Traumatic Rupture of a Duodenal Diverticulum: Case Report and Review of the Literature.

Duodenal diverticula are relatively common and usually asymptomatic (95%). Their perforation is a rare but harmful event. Traumatic perforation is exceptional. We report the case of a patient with such a lesion following a blunt trauma secondary to a car accident, and review the literature. Clinical presentation is aspecific and diagnosis is based upon CT scan imaging. Surgery is the recommended treatment consisting of diverticulectomy with transverse duodenal closure of the duodenum associated with retroperitoneal drainage.

Influence of respiratory cycle on proximal renal artery motion: an angiographic study in patients undergoing endovascular aneurysm repair.

BACKGROUND: The purpose of our study was to evaluate the influence of respiratory cycle on proximal renal artery (RA) motion in twenty consecutive patients with abdominal aneurysm and the potential impact on endograft deployment during endovascular aneurysm repair (EVAR). METHODS: Prior to the device introduction, a preoperative angiography to define the location of the RAs was performed by a calibrated pigtail catheter. A measuring tape on the table served as the reference point for all measurements. Images of RA levels were acquired during expiration (E) and inspiration (I) cycles. In order to have homogenous comparative values for each patient during inhalation, the anaesthesiologist maintained a controlled inspiration with a uniform pressure of 30 cm of water. Motion of the RAs was defined as the changes in distance between E and I measures, adjusted to the calibrated pigtail. RESULTS: The median right proximal RA motion was 3.0 mm (IQR 2.4 mm; range: 0 to 5.6 mm). The median left proximal RA motion was 3.1 mm (IQR 2.2 mm; range: 0.54 to 5.6 mm). The current results demonstrate the proximal RAs motion during breath with a median magnitude of 3 mm, without significant differences between both RA (P = .83). CONCLUSION: Our data confirm the RAs motion during respiratory cycle. More than the predictive absolute value of the RA motion between inspiratory and expiratory phases, it is the motion itself which is important. This unrecognized condition, even if it interests only a minority of patients, could potentially have clinical disastrous consequences : potential stenosis or covering of RAs.

Spinal cord stimulation. New regulation of national health insurance.

Since January 1, 2008, the Belgian national health insurance (INAMI/RIZIV) edited a new agreement for the prolongation of the pilot-study on spinal cord stimulation for chronic critical unreconstructable lower limb ischemia. After a short introduction and a summary of the results of the initial Belgian pilot study (2000-2005) on spinal cord stimulation, the official new text is now published in both languages.

Varicose veins in ambulatory surgery : patients' perception.

INTRODUCTION: It is mandatory to perform venous surgery in ambulatory surgery units. The aim of this study is to analyse the patient's perception concerning the period before hospital discharge. STUDY DESIGN: This was a prospective observational study of 100 patients who underwent primary varicose vein surgery. Venous disease was assessed according to the CEAP classification and VCSS system. The perception of anxiety or psychological apprehension was documented by simple questions. Additionally, we recorded the daily postoperative pain, the return to normal activity and the patient's satisfaction score. RESULTS: Four patients required unplanned admission from the ambulatory surgery floor to the hospital unit: two for medical reasons (urinary retention and haematomas) and two ladies who stayed overnight because of a severe anxious state. When questioned about the potential anxiety before hospital discharge, the majority of patients (87%) declared no psychological apprehension. Eleven patients decided to leave the hospital despite potential distress. Patients with distress were more frequently male (p = .75) with superficial phlebitis (p = .49), pre-operative painful varicose veins (p = .13) and a higher number of surgical incisions (p = .35). The only significant difference existing between patients with or without anxiety was regarding the complication rate in the recovery room (p = .04). CONCLUSION: Despite careful patient selection, psychological distress could not be prevented or predicted. There is no doubt however that taking these emotional factors into consideration in outpatient surgical practice is essential.

Carotid endarterectomy with internal carotid artery segmental resection, temporary shunt and vein patch angioplasty: early and mid-term results.

AIM: The authors report an alternative procedure to carotid endarterectomy with internal carotid artery (ICA) segmental resection and end-to-end anastomosis associated with temporary shunt and venous patch angioplasty. DESIGN: prospective cohort study. METHODS: Between May 1995 and December 2004, 192 patients underwent 200 primary CEAs for significant ICA stenosis. There were 131 men and 61 women with a mean age of 72.4+/-8.4 years. The indications for CEA were asymptomatic lesions in 51.5%, transient ischemic attack in 27.5% and stroke in 21%. RESULTS: The combined early morbidity and mortality rate was 2%. Two patients died, one due to fatal intracerebral hemorrhage and the second patient died of acute mesenteric ischemia. Neurological complications occurred in 2 patients, including 1 TIA and 1 nondisabling cerebrovascular accident. Non-neurological complications occurred in 26 patients (13.5%). Seventeen patients (8.8%) developed hypertension, 3 neck hematomas (1.5%) required surgical evacuation, 1 patient had reversible supraventricular arrhythmia (0.5%) and 1 patient had pneumonia (0.5%). Furthermore, 1 asymptomatic carotid occlusion was identified (0.5%) and 3 patients suffered permanent cranial nerve injury (1.5%). Mean follow-up was 45.7 months and there were 41 late deaths (21.8%). Survival rates at 1 and 5 years were 96.7+/-1.2% and 73.58+/-4.2%, respectively. CONCLUSIONS: CEA with ICA shortening and reanastomosis is a safe and reliable procedure without any increase in morbidity or mortality.

Functional evaluation of internal mammary artery bypass grafts in the early and late postoperative periods.

OBJECTIVES: We sought to determine whether internal mammary artery grafts adapt to an increase in myocardial flow demand and whether they restore maximal flow reserve. BACKGROUND: Although mammary grafts are now considered the graft of choice for coronary artery bypass surgery, there is still controversy about whether they can provide adequate flow at periods of peak myocardial demand. METHODS: Of 28 patients with a mammary graft anastomosed to the left anterior descending coronary artery, 15 were studied early (mean [+/- SD] 8 +/- 2 days) and 13 late (19 +/- 15 months) after operation by quantitative angiography and selective intravascular Doppler analysis at baseline, during pacing and after injection of papaverine and isosorbide dinitrate into the graft. Eleven patients with a normal left anterior descending artery served as control subjects. RESULTS: At baseline, mean graft diameter (2.39 +/- 0.41 vs. 2.42 +/- 0.45 mm) and bypass flow (38 +/- 22 vs. 30 +/- 12 ml/min) were similar in the early and late postoperative periods. Significant and similar vasodilation was observed in mammary grafts after administration of papaverine (+6 +/- 5% vs. +9 +/- 6%) and nitrates (+14 +/- 7% vs. +16 +/- 9%) both early and late after bypass surgery. Graft diameter increased during pacing late (+6 +/- 3%, p < 0.05) but not early after operation. Bypass flow increased similarly during pacing in both groups, but maximal flow reserve induced by papaverine was significantly lower in mammary grafts studied early (2.70 +/- 0.62) than those studied late (3.66 +/- 0.81, p < 0.01) and in normal coronary arteries (4.05 +/- 0.96, p < 0.001). CONCLUSIONS: An increase in myocardial blood flow induced by pacing resulted in vasodilation of mammary grafts in the late but not in the early postoperative period. Significant vasodilation of mammary grafts after papaverine and isosorbide dinitrate administration was observed both early and late after operation. However, bypass flow reserve after papaverine injection was significantly lower in the early postoperative period but normalized over time. This finding seems unrelated to the conduit; rather, it appears to be related to the periphery and could be the result of injury to the microvasculature during operation.

Transilluminated powered phlebectomy. Mid-term clinical experience.

AIM: Transilluminated powered phlebectomy (TIPP) was first described in 1996 by Sptiz et al. and was designed to allow minimally invasive surgical treatment of varicose veins (VV). We report our updated experience with TIPP technique. METHODS: Between January 2001 and February 2004, 84 patients underwent treatment by TIPP technique for primary symptomatic VV. Saphenofemoral junction with complete stripping of the great saphenous vein was performed in all patients. Incompetent perforating veins was ligated and prominent VV were ablated with TIPP technique. RESULTS: Mean age of patients was 50.6 years (range 29-79 years) and most of patients were women (73%). The major varicose vein risk factors were standing position and parity. Heaviness (62%), pain (57%) and unsightly veins (30%) were the most common indications for surgery. The mean number of surgical incisions was 6 (range 3-10), the average operative time was 59 min (range 30-100 min) and the mean cosmetic score (out of 10) at 6 weeks was 8 (range 2-10). The mean pain score (out of 10) was at 2 days, 7 days and 6 weeks was 5, 3 and 0, respectively. All the complications were documented. CONCLUSIONS: The TIPP technique is safe without any adverse events, presents advantages and inconvenient which are discussed in this paper.

Bilateral Pretibial Varices with Intraosseous Venous Drainage Anomaly: A Case Report.

We report the case of a 35-year-old male patient who complained of right anteromedial leg pain, after an intensive sport exercise. At physical examination, internal pretibial soft tissue swelling containing prominent painful varices was found. Color Doppler ultrasound, radiographic examinations, followed by CT and MR complementary investigation, were performed.

Intraoperative electromagnetic flowmeter measurements in coronary artery bypass grafts.

This study attempts to relate flow findings in internal mammary (IMA) and saphenous vein coronary artery bypass grafts to postoperative outcome. From 262 patients undergoing coronary artery bypass grafting, 601 electromagnetic flow measurements were obtained in IMA and saphenous vein grafts, and free graft flow was measured in 227 IMAs prior to grafting. Retrograde flushing of the IMA with diluted papaverine hydrochloride resulted in a marked increase in IMA free flow (124 +/- 4 mL/min versus 66 +/- 5 mL/min; p < 0.001). However, IMA free flow did not correlate with electromagnetic flow measurements after grafting to the left anterior descending coronary artery. The use of IMAs with free flows lower than 50 mL/min did not affect clinical outcome. Flow measured in saphenous vein grafts (66 +/- 9 mL/min) with an electromagnetic flowmeter was significantly greater (p < 0.001) than that in the IMA grafted on the left anterior descending coronary artery (36 +/- 3 mL/min) under comparable hemodynamic conditions. For the purpose of data analysis, patients were separated into three groups based on increasing incidence of complications: levels 0, 1, and 2. Patients with an uneventful outcome had a mean graft flow at chest closure of 51 +/- 3 mL/min versus 51 +/- 4 mL/min for patients in complication level 1 and 45 +/- 11 mL/min for patients in complication level 2 (p = not significant). Free flow measured in a vasodilated IMA was a poor predictor of flow into a grafted IMA and did not affect clinical outcome. We were unable to validate any flow limit to use of the IMA.(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual pitfall of use of retrograde cardioplegia.

The use of retrograde cardioplegia can lead to several complications, mainly related to injuries during the cannulation of the coronary sinus. We herein present a case report of injury to the right coronary artery related to kinking due to the pursestring on the right atrium.

Intraoperative assessment of coronary artery bypass grafts using a pulsed Doppler flowmeter.

A pulsed Doppler flowmeter was used in a series of 352 consecutive patients undergoing isolated coronary artery bypass grafting. Doppler flow measurements were available on 909 single terminolateral bypass grafts (327 internal mammary arteries and 582 saphenous veins) and 58 sequential bypass grafts anastomosed to combinations of arteries. Flow (mL/min) categorized as a function of the recipient artery was distributed as follows: left anterior descending coronary artery, 69.9 +/- 2.5; right coronary artery, 68.0 +/- 5.0; diagonals, 61.0 +/- 4.1; obtuse marginals, 55.9 +/- 2.2; and posterior descending coronary artery, 53.3 +/- 3.0 (p < 0.001). Graft outflow obstruction resulting from torsion of the graft pedicle or anastomotic stricture was identified in 7 patients (2%). After graft revision, flow increased from 9 +/- 4 mL/min to 69 +/- 13 mL/min (p = 0.023), and velocity rose from 4.6 +/- 1.1 cm/s to 18.1 +/- 2.4 cm/s (p = 0.009). In conclusion, the system was adequate for operative use and allowed identification and correction of technical errors.

Thoracoscopic resection of pulmonary nodules after computed tomographic-guided coil labeling.

BACKGROUND: A limiting factor in performing video-assisted thoracic surgery for resection of peripheral solitary pulmonary nodules has been the recognition of the lesion visually. This study reports our clinical experience of injecting a small metallic marker under computed tomographic scan guidance before the operation, allowing localization of the lesion. METHODS: A series of 14 patients underwent video-assisted thoracic surgery for removal of 15 pulmonary nodules situated in the outer third of the lung. Before operation, a radiopaque microcoil was injected just behind the lesion and then used to locate, under fluoroscopy, the area to be resected during thoracoscopy. The technique was evaluated for accuracy, reliability, and ease of use. RESULTS: Microcoil labeling of peripheral pulmonary nodules allowed in every case a complete resection and a histologic identification of the lesion. It is more stable and accurate than methylene blue dye marking, and it is as easy to perform as computed tomographic scan-guided biopsy. The incidence of complication was small in spite of our inexperience with the technique. CONCLUSIONS: Our experience with microcoil injection shows that it provides consistent and highly accurate marking of pulmonary nodules for video-assisted thoracic surgery, allowing secure resection with a safe margin.

[Spontaneous thrombosis of an iatrogenic pseudoaneurysm of the arterial brachiocephalic trunk following central venous catheterization]. / Thrombose spontanée d'un pseudo-anévrisme iatrogène du tronc artériel brachiocéphalique au décours d'un cathétérisme veineux central.

Following the unsuccessful puncture of the right subclavian vein during central catheterism, a 80-year-old women developed a pseudoaneurysm on the external face of the brachiocephalic artery. Her symptomatology and haemodynamic status having remained steady, the patient was closely observed. The pseudoaneurysm itself thrombosed spontaneously and the foreseen endovascular procedure doesn't have been achieved. A review of the literature has been done concerning the venous catheterism complications and the pseudoaneurysm treatment.

Mycotic aneurysm of the right iliac artery: imaging diagnosis and correlation with pathological findings.

We report the case of a 55-year-old woman who presented at the emergency department with hypogastric pain, fever, clinical signs of sepsis and a critical inflammation syndrome in her blood test values. CT-scan of the abdomen demonstrated an infected aneurysm of the right iliac artery. The patient underwent surgery with a favorable outcome. Histological examination of resected artery was performed and compared to the CT features. The authors review the literature and stress the importance of early diagnosis and treatement.

Operative risk assessment in coronary artery bypass surgery, 1990-1993: evaluation of perioperative variables.

Patient characteristics and the results of cardiac surgery change with time. To achieve the best possible treatment a continual analysis of results is necessary. The present study analyzes 1225 consecutive patients undergoing isolated aortocoronary bypass surgery for the four-year period ending September 1993. Average age was 63 years (range 32-86 years), 927 (75.7%) patients were male and 298 (24.3%) were female. Hospital mortality was 2.2% (17/787) for elective surgery, 6.3% (21/336) for urgent surgery, and 9.8% (8/82) for emergency surgery. Intraoperative variables increasing independently operative mortality as evidenced by multivariate analysis were the following: prolonged aortic cross-clamping time (p < 0.0001), absence of cold-blood cardioplegia (p = 0.0012), absence of bilateral use of internal mammary artery (p = 0.0035). Likewise, intraoperative variables influencing major adverse outcome (operative mortality and/or need for intra-aortic balloon pulsation) were the following: prolonged aortic cross-clamping time (p < 0.0001), absence of cold-blood cardioplegia (p = 0.0360). In conclusion, global ischemic time was the dominant variable in predicting operative outcome. Furthermore, a protective effect of cold blood cardioplegia and bilateral internal mammary artery grafting was evidenced.

Doppler flow measurement in coronary artery bypass grafts and early postoperative clinical outcome.

The present investigation attempts to correlate flow measurements made intraoperatively in coronary bypass grafts with clinical outcome. A total of 352 consecutive patients undergoing isolated coronary artery surgery underwent hemodynamic assessment of their bypass grafts (328 internal thoracic artery and 582 saphenous vein grafts) at the end of cardiopulmonary bypass (CPB) by using a 8 MHz pulsed Doppler ultrasound flowmeter. The total patient population was divided into three groups of distinct outcome (A: normal, 228 patients; B: complicated, 106 patients; C: poor, 18 patients) on the basis of a combination of the following parameters: difficult weaning from bypass, use of inotropic drugs, reduced left-ventricular stroke work index, myocardial infarction, intraaortic balloon counterpulsation, and death of cardiac origin. Univariate analysis has shown clinical outcome to be influenced by preoperative clinical condition and not by flow in bypass grafts (average flow per graft [ml/min] was 60 +/- 2 [mean +/- SEM] in group A, 58 +/- 3 in group B and 43 +/- 6 in group C: NS by analysis of variance). Multivariate analysis (Fisher linear discriminant analysis) selected only the two following factors leading to normal (group A) or adverse (groups B and C) outcome: unstable angina (p = 0.026) and duration of additional CPB after unclamping the aorta (p < 10(-5). To conclude, clinical outcome was not influenced by flow as measured in well-functioning bypass grafts by pulsed Doppler technique.

Chronic lung abscess due to Pasteurella multocida.

A case of chronic lung abscess due to Pasteurella multocida presenting as a solitary pulmonary mass with a computed tomographic appearance suggestive of malignancy is described.

Peroperative hemodynamic study of left internal mammary artery grafts.

The present study was undertaken to analyse hemodynamic features of an arterial graft and to determine parameters which influence primarily flow and velocity. A total of 284 consecutive patients having isolated coronary bypass surgery underwent peroperative hemodynamic assessment by pulsed Doppler ultrasonics of a left internal mammary artery bypass graft implanted onto the left anterior descending artery. Internal mammary artery free flow was 109.2 +/- 3.7 ml/min and flow in the internal mammary artery measured after completion of the distal anastomosis was 70.9 +/- 2.7 ml/min. All values quoted are mean +/- standard error of the mean. Mean velocity was 21.2 +/- 0.6 cm/sec, internal diameter was 2.65 +/- 0.04 mm and pulsatility index was 2.24 +/- 0.12. Resistance was expressed as mmHg/(ml . min-1) and averaged 1.65 +/- 0.13 for total resistance, 0.87 +/- 0.05 for graft resistance, and 0.73 +/- 0.13 for coronary resistance. From a set of 35 variables, stepwise multiple regression analysis selected two parameters influencing independently flow in internal mammary artery (R2 = 0.8762): flow velocity (p < 10(-4)) and internal diameter (p < 10(-4)). Variables influencing velocity (R2 = 0.3071) were: pulsatility index, which is a dimensionless expression of peripheral resistance (p < 10(-4)), and free internal mammary artery flow (p = 0.0007). Furthermore, a significant correlation between internal diameter and total resistance was observed (R = -0.5363, p < 10(-4), Y = 1.676X-1.545), and the exponentially fitted regression line was characterized by a marked increase of resistance at diameters less than 2 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial revascularization for severe left ventricular dysfunction. Factors influencing early and late survival.

The results of coronary bypass surgery have been assessed in 102 patients with severe left ventricular dysfunction who had a preoperative left ventricular ejection fraction of < or = 0.35 (mean (s.e.m.) 0.29 (0.01)). Independent risk factors influencing operative mortality were obesity (P = 0.0290) and the need for preoperative intra-aortic balloon counterpulsation (P = 0.0010). Cox regression analysis using as its end-point 'cardiac-related death' demonstrated three variables; the need for preoperative intra-aortic balloon counterpulsation (P < 0.001), advanced age (P = 0.011), and obesity (P = 0.36). In a subset of 43 patients who did not have these risk factors, the 4-year cardiac-related death rate was 95.1 (3.4)%. The operative mortality and long-term survival can be expected to be satisfactory in patients with severe left ventricular dysfunction, provided they have a viable myocardium rather than myocardial fibrosis.