Polydioxanone suture material in growing vascular anastomoses. Experimental study.

We studied the growth of vascular anastomoses after use of absorbable suture material in 21 piglets. In six piglets, end-to-end anastomosis of the infrarenal aorta was performed with 5-0 continuous polypropylene suture; stenosis developed in two of these animals. In 15 piglets, continuous polydioxanone sutures were used for the anastomoses, and no stenosis developed. On the contrary, 14 of these anastomoses showed some degree of dilation at the anastomotic site. Burst testing to 300 mm Hg caused no disruption. On histologic examination, only scar tissue at media and intima with good degree of differentiation was noted. Growth of a vascular anastomosis after use of absorbable polydioxanone suture material seems to be perfectly possible without stricture formation. Because the growing process takes years instead of months in human beings, with obviously less stress at the anastomotic site, it is likely that dilatation at the level of the suture line will not occur in clinical use.

Surgery for arteriovenous fistulas and dilated vessels in the right lung after the Glenn procedure.

A superior vena cava-right pulmonary artery (SVC-RPA) anastomosis was constructed in a 2-year-old boy with tetralogy of Fallot. Ten years later and 5 years after "corrective" surgery without removal of the shunt, cyanosis and heart failure developed. Stereocineangiography and lung scanning revealed arteriovenous fistulas and dilated vessels in the right lung. The SVC-RPA anastomosis was taken down, the SVC being reimplanted in the right atrium and the RPA end being closed with a few stitches. Neither lobectomy nor pneumonectomy was performed. Immediately after the operation and during a follow-up period of almost 2 years, the boy has remained asymptomatic. Whenever a correction is planned in a patient with SVC-RPA anastomosis, the vessels of the right lung should be examined by scanning and angiography. If important arteriovenous fistulas do exist, the affected lung should be excluded from the pulmonary artery circulation.

Intrapleural quinacrine instillation for recurrent pneumothorax or persistent air leak.

From 1982 to 1990, 27 patients with recurrent pneumothorax or persistent air leak (28 episodes) underwent pleurodesis with intrapleural administration of quinacrine, according to a standardized scheme. A first evaluation was done about 1 month after the intervention. In August 1990, all patients were invited for a second check-up. In 4 patients quinacrine plasma concentrations were determined. There was one early failure. No late recurrences were observed. Neither serious nor late complications were seen with our low-dose regimen. Transient fever was the only constant side effect. In contrast to other chemicals proposed for pleurodesis, quinacrine did not cause major pain. Only very low quinacrine plasma concentrations (peak, < 10 ng/mL) were found. In conclusion, chemical pleurodesis with quinacrine can be considered a safe and effective treatment. The number of administrations as well as the dosage are important to prevent morbidity and recurrence.

Use of the biomedicus pump in resection of renal carcinoma invading the vena cava.

The authors report a 7-year old boy suffering from a renal carcinoma with a tumoral thrombus invading the vena cava. The kidney and the tumoral thrombus were removed with the help of a Biomedicus pump. This paper shows how to avoid a cardiopulmonary bypass procedure in order to perform safely a tumoral thrombectomy with this relatively new technique.

Intraoperative identification of parathyroid glands with methylene blue infusion.

Intraoperative staining of parathyroid glands with methylene blue was used in 120 cervical explorations for hyperparathyroidism. The dye clearly stained 66 of 67 adenomas (98%) and 194 of 198 hyperplastic glands (98%). No recurrences were observed in 66 patients undergoing surgery for an adenoma. Six of 48 patients (12%) had recurrences of hyperplasia of the parathyroid glands. We found methylene blue to be an effective, safe, and easy applicable method to quickly identify abnormal parathyroid glands, thereby considerably shortening the operating time.

Venous allografts for vascular reconstructions.

In order to evaluate various protocols for the preservation of venous allografts 162 arterial reconstructions were performed in mongrel dogs bypassing their ligated femoral arteries. The cumulative 6-month patency-rates as determined by weekly palpation and regular angiography were. Group I = Synthetic grafts: (a) Dacron 48%, (b) PTFE 53%. Group II = Fresh venous grafts: (a) autografts 100%, (b) allografts 37%. Group III = Veins preserved in saline at 4 degrees C for 1 month: (a) autografts 44%, (b) allografts 34%. Group IV = Veins preserved in saline at -70 degrees C: (a) autografts 58%, (b) allografts 47%. Group V = Veins preserved in glutaraldehyde solution: (a) autografts 26%, (b) allografts 22%. Group VI = Veins preserved in Hanks-solution with 15% DMSO at -160 degrees C: (a) autografts 77%, (b) allografts 35%. Histological as well as immunological studies suggest that these results are determined by the preservation protocol in Groups III, IV and V and by the presence of rejection in Groups I and VI. As the results with the allografts are not superior to those obtained with synthetic grafts, their use should be confined to those cases where the use of synthetic materials should be avoided at any price. Further experiments with immunosuppression and antigenic matching are indicated to see whether this would improve the results obtained with viable venous allografts.

Fistula survival in single needle hemodialysis.

This study presents an average follow up per patient of 33.5 +/- 3.7 and 70.1 +/- 5.9 months (hospital and home dialysis) showing an actuarial fistula survival rate of 86.2% and 85.5% respectively after 5 years. The data suggest a satisfactory survival rate of the fistula when a single needle technique is used in comparison to the survival observed with the two needles technique.

Peritoneal lavage after abdominal trauma: indications, technique, results.

This study represents our experience with 1461 patients who were seen in the Emergency Room of the University Hospital in Ghent with multiple traumatic lesions, between 1978 and 1982. In 43% of these polytraumata, we did an explorative peritoneal lavage in order to obtain a quick evaluation of intrabdominal haemorrhage. In 65% of the patients, the lavage was negative; 221 positive lavages (35%) underwent abdominal exploration; in 85% of these there were evident positive findings. The remaining 15% showed either no lesions, or minor lesions not involving risk of life. The overall accuracy-rate of the technique described above is at least 93%.

Cardiac contusion.

During a consecutive period of 24 months, 244 patients with a major trauma were admitted to the Intensive Care Unit. From this pool of patients 60 consecutively were selected who did fulfill the selected criteria. We intended to determine within this studygroup the incidence, clinical features and outcome of patients with myocardial contusion (MC). We could conclude that no currently used diagnostic test may be seen as an accurate prediction of patients who still develop morbidity or mortality from cardiac contusion. Data from the literature suggest that at present only radionuclide angiography, direct hemodynamic measurement with construction of a Starling curve, and/or 2D-echocardiography may be useful in the identification of the patients at the greatest risk and predictive of the severity of the myocardial injury.

[Intraoperative identification of parathyroid glands with methylene blue (author's transl)]. / Peroperatoire identificatie van de parathyroïden na methyleenblauwkleuring.

Identification of parathyroid glands during surgery for treatment of hyperparathyroidism remains difficult. The staining with methylene blue was first described by Dudley. Twenty-one patients were explored. Thirty to sixty minutes before surgical incision, an intravenous perfusion of methylene blue was started. The dose varied between 5 to 10 mg per kg. Thirty-seven enlarged glands were found of which 33 were obviously stained; 13 showed some color that could not be attributed with certainty to the dye; 1 adenome was not stained at all. In 89.2% of the cases the staining had the favorable effect of shortening the operation. Only 4 normal glands showed the blue stain. The affinity for methylene blue is thus mainly found in pathological parathyroid glands.

Portal derivation surgery in children. A long-term follow-up report.

Eight children and two adults with portal hypertension were treated by portal diversion surgery. In all cases recurrent gastro-intestinal bleeding from esophageal varices was the indication for shunt-operation. Still in early childhood, three of these patients had had a splenectomy in other hospitals: one emergency splenectomy for hemoperitoneum and two elective splenectomies for hypersplenism. Three operative techniques were used: 5 spleno-renal shunts, 3 meso-caval shunts and 2 porto-caval shunts. All, but one, were followed over a period from 2 to 13 years after shunt-surgery. There was no mortality in this series. After shunting all children remained free of esophageal bleeding. We did not find any complication directly related to the shunt procedure.

[Current trends in the surgical treatment of chronic pancreatitis]. / Nieuwe trend in de heelkundige behandeling van chronische pancreatitis.

Since May 1980, we started treating patients suffering from chronic pancreatitis with pancreatic duct obstruction. During surgery, prolamine, a alcoholic amino-acid solution, was injected into the pancreas through the papil of Vater or directly into the pancreatic duct following pancreatic tail resection. So far thirteen patients were treated this way. Operative mortality was nil and complications were minimal. There were no clinical recurrences of pancreatitis after nearly two years of follow-up.

Anastomotic aneurysms of the femoral anastomosis after aortic bifurcation graft.

A 17 year experience (1958-1975 with anastomotic aneurysms of the femoral anastomosis after aortic bifurcation graft is presented. An anastomotic aneurysm is a progressive dilatation of an anastomosis between an artery and a prosthesis, caused either by a defective suture line or by a wall dilatation. One thousand one hundred and eighty-four femoral anastomoses with a decent follow-up were reviewed and 89 aneurysms were encountered, a per site incidence of 7.5%. Aetiological agents were arterial hypertension, non-infective bad wound healing, type of suture material, defect of the graft and trauma. The therapeutical approach with only 12% recurrences is a segmental interposition. The rate of satisfactory results was 78%. By reducing our bad wound healing from 15 to 10% of the anastomoses over the last five years, we reduced considerably our percentage of anastomotic aneurysms. The use of ultraleight weight prostheses seems to have also reduced the incidence and, in our study that we closed in December 1975, we encountered no aneurysm on Cooley or Milliknit, even with a follow-up of four years. Since the end of the study, however, we encountered one case of bilateral anastomotic aneurysm with Milliknit, one year after the primary operation but with a definite trauma in the anamnesis.

Aorto-enteric fistula as clinical entity.

A 19 year experience (1958-1977) with aortoenteric fistulas is presented. An aorto-enteric fistula is a direct communication between the aortic lumen and the gastro-intestinal tract producing a gastro-intestinal bleeding. The commonest cause of a primary or spontaneous aorto-enteric fistula is aneurysm formation. If there has been an operation on the aorta then the aorto-enteric fistula is called secondary. No primary aorto-enteric fistulas were encountered but thirteen secondary aorto-enteric fistulas are reported on a total of 841 aorto-femoral by-pass operations reviewed. Six hundred and sixty-one of these had an acceptable follow-up: this gives a 2% incidence. Our survival rate is 40%. Four different possible mechanisms are proposed for the formation of the secondary aorto-enteric fistula: anastomotic aneurysm formation, fibrous reaction, intra- or postoperative contamination or a combination of these possibilities. Some etiological factors as type of anastomosis, suture material, prosthesis material, hypertension, end-arterectomy and preoperative aneurysmatic tendency are analysed. A study is made of the different available diagnostic tools and the different possible therapies are discussed.

Two-stage orchiopexy.

A number of well known complications and disorders force operative correction of cryptorchism, once the diagnosis of true cryptorchism is certain. In order to perform a successful orchiopexy, an extensive mobilization of the testis, up to the kidney, is sometimes needed. However, one can not always bring the testis down to the bottom of the scrotum. In this case it seems reasonable to bring the testis as low as possible. A second exploration can be planned, a few years later and, in most cases, the testis will then easily be brought down to the bottom of the scrotum. In our series (76 patients with unilateral or bilateral cryptorchism, between January 1967 and December 1978), 7 patients have been treated according to this procedure: four underwent a successful two-stage orchiopexy, two patients are waiting for the second intervention and one had a bilateral orchiectomy. A review of the literature reveals only a small number of attempts to staged orchiopexies. These small series are completely comparable to our series.

[A case of post-traumatic aortic valve insufficiency (author's transl)]. / Een geval van posttraumatische aortaklepinsufficiëntie.

A case of posttraumatic aortic valve insufficiency is presented. A brief discussion of etiology, mechanism, evolution, diagnosis and treatment is included. Some important historical events are reviewed from the literature. The treatment of this uncommon heart injury is aortic valve replacement. In this case an intimal repair also had to be done.

Repair of a high esophageal stenosis with a mucosal flap of a Zenker's diverticle.

A patient presented an esophageal stenosis due to lasertherapy by Dohlmann's technique for the treatment of a Zenker's diverticle. This esophageal stenosis has been repaired by taking a mucosal flap out of the Zenker's diverticle. The technique is presented in this paper, together with some analogue data from literature.

[Surgical repair of a congenital cervical lung hernia in a baby (author's transl)]. / Chirurgisch herstel van een congenitale cervicale hernia van de long bij een zuigeling

Case report of a congenital cervical lung hernia causing serious feeding and respiratory problems in a 5 1/2 months old baby. Surgical repair of the endothoracic fascia defect with a MARLEX mesh. As far as we know the first report of a surgical repair of a congenital cervical hernia in an infant. Review of frequency, signs and therapy of lung hernia in literature. Analysis of the anatomic situation of a lung hernia in the cervical region.

Transthoracic vagotomy for recurrent peptic ulcer after gastrectomy. An appraisal of fifteen years experience.

The case records of 38 patients operated for recurrent ulcer following partial gastrectomy were examined. They all underwent a transthoracic vagotomy. Two patients died during follow-up, one because of a gastro-intestinal bleeding 14 days after operation and one following a psychiatric disorder (vital depression) three months after his second intervention. According to Visick's grading overall results are very good in 89%, moderate in 5.5% and disappointing in 5.5%. These figures indicate that transthoracic vagotomy is the treatment of choice for recurrent ulceration after partial gastrectomy.

[Therapeutic strategy in the cold nodule of the thyroid (author's transl)]. / Therapeutische houding bij een "koude" knobbel in de schildklier.

The benign or malignant nature of a cold nodule in the thyroid can never be definitely assessed before surgery. All cold nodules that show no tendency to regress must be resected. The nodule is resected with surrounding healthy tissue and immediately examined in freezen sections. Out of 108 cases of simple resection of the nodule only one diagnosis of carcinoma was missed at the operation. That patient was reoperated two weeks later with curative intention.