The art of surgery.

, Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10863 In times when art usually depicted perfection, Caravaggio (1571-1610) painted everyday reality. He used people walking the streets of Rome to represent holy figures. Caravaggio loved many women. He killed a man in a duel and had to flee from Rome to avoid being 'beheaded by anybody who saw him'. In this biblical scene he painted, Judith Beheading Holofernes, Judith is a portrait of Fillide Melandroni, the reason for the duel. Holofernes is a self-portrait. Judith looks cruel, in mourning clothes, seeking revenge for the assassination of her lover. The maidservant, almost an evil spirit, has a voluminous thyroid goitre, and she seems to encourage the revenge of Fillide. Read more about Caravaggio and this painting in an essay online.

Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results.

AIM: To treat patients with rectovaginal fistula after anterior resection for cancer using self-expanding metal stents. METHOD: Ten patients of mean age of 56.3 years with rectovaginal fistula after colorectal resection for cancer were treated with endoscopic placement of a self-expanding metal stent. In three patients a diverting proximal stoma had been performed elsewhere. The rectal opening of the fistula was located from 3 to 10 cm from the anal verge (mean 6 cm). All patients had preoperative radiotherapy. In seven patients the stent was placed as the initial treatment while three referred patients had had multiple failed operations. RESULTS: There were no complications after the procedure. At a mean follow-up of 24 months the rectovaginal fistula has healed without major faecal incontinence in eight patients. In the remaining two the fistula has reduced significantly in size to allow a successful flap transposition. CONCLUSION: Endoscopic placement of a self-expanding metal stent is a valid adjunct to treat patients with rectovaginal fistula after colorectal resection for cancer.

Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer.

AIM: To evaluate the use of self-expandable metallic stents to treat patients with symptomatic benign anastomotic stricture after colorectal resection. METHOD: Ten patients with a benign symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. RESULTS: The stent was placed successfully in all 10 patients without any major morbidity. At a mean follow-up of 18 months the stenosis was resolved successfully in 7 out 10 patients (70%). The remaining three patients were subsequently treated successfully with balloon dilatation. CONCLUSION: Self-expandable metal stents represent a valid alternative to balloon dilatation to treat patients with benign symptomatic anastomotic stricture after colorectal resection for cancer.

Self-expanding metal stents for treatment of anastomotic complications after colorectal resection.

Self-expanding metal stents (SEMS) can be used to treat patients with symptomatic anastomotic complications after colorectal resection. In the present case series, 16 patients with symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of SEMS. Seven patients had a "simple" anastomotic stricture and nine patients had a fistula associated with the stricture. The anastomotic fistula healed without evidence of residual stricture or major fecal incontinence in seven of the nine patients. Overall the anastomotic stricture was resolved in 10 of the 16 patients. SEMS placement represents a valid adjunctive to treatment in patients with symptomatic anastomotic complications after colorectal resection for cancer.

Operative strategies in patients with symptomatic internal carotid artery occlusion.

A 15-year experience with 98 patients who underwent extracranial artery reconstruction for symptomatic internal carotid artery occlusion is reviewed. Thromboendarterectomy of the occluded carotid artery resulted in unacceptably high mortality and morbidity rates, and long-term patency of the internal carotid artery was rarely achieved. Carotid endarterectomy on the side opposite the occlusion proved to be successful in relieving nonlateralizing symptoms of cerebral ischemia, whereas results were less encouraging in patients with focal symptoms in the hemisphere ipsilateral to the occlusion. External carotid artery reconstruction on the side of the occlusion was successful in relieving focal symptoms. Surgical treatment in patients with symptomatic internal carotid artery occlusion should be planned in each patient on the basis of symptoms and anatomic pattern.

Thoracic aorta as source of inflow in reoperation for occluded aortoiliac reconstruction.

We reviewed our experience with reoperations for recurrent obstruction occurring after aortoiliac or aortofemoral reconstruction. Patients who underwent successful transfemoral thrombectomy of the aortofemoral graft or femorofemoral crossover graft were excluded from the study. A more proximal source of inflow to revascularize the ischemic limbs was required in the remaining 35 patients. Bilateral reconstruction was performed in 22 patients. Operative indication was rest pain or necrosis in 36 limbs and severe claudication in 21 limbs. Preoperative ankle/brachial pressure index (API) ranged from 0.05 to 0.61. Thirteen patients (21 limbs, group I) underwent transabdominal reoperation. Since the transabdominal approach was considered hazardous because of multiple previous operations, the remaining patients underwent retroperitoneal descending thoracic aorta-femoral artery bypass (15 patients, 25 limbs; group II) or axillofemoral bypass graft (7 patients, 11 limbs; group III). No statistically significant difference was present between the three groups in regard to the operative indication, API, and angiographically determined outflow (analysis of variance, p greater than 0.2). Axillofemoral bypass was preferred in patients with severe chronic pulmonary disease. Postoperative deaths (2 of 35 patients) and morbidity (6 of 35 patients) had a similar incidence in the three groups (p greater than 0.2). Follow-up ranged from 3 to 120 months (mean 37 months). The 5-year actuarial patency rate was 80.5% for group I and 80.2% for group II. In group III it was statistically lower (32.9%, p less than 0.05). Serial measurement showed a significant decrease of API in group III compared with group I and group II. We conclude that retroperitoneal descending thoracic aorta-femoral artery bypass is a valid alternative to transabdominal reoperation when exposure or availability of the abdominal aorta poses a specific hazard and is preferable to axillofemoral bypass in terms of long-term patency and hemodynamic results.

Healing of high-porosity polytetrafluoroethylene arterial grafts is influenced by the nature of the surrounding tissue.

The aim of this study was to determine the influence of the nature of the perigraft tissue in the healing pattern of high-porosity polytetrafluoroethylene (PTFE) vascular grafts. Nine-centimeter long segments of unreinforced experimental high-porosity (60 microns) PTFE grafts were placed as abdominal aortic interposition in mongrel dogs. Three grafts served as controls (group A); in five dogs (group B) a 25 x 25 cm piece of devascularized omentum was wrapped around the graft. In five dogs (group C) the omentum with its own vascular supply was completely wrapped around the graft. Animals were killed 4 weeks after surgery. The percentage of thrombus-free area was 31% in group A grafts, 39% in group B grafts, and 79% in group C grafts (p less than 0.01). Scanning electron microscopy showed many confluent areas of endothelium-like cells in the midportion of group C grafts, corresponding to capillary ingrowth. Transmural endothelial migration was more evident in group C grafts. We conclude that the nature of the perigraft tissue influences transmural capillary migration and the endothelialization rate of high-porosity PTFE grafts in dogs. Agents able to increase capillary formation in the perigraft tissue might improve endothelialization of vascular grafts.

Subclavian artery revascularization: a comparison between carotid-subclavian artery bypass and subclavian-carotid transposition.

Extrathoracic revascularization has become the most popular form of surgical treatment of symptomatic subclavian disease. Despite the many theoretical advantages, subclavian-carotid transposition (SCT) has not gained wide popularity. During a 15-year period, 46 patients underwent carotid-subclavian bypass (CSB) or SCT for symptoms referable to occlusion of the subclavian artery. Follow-up ranged from 2 to 148 months (mean, 46.9 months). Seven-year actuarial patency rate was 100% for SCT and 86% +/- 7% for CSB (p = NS). Mean operative time and intraoperative blood loss were significantly reduced for SCT (p less than 0.05). After CSB a continuous deterioration of the hemodynamic status of the reconstruction was noted, whereas there were no significant changes after SCT (p less than 0.05). Whenever feasible, SCT should be considered the operation of choice for patients with symptomatic severe subclavian artery disease.

Shear stress modulates the proliferation rate, protein synthesis, and mitogenic activity of arterial smooth muscle cells.

BACKGROUND: The aim of this study was to determine the correlation between hemodynamic forces and proliferation of smooth muscle cells (SMC). METHODS: Bovine arterial SMC were seeded in a fibronectin-coated polystyrene cylinder at 5 x 10(5) cells/tube and allowed to reach confluence and to adhere for 48 hours. The experimental groups were subjected to a laminar flow of 150 ml/min (9 dyne/cm2), 100 ml/min (6 dyne/cm2), and 50 ml/min (3 dyne/cm2) for 24 hours. The control group was subjected to similar incubation conditions without flow. The cells in the experiments remained attached and viable. All experiments were performed in triplicate or more. RESULTS: Shear stress significantly reduced (p < 0.001) the 24-hour incorporation of tritiated thymidine and cell proliferation. This effect was proportional to the level of shear stress and was still evident 24 hours after flow cessation. Results of flow cytometry confirmed a lower percentage of SMC in S phase with increasing shear stress. Synthesis of cell-associated proteins was increased twofold (p < 0.01) in SMC subjected to laminar flow. SMC subjected to shear stress released a higher quantity of mitogens, including a platelet-derived growth factor (PDGF)-like substance as detected by immunologic testing. Fifty percent volume per volume conditioned serum-free medium from SMC subjected to shear stress increased threefold the tritiated thymidine uptake in PDGF receptor-bearing Swiss 3T3 cells as compared with conditioned serum-free medium from control SMC not subjected to shear stress and twelvefold as compared with standard control. The release of mitogens was proportional to the level of shear stress and was still evident 24 hours after flow cessation. The mitogenic activity was partially reduced (30%, p < 0.01) by an excess of monospecific anti-PDGF antibody. CONCLUSIONS: We conclude that (1) increasing shear stress inhibits SMC proliferation and stimulates the synthesis of cell-associated proteins and the release of mitogens and (2) decreasing shear stress facilitates proliferation of SMC. Thus, in situations of arterial flow separation, the increased release of mitogens from SMC subjected to high shear stress and the increased proliferation rate and susceptibility to mitogens of SMC subjected to very low shear stress may generate a critical condition that predisposes to the development of atherosclerosis with early plaque formation in regions of low-flow shear stress.

Shear stress induces transforming growth factor-beta 1 release by arterial endothelial cells.

BACKGROUND: Myointimal hyperplasia is a common complication after vascular reconstruction. Increasing shear stress has been shown to reduce formation of myointimal hyperplasia. The aims of our study were (1) to analyze the correlation between shear stress and release of transforming growth factor (TGF)-beta 1 by endothelial cells and (2) to determine the effect of TGF-beta 1 on smooth muscle cell proliferation. METHODS: Bovine arterial endothelial cells were subjected to increasing shear stress in an in vitro serum-free system. The release of TGF-beta 1 by endothelial cells was assessed by enzyme-linked immunosorbent assay and Western blot analysis. The effect of TGF-beta 1 on the proliferation of the subconfluent monolayer of bovine smooth muscle cells was determined by tritiated thymidine uptake. RESULTS: Shear stress induced a significant increase of the release of TGF-beta 1 by endothelial cells (p < 0.001). This phenomenon was proportional to the level of shear stress. The amount of TGF-beta 1 released by endothelial cells subjected to shear stress had a significant inhibitory effect on growth rate and tritiated thymidine uptake of smooth muscle cells. CONCLUSIONS: On the basis of the results of our study, we conclude that increasing shear stress induces release of TGF-beta 1 by arterial endothelial cells in a concentration that has a clear inhibitory effect on smooth muscle cell proliferation. This phenomenon could explain the inhibitory effect of increasing shear stress on the formation of myointimal hyperplasia.

Ultrasonographic features of carotid plaque and the risk of subsequent neurologic deficits.

In a prospective study, 214 consecutive patients considered not to be candidates for surgical intervention were evaluated by means of duplex scanning. Of the patients, 135 had no symptoms and 79 had a history of previous neurologic symptoms. In 139 sides duplex scanning demonstrated nonhemodynamic stenosis (lumen diameter reduction, less than 50%) and in 99 sides, hemodynamic stenosis (lumen diameter reduction, 50% or greater). Of the 238 carotid artery plaques examined, 167 were homogenous and 71 were heterogenous. During a mean follow-up of 34 months, 27 new focal neurologic deficits occurred. Patients with previous symptoms had a higher incidence of new deficits (18/79 vs 9/135) (p less than 0.01). The severity of the stenosis and the presence of a heterogenous plaque were statistically correlated with the occurrence of new deficits (p less than 0.001). Multivariate analysis showed that the ultrasonographic pattern and the severity of the stenosis were independent variables. We conclude that a heterogenous plaque should be considered an unstable plaque with the possibility of causing cerebral ischemia.

Shear stress increases the release of interleukin-1 and interleukin-6 by aortic endothelial cells.

BACKGROUND: The aim of this study was to determine the correlation between shear stress and the release of interleukin-1 (IL-1) and interleukin-6 (IL-6) by endothelial cells (EC). METHODS: Bovine aortic EC were seeded in fibronectin-coated cylinders at 1.0 x 10(6) cells/tube and allowed to reach confluence and to adhere for 48 hours. The experimental groups were subjected to a laminar flow of 100 ml/min (6 dyne/cm2). The control group was subjected to similar incubation conditions without flow. The release of IL-1 and IL-6 by EC was measured by enzyme-linked immunosorbent assay. RESULTS: Shear stress increased significantly (p < 0.01) the release of IL-1 and IL-6 by EC. The release of these two cytokines had different kinetics. CONCLUSIONS: Increasing shear stress facilitates release of IL-1 and IL-6 by EC. Previous reports have shown that IL-1 and IL-6 promote vascular smooth-muscle cell proliferation. Thus abnormal flow conditions with increasing shear stress may predispose to smooth-muscle cell proliferation that characterizes early atherosclerotic plaque development by an interleukin-mediated mechanism.

Growth factor production by arterial and vein grafts: relevance to coronary artery bypass grafting.

BACKGROUND: Occlusion caused by myointimal hyperplasia, atherosclerosis, or both is the main reason for late failure of saphenous vein coronary artery bypass grafts. On the other hand, internal mammary artery grafts are usually spared from atherosclerosis. Evidence exists that platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) are involved in the genesis of myointimal hyperplasia and atherosclerosis. The aim of this study was to assess the production of PDGF and bFGF by arterial and vein grafts. METHODS: In 20 inbred Lewis rats alpha 1 cm long segment of arterial graft was interposed at the level of the abdominal aorta. In a control group of 20 Lewis rats alpha 1 cm long segment of vein graft was implanted at the level of the abdominal aorta. Animals were killed 4 weeks after operation, and the grafts were studied in serum-free organ culture to assess the production of PDGF and bFGF. RESULTS. Arterial grafts produced a smaller quantity of PDGF and bFGF than vein grafts (p < 0.01) Higher mitogenic activity was present in the conditioned media from vein grafts than in the conditioned media from arterial grafts (p < 0.001). A large amount of myointimal hyperplasia was present in all vein grafts. CONCLUSIONS: This phenomenon could explain the rarity of atherosclerotic changes in internal mammary coronary bypass grafts.

Formation of myointimal hyperplasia and cytokine production in experimental vein grafts.

BACKGROUND: The purpose of this study was to determine the correlation between progression and regression of myointimal hyperplasia (MH) and cytokine production in experimental vein grafts. Although the autologous vein is the best suitable bypass conduit for reconstruction of peripheral arteries, at the end of the first year thrombosis in the coronary and lower extremity circulation ranges from 20% to 50%. Many of these failures are caused by MH. METHODS: In 76 inbred Lewis rats, a 1 cm long segment of inferior vena cava was inserted at the level of the abdominal aorta. The segments of inferior vena cava were obtained from syngeneic Lewis rats. In 56 animals the arterial vein graft was explanted 3 days (n = 10), 7 days (n = 10), 4 weeks (n = 26), and 12 weeks (n = 10) after operation. In 20 animals the vein graft was explanted 4 weeks after being in the arterial system and reimplanted as iliac venovenous bypass in syngeneic Lewis rats. These grafts were explanted 2 weeks (n = 10) and 8 weeks (n = 10) later. Grafts were analyzed by light and electron microscopy, morphometric study, and histochemical analysis and were put in an organ culture to assess cytokine production. RESULTS: We observed MH formation in arterial vein grafts and MH regression in reimplanted vein grafts (p < 0.001). MH formation was correlated with production of platelet-derived growth factor, basic fibroblast growth factor, interleukin-1, and tumor necrosis factor-alpha. MH regression was correlated with transforming growth factor-beta 1 production. CONCLUSIONS: On the basis of the results of our study, we conclude that MH formation in experimental vein grafts depends on production of platelet-derived growth factor, basic fibroblast growth factor, interleukin-1, and tumor necrosis factor-alpha, and MH regression depends on transforming growth factor-beta 1 production. Cytokine therapy may represent a valuable new treatment to prevent vein bypass failures caused by MH.

Combined aortofemoral and extended deep femoral artery reconstruction. Functional results and predictors of need for distal bypass.

In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required.