Management of acute perianal sepsis in neutropenic patients with hematological malignancy.

In neutropenic patients with acute perianal sepsis in the setting of hematological malignancy, the classical clinical features of abscess formation are lacking. Additionally, the role of surgical intervention is not well established. In this review, we discuss the challenges and controversy regarding diagnosis and optimal management when clear surgical guidelines are absent. In the literature, there is great diversity in the surgical approach to these patients, which leads to a high percentage of diagnostic errors, risks of complications, and unnecessary interventions. We review the literature and assess whether surgical intervention produces better outcomes than a non-surgical approach. Studies published on perianal sepsis in neutropenic cancer patients were identified by searching PubMed using the following key words: "perianal sepsis/abscesses, anorectal sepsis/abscess, neutropenia, hematological malignancy, cancer". No randomized or prospective studies on the management of acute perianal sepsis in hematological malignancies were found. The largest retrospective study and most comprehensive clinical data demonstrated that 42% of patients were treated successfully without surgical intervention and without morbidity or mortality related to treatment chosen. Small retrospective studies advocated surgical intervention, while the majority of successes were in a non-operative treatment. It is difficult to formulate a conclusion given the small retrospective series on management of neutropenic patients with hematological malignancies. While there is no evidence mandating a routine surgical approach in this category of patients, non-surgical management including careful follow-up to determine whether the patient's condition is deteriorating or treatment has failed is an acceptable approach in selected patients without pathognomonic features of abscess. Comprehensive and well-designed prospective studies are needed to firmly establish the guidelines of treatment protocols.

Traumatic arteriovenous fistula.

Traumatic arteriovenous fistula in the head and neck may present a difficult problem in management. We present a surgical case of traumatic arteriovenous fistula between the right subclavian artery and internal jugular vein with false aneurysm formation. Traumatic injury of the subclavian artery causing arteriovenous fistula with false aneurysm is a serious surgical emergency with appreciable morbidity and mortality that requires early recognition and prompt surgical intervention.

Venous ulcers in chronic venous insufficiency: King Khalid University Hospital experience.

BACKGROUND: The purpose of this study was to identify the anatomical location of the venous disease in C.V.I. patients presented with venous ulcers in addition to discussing the management. DESIGN: Retrospective study, at King Khalid University Hospital. METHODS: Between January 1991 to January 1997, 90 patients (63 females, 27 males) with CVI were evaluated. The evaluation included history, clinical examination, bidirectional ultrasound continuous wave Doppler, Duplex, ambulatory venous pressure (AVP), ascending and descending venography. RESULTS: Forty eight (48) patients (57 limbs) had Stage III with venous ulcers. Out of these 48 patients, fifteen (15) showed deep venous system involvement with deep vein thrombosis (DVT). Thirty three (33) patients had venous reflux in the superficial or deep systems without occlusion. Out of these 33 patients, 24 patients had superficial system reflux, while the remaining 9 patients revealed deep system reflux with a competent superficial system. CONCLUSIONS: Superficial venous incompetence plays a major role in venous ulcer formation and that location and type of venous disease should be thoroughly investigated as surgical excision of the superficial system leads to a long standing recurrence free period.

Intraoperative balloon angioplasty: a useful adjunct.

Intraoperative balloon angioplasty is a useful adjunct to a bypass procedure where the latter requires obvious enhancement of either inflow or outflow tracts. This retrospective study reviews experience with 62 patients (72 procedures) managed between January 1990 and January 1997 at UBC and KKUH. There were 36 men and 26 women. The indications were severe claudication in 44 (71%) patients and limb salvage in 18 (29%) patients. There were 42 cases of iliac artery (58%), 22 cases SFA (31%), and 8 cases pop/tibial (11%). The initial technical success for iliac balloon angioplasty was 90% (38 out of 42 cases), for SFA 91% (20 out of 22) and for popliteal/tibial 63%, (5 out of 8 cases). There were eight major complications, five of them treated surgically (7%), three patients needing amputations. The followup period ranged from 6 to 54 months with accumulated patency rate of 90% in iliac, 78% in SFA and 60% in pop/tibial in 12 months. Intraoperative angioplasty is a valuable adjunct to vascular surgery either to improve inflow or outflow in association with a reconstructive vascular procedure.

Groin lymphorrhea postoperative nuisance.

Lymphorrhea is defined as the flow of lymph from disrupted lymphatic channels that drains externally or is contained within a wound. It complicates approximately 2% of vascular incisions in the groin. Of 116 patients who underwent different arterial reconstructions involving 186 groin wounds, lymphorrhea developed in 4 patients (3.4%) including 4 groins (2.1%). They have been managed in the Division of Vascular Surgery at King Khalid University Hospital (KKUH) in Riyadh, during a 3-year period ending in February 1996. There were 105 (90.5%) males and 11 (9.5%) females. The ages ranged from 32 to 96 years with a mean age of 63 years. All the 4 cases complicated with lymphorrhea were managed conservatively for a period of three to five weeks. In 2 cases, the lymphatic leak stopped and the patients discharged without other local complications. In the other 2 cases, lymphatic leakage stopped immediately and permanently following direct surgical ligation. The use of isosulphane blue for localization of the site of the lymphatic leak was a simple, reliable and accurate method during wound exploration. Follow-up of all cases for 6 months showed no recurrence, no sepsis and patent vascular graft.

Neurobehavioral effects of carotid endarterectomy.

OBJECTIVE: Nineteen patients with symptomatic carotid stenosis (>70%) were subjected to carotid endarterectomy in a prospective study to evaluate neurobehavioral changes before and 6 months following the operation. METHODS: All patients were subjected to neurobehavioral rating scale one week before and 6 months after the operation. RESULTS: There were no significant changes in the 27 items of this scale before and 6 months following the operation. Some patients showed no difference at all in some items of this scale before and after operation such as suspiciousness excitement, speech and articulation using Mann-Whitney rank test, P values were (> 0.05) as regards to all items of neurobehavioral rating scale. CONCLUSION: Uncomplicated carotid endarterectomy does not seem to be associated with significant long time neurobehavioral impairment following the operation.

Arteriovenous fistula in chronic renal failure patients: comparison between three different anesthetic techniques.

The creation of arteriovenous fistula is an established form of therapy for patients with chronic renal failure. Anesthetic management in such patients is governed by the presence of risk factors such as hypertension, ischemic heart disease, diabetes, chronic pulmonary disease, anemia, coagulopathy, metabolic acidosis and/or hyperkalemia. In an attempt to improve the quality of anesthetic care and outcome we designed the present study to compare the different anesthetic techniques which are used for creation of arteriovenous fistula. Retrospectively we reviewed 164 patients who underwent creation of arteriovenous fistula. We retrieved the data concerning the age, sex, ASA class, and coexisting diseases. The patients were classified into three groups depending on the anesthetic technique received. Group A (n = 48) patients received general anesthesia; group B (n = 39), patients received brachial plexus block and group C (n = 77), patients received local infiltration anesthesia. Chi-square test was used to compare between the percentages among the different groups. The percentages of cardiac patients showed significant differences between groups A and B and also between groups A and C. There was a significant difference between the groups A and B also between the groups A and C but not between groups B and C concerning age. ASA classes were not significantly different among the groups. Among the total number of patients, 34 were diabetics and 75 patients were cardiac. Axillary brachial plexus block was complete in 70% of patients and incomplete in 27% and failed in 3% of patients. We conclude that chronic renal failure patients are at increased risk during anesthesia. We conclude that brachial plexus blockade or local anesthetic infiltration are good alternatives to general anesthesia in these patients undergoing creation of arteriovenous fistula. Age, ASA class and cardiac status were the three determining factors for the choice of the anesthetic technique. Further multivariate prospective study are needed to confirm these results.

Neurobehavioral effects of carotid endarterectomy.

OBJECTIVE: Nineteen patients with symptomatic carotid stenosis (>70%) were subjected to carotid endarterectomy in a prospective study to evaluate neurobehavioral changes before and 6 months following the operation. METHODS: All patients were subjected to neurobehavioral rating scale one week before and 6 months after the operation. RESULTS: There were no significant changes in the 27 items of this scale before and 6 months following the operation. Some patients showed no difference at all in some items of this scale before and after operation such as suspiciousness excitement, speech and articulation using Mann-Whitney rank test, P values were (> 0.05) as regards to all items of neurobehavioral rating scale. CONCLUSION: Uncomplicated carotid endarterectomy does not seem to be associated with significant long time neurobehavioral impairment following the operation.

Klippel-Trénaunay syndrome: clinical features, complications, and management.

Klippel-Trénaunay Syndrome (KTS) is rare and not well recognized among most physicians, which has lead to inappropriate management and delayed referral in many cases. Presented herein is the largest series ever reported from a single center in Saudi Arabia, comprised of 18 patients seen between 1990 and 1996, whose clinical features, complications, and management are discussed. All 18 patients had large angiomatous navei, hypertrophy of the soft tissue with bone overgrowth in the lower limbs, and extensive lower limb varicosities, which extended to the buttocks and lower abdomen in 2 patients. There were 4 patients who had undergone at least one operation for lower limb varicose veins prior to referral. The diagnostic workup and treatment for KTS is discussed in detail. It is essential that physicians understand how this complex syndrome presents, and the most appropriate means of investigating and managing it, to avoid unnecessary surgery being performed prior to referral to a specialist center.

Comparison of percutaneous with intra-operative balloon angioplasty for arteriosclerotic occlusive disease.

The purpose of this study was to compare the technical success and short-term outcome of intraoperative balloon angioplasty (IBA) with percutaneous transluminal angioplasty (PTA) in the iliac and femoropopliteal segment. From January 1988 to February 1991, 99 consecutive patients underwent 114 angioplasties in the iliac (37 PTA, 26 IBA) and femoropopliteal segment (15 PTA, 36 IBA). Mean age and sex distributions were similar between the groups. Claudication was the primary indication for both groups. All patients who underwent IBA had another concomitant surgical procedure performed. Immediate technical success for PTA and IBA were 50/52 (96%) and 58/62 (94%), respectively. Cumulative patency up to 12 months following angioplasty of the iliac artery was 94% for PTA and 78% for IBA (P-value NS). For the femoropopliteal segment, 12 month patency results were 100% for PTA and 78% for IBA (P-value NS). Complications requiring surgical intervention occurred in 3 (6%) PTA and 5 (8%) IBA cases. Results from this study indicate that technical success and early patency are similar for PTA and IBA in the iliac and femoropopliteal segments. However angioplasty-related complications were not avoided by performing balloon angioplasty in the operating room.

Intraoperative balloon angioplasty: a surgical approach.

Percutaneous balloon angioplasty is a recognized treatment for peripheral atherosclerosis involving the iliac and femoropopliteal segments. From their experience in 38 patients the authors have examined the efficacy of intraoperative balloon angioplasty for tandem lesions requiring both balloon angioplasty and surgical intervention. Between January 1988 and July 1990, 43 intraoperative balloon angioplasties were performed in 19 women and 19 men who required inflow or outflow angioplasty in addition to surgical bypass. The indication for surgery was incapacitating claudication in 32 (74%) patients and limb salvage in 11 (26%) patients. Initial technical success was achieved in 17 (89%) of 19 patients who required iliac surgery and in 22 (92%) of 24 patients who required femoropopliteal balloon dilatations. There were four major complications (9%), all requiring surgical intervention. In two cases there was dissection with thrombosis and in two cases failure to improve the pressure gradient. Patients were followed up for up to 24 months. Two of the inflow angioplasties failed between 6 and 9 months. Two of the outflow angioplasties failed between 12 and 15 months. Three patients died in the follow-up period, two from myocardial infarction. In the authors' experience intraoperative balloon angioplasty has proven a worthwhile adjunct for tandem lesions in the iliac and femoropopliteal segments.

Prevention of vascular injuries in revision total hip replacement.

Iliac-vessel injury from total hip arthroplasty is associated with hemorrhagic complications and an increased death rate. The authors identified seven patients who had severe medial displacement of the acetabular prosthesis and associated vascular injury to the iliac vessels after total hip replacement. One patient had two hip replacements. Preoperative findings included a pelvic mass (three hips), pelvic pain (eight), radiologic evidence of cement in the pelvis (three) and the acetabular prosthesis in the pelvis (eight), computed tomographic evidence of cement in the pelvis and proximity of the prosthesis to the iliac vessels (four), and arteriography showing displacement or compression of the iliac vessels (seven). Operative management in all cases involved medial exposure, mobilization and repair of the iliac vessels before revision of the hip prosthesis. Postoperative complications were deep vein thrombosis (three), in spite of prophylaxis, and occlusion of a vein interposition graft (one) requiring placement of a femoral crossover graft. There were no deaths, amputations or hemorrhagic complications. The authors advocate preoperative identification of patients who have iliac-vessel involvement by their total hip prosthesis and initial medial extraperitoneal exposure and repair of these vessels before removal of the displaced acetabular prosthesis.

Effect of arteriovenous fistula for hemodialysis on limb circulation.

The number of patients with end-stage renal disease maintained on chronic hemodialysis is increasing progressively. Arteriovenous fistula (AVF) is a common vascular access for hemodialysis, however, its effect on limb distal circulation has not been studied well. Palpation of pulse at the wrist is a crude method of clinical assessment. Over one year period, 26 AVFs were created; 16 at the wrist (61.5%) and ten fistulas at the elbow (38.5%). Six of the latter were through the brachio-basilic approach while the other four were performed by basilic vein transposition. Doppler measurement of both wrist-brachial index (WBI) and finger pressure was carried out for all patients pre-operatively and on the first post-operative day. Of the patients with AVF created at the elbow, there was a decrease of WBI in seven patients (70%) and a decrease of finger pressure in three (30%); one patient (14%) had steal syndrome. Creation of AVF at the wrist resulted in a decrease of WBI in one patient (6.25%) and a decrease of finger pressure in another patient (6.25%). WBI changes as a result of creation of AVF at the elbow were significantly greater than the changes of those fistulas performed at the wrist (P < 0.001). On the other hand, the difference between the effect of both procedures on finger pressure was statistically not significant. These results may help to explain the higher incidence of steal syndrome in patients with elbow fistulas compared to patients with wrist fistulas. Further studies on a larger scale are required to determine the value of non-invasive indices at which AVF creation would have future risk of compromised distal limb circulation.

Vascular compromise associated with supracondylar fractures in children.

OBJECTIVE: Our aim was to study the significance of persistently absent radial pulse, with monophasic doppler flow after close reduction percutaneous pinning of displaced supracondylar fracture of humerus, and the need of early exploration of brachial artery in such cases. METHODS: Between July 1992 and 1999, 86 children with Grade III supracondylar fracture of humerus were treated at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia The history, physical examination, vascular status of limb before and after close reduction percutaneous pinning of fracture were recorded. All children having persistently absent radial pulse and monophasic flow doppler signals after close reduction percutaneous pinning under went exploration of brachial artery. RESULTS: Of the 86 children with Grade III supracondylar fracture of humerus, 6 had persistently absent radial pulse with monophasic flow doppler signals after close reduction percutaneous pinning. Five children had one warm pink well perfused hand and one cold pale poorly perfused hand. All 6 under went exploration of brachial artery and were found to have entrapped artery at the fracture site. There was an immediate return of radial pulse with triphasic Doppler flow on release of brachial artery. CONCLUSION: Persistently absent radial pulse with objectivity, obtained by doppler ultrasound in the form of absent or monophasic flow in radial artery, is a reliable indicator of vascular compromise. Surgical exploration of brachial artery by a competent surgeon is to be carried out to avoid early and late complication, of pulseless limb in children with displaced supracondylar fracture of humerus.

Vascular injuries associated with limb fractures.

The records of 46 patients with vascular injuries of the lower and upper limbs associated with bone fractures and managed in the authors' vascular and orthopaedics divisions were reviewed. All were young men, 26 with blunt and 20 with penetrating vascular injuries; 20 were treated by end to end anastomosis, 12 by vein interposition grafting, six by prosthetic graft, six by vein patches and lateral sutures and two by ligations. The limb salvage rate was 93 per cent. Three patients died (6.5 per cent) of severe associated injuries. Amputations were needed in three patients (6.5 per cent) with popliteal, tibial arteries and vein injuries. An aggressive approach to limb salvage is needed in these extensive injuries.

Central vein stenosis in patients with prior subclavian vein catheterization for maintenance dialysis.

We evaluated the prevalence of central vein stenosis in patients with prior central vein catheterization for vascular access for hemodialysis. A total of 36 patients with end-stage renal disease (ESRD) who were referred to the division of vascular surgery at King Khalid University Hospital in Riyadh were evaluated. Bilateral ascending venogram was performed in all cases. The patients were divided into three groups: Group I included 38 extremities in 32 patients who were referred for construction of an arteriovenous fistula. All these patients had previous history of subclavian vein catheterization. This included six patients who had bilateral catheter insertion. Venography demonstrated greater than 50% central vein lesions in 13 of the 38 extremities yielding a prevalence of 34%. Group II included four extremities in four patients who were on hemodialysis for many years all of whom presented with features suggestive of venous obstruction in their already existing arteriovenous fistulae. All four patients gave history of prior subclavian vein catheterization for dialysis. Three of these patients had > 50% subclavian vein stenosis while one showed complete occlusion of the vein. Group III included 30 extremities without history of prior central vein cannulation and none of them showed any lesions on venography. Our study further confirms previous reports that show a high prevalence of central vein stenosis following use of subclavian catheter as vascular access. We suggest that the subclavian route should be abandoned in patients with ESRD and temporary venous cannulation, if needed, should be performed in the femoral or internal jugular veins. Also, in individuals with history of prior central vein cannulation, venography is strongly recommended before an arteriovenous fistula is made.