irrespective of which side the symptoms are located on. Only those patients who continue to have TIA's on the side of the occlusion after endarterectomy of the stenotic side should be considered for an ECIC bypass.

A comparison of conventional and digital intravenous arteriography in the follow-up of femoro-crural bypass operations.

The value of intravenous arteriography, otherwise known as digital vascular imaging (DVI) in the late postoperative control of femoro-crural bypass operations is determined by comparing its results with those of conventional arteriography. Ten patients with 12 grafts were studied by both methods after a mean postoperative follow-up period of 83.5 months. DVI was 100% accurate in the determination of graft patency. In most patients it provided reliable information regarding the status of the distal anastomosis and the patency of the distal runoff. Since DVI has been proven accurate, has a good patient acceptance, and can be performed as an outpatient procedure, it is preferable to conventional arteriography for the objective documentation of long-term graft patency.

[One stage operation of bilateral carotid lesions (author's transl)]. / Opération en un temps de lésions carotidiennes bilatérales.

Bilateral one stage carotid endarteriectomy was performed in 11 patients presenting with bilateral symptomatics stenoses without neurological nor cardiac major complications. We only found one such experience in the literature (1). The choice of a simultaneous procedure is based solely on electroencephalogram analysis and on the residual pressure after the test of carotid occlusion; the side where occlusion is tolerated and/or where the residual pressure is highest, is operated first. This simultaneous bilateral procedure carries the theoretical risk of ischemia. It has the advantage of decreasing the cardiac complications and the risk of neurological deficit and at the same token avoids intercurrent controlateral thrombosis and recurrent symptoms between two non-simultaneous procedures. In cases of symptomatic lesions, the indication of surgery is evident; for asymptomatic lesions we only consider a simultaneous procedure in special cases where there exists a threat of neurological complications.

Minimal osteosynthesis of lateral malleolar fractures.

An oblique fracture of the lateral malleolus caused by a supination-external rotation injury (Danis-Weber type B) is the most common ankle fracture and is preferably treated operatively. Interfragmentary compression and lateral plating are generally used as the method of osteosynthesis. As an alternative two posteriorly inserted lag screws in the antero-posterior direction were used in 18 patients. In all but one good to excellent results as regards pain, function and radiographic appearance were achieved. The advantages of less extensive dissection, smaller amounts of foreign material and shorter operation time tend to make this the technique of choice for this type of fracture.

The primary aortoenteric fistula in The Netherlands--the unpublished cases.

OBJECTIVE: Primary aortoenteric fistula is a rare disorder of which only four patients have been reported in the Dutch literature so far. The objective of our study was to obtain more realistic figures on the incidence of this condition, with data on the clinical presentation, diagnostic procedures, treatment and results in a group of patients not previously reported as "case histories". METHODS: A questionnaire was sent to all surgical clinics in The Netherlands. Out of 180 questionnaires, 102 have been returned reporting 27 patients to which data of eight others treated in our own institution were added. RESULTS: In all but one of these 29 patients the fistula was caused by an atherosclerotic aneurysm, the one exception being caused by an ingested cocktail pin. Gastrointestinal haemorrhage was the predominant symptom, being present in 28 of the patients, while the complete triad of haemorrhage, pain and a pulsating mass was found in only eight patients. Twenty-seven patients were treated with an in situ graft of which 14 are doing well at long term follow-up. CONCLUSIONS: Primary aortoenteric fistula is far more common than one would expect from the number of patients reported in literature. A high index of suspicion based on a complete physical examination remains the key to a correct diagnosis. Direct closure of the intestine and in situ grafting of the aorta is the treatment of first choice.

Intramural hematoma of the duodenum in a patient with chronic pancreatitis.

Intramural hematoma of the duodenum is usually caused by blunt abdominal injury. Sometimes this lesion occurs in patients with coagulation disturbances or pancreatic disease such as chronic pancreatitis. There also appears to be a link with alcohol abuse. We describe the case-history of a 45-year-old male with chronic pancreatitis who presented with abdominal pain. The diagnosis of a space-occupying process of the duodenum was made and subsequently a pancreatico-duodenectomy was performed. The duodenum revealed an intramural hematoma, the pancreas showed signs of mild chronic pancreatitis.

[Palliative treatment of wrist joint metastasis of primary bronchial carcinoma with a dynamic compression plate]. / Palliative Behandlung einer Handgelenkmetastase eines primären Bronchialskarzinoms mit einer dynamischen Kompressionsplatte.

The authors describe a patient with a wrist metastasis of a primary pulmonary carcinoma. Palliative radiotherapy in combination with splinting failed to release the pain. He was then successfully treated by radiocarpal bridging with a dynamic condylar plate.

Operative repair of ruptured achilles tendon and functional after-treatment--I. Acute rupture.

The results are described of primary operative repair of acute achilles tendon rupture with a simple suture technique and functional after-treatment, followed by immobilisation after a few days in a lower leg walking plaster with the foot in right angle position. In our experience with two groups of patients (64 cases) the described method appeared simple and safe, after-treatment is convenient for the patient and the results are good.

Cryptogenic Salmonella-infected ruptured aortic aneurysms.

Salmonella-infected ruptured aortic aneurysms are a difficult surgical problem. Five patients with Salmonella-infected ruptured aortic aneurysms are presented. All patients were initially treated by in situ graft replacement, wide debridement of the infected aortic tissue and long-term systemic antibiotic therapy. The surgical technique of choice in acute situations, such as a rupture of the aneurysm, remains controversial. In the recent literature 26 reported cases were reviewed. Based on our clinical experience and these case reports, in situ bypass reconstruction can be justified as a surgical technique that gives at least a good short-term prognosis.

Ischaemic disease of the colon and rectum after surgery for abdominal aortic aneurysm: a prospective study of the incidence and risk factors.

In a prospective study of 100 patients operated on for an infrarenal localised aortic aneurysm, routine postoperative colonoscopy revealed ischaemic colonic disease, defined as ulceration or necrosis of different degrees in three of 66 patients (4.5%) operated on electively or semi-acute, and in six of 34 patients (17.6%) operated on for a rupture of their aneurysm. Colonoscopic findings were interpreted as transmural gangrene in three patients, extensive superficial necrosis in one, and ulceration in five. Exploratory laparotomy, however, led to a definite diagnosis of transmural gangrene in only one patient. This patient was the only one whose death was directly related to this complication, notwithstanding timely surgical intervention. Four patients had severe and protracted diarrhoea, while four others exhibited no clinical symptoms at all. Ischaemic colonic lesions were found more often in patients who had been exposed to a period of preoperative shock, than in those who were operated on in a stable circulatory state (20.7 vs. 4.2%; P less than 0.05). It was also more common in patients in whom the patency of at least one hypogastric artery could not be preserved (36 vs 5.6%; P less than 0.02). Ligation of a patent inferior mesenteric artery was not in this study related to the development of ischaemic colonic disease, nor was a period of prolonged (greater than 1 h) cross clamping of the aorta. Postoperative diarrhoea was an early warning sign of ischaemic colonic disease in five of nine patients. Other clinical symptoms or signs were of no value at all in this respect.(ABSTRACT TRUNCATED AT 250 WORDS)

The dynamic condylar screw in subtrochanteric fractures of the femur.

Early experience with the AO dynamic condylar screw in subtrochanteric fractures of the femur showed a solid and stable osteosynthesis in 19 patients. The ease of insertion of the dynamic condylar screw, the firm proximal fixation, the increased strength and resistance to stress failure should, in our opinion, make this technique a favoured form of treatment for this particular type of fracture.

The preperitoneal approach in the repair of recurrent inguinal hernias.

Preperitoneal repair of 98 recurrent inguinal hernias performed at our teaching hospital was studied. In 55 instances, primary closure was performed and in 43 hernias, mesh prosthesis was applied. Rerecurrence was seen after 32 corrections (a follow-up examination period of 45 months). Nine asymptomatic recurrences were found. Unilateral versus bilateral repair showed a 27 and 50 per cent recurrence rate, respectively (p = 0.037). Results after primary closure and after mesh application were similar, and no correlation with the number of recurrences, age or presence of causes of raised abdominal pressure was observed. In 20 reoperations performed after the follow-up date, ten lateral hernias were found, indicating technical failure as a possible cause of rerecurrence. A high rate of recurrence after preperitoneal approach for recurrent inguinal hernia may be explained by technical shortcomings and detection of a high percentage of asymptomatic recurrences at physical examination.

Primary aortoenteric fistula: report of eight new cases and review of the literature.

Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.