[Experiences in surgical management of acute arterial occlusions of the lower limb in the course of 20 years]. / Az alsó végtag akut veroér-elzáródásának sebészi kezelésével 20 ev során szerzett tapasztalataink.

INTRODUCTION: In Hungary surgeons perform every year more then 2000 operations for treatment of acute arterial occlusion. Because of the advanced age and poor general condition of these patients, the postoperative mortality and complication rate is considerable. AIM: Authors analyzed changes in the etiology and therapy of acute arterial occlusions of lower limb in the last 20 years in a retrospective study. PATIENTS AND METHODS: 563 patients were operated on with acute arterial occlusion of lower extremities from 1983 to 2002 by the authors. Patients with vascular surgery in their history were excluded from this study. Student's two-samples "t"-test, chi2- and Fisher's exact test were used in Statistica 6.0 for statistics. RESULTS: Period of 1983-1992 compared to period of 1993-2002 they found increased rate of occlusions caused by thrombosis (35 vs. 46%, p < 0.01) and increased number of acute vascular reconstructions performed with indication of acute thrombosis (17.6 vs. 47.0%, p < 0.001). Mortality was higher in patients operated with embolism than in patients with thrombosis (17.7 vs. 11.6%, p < 0.01), but the ratio of postoperative amputation following embolectomy was lower than following thrombectomy (5.0 vs. 16.0%, p < 0.01). Thrombectomy itself could solve the occlusion caused by thrombosis only in 50% of cases. Results of reoperations following unsuccessful thrombectomies are very poor. Amputation was necessary in 6.8% (in 5 cases of 74 patients) after primary reconstructions, but in 28.6% (in 14 cases of 49 patients) after reoperations. There was no significant difference in postoperative mortality among primary reconstructed, reoperated and conservatively treated groups. CONCLUSIONS: By author's experience, in cases of acute occlusion caused by thrombosis as a complication of chronic obliterative arterial disease, basic cause of occlusion should be searched for and--if conditions are suitable--procedure should be extend to vascular reconstruction.

[Early results after aortoiliac reconstruction in our department in the past six years]. / Aortoiliacalis rekonstrukciók korai eredményei klinikánk 6 éves beteganyagában.

The authors analyze early postoperative results of 320 patients operated on because of aortoiliac occlusion. The mortality of the interventions was 4.1%, the proportion of reocclusions was 7.2% and the rate of amputations was 3.1%. The operations were as follows: 88 aorto-bifemoral bypasses, 157 iliofemoral bypasses, 75 iliofemoral thrombendarteriectomies. There were no statistical variations in the rate of mortality, complications and amputations between different types of operations. Comparing the results of aortobifemoral bypasses with opening of the peritoneal cavity (6 patients died of 74, i.e. 8.1%) with those performed retroperitoneally (14 patients no death), despite the marked difference there was no significant difference probably due to the small number of patients (p = 0.34). In 26% it was necessary to extend the reconstructions distally to peripheral arteries or deep onto the profundal femoral artery. The peripheral extension did not effect early mortality, or amputation rate. Seven patients needed reoperation because of general surgical reasons, with 2 mortalities (28.6%), both had bowel necrosis; mortality rate was significantly higher compared to other patients (p < 0.05). Vascular complications developed in 30 cases. The mortality and the amputation rate of 27 reoperated patients was 3.7%, which did not differ significantly from the results of other patients group. Fifteen operations were carried out because of acute ischaemia, 4 patients were lost (26.7%), significantly more than after elective operations (305/9, 2.95%, p < 0.01). In our department retroperitoneal approach in aortobifemoral bypasses decreased mortality. If the quality of the outflow is uncertain or insufficient, one has to consider immediate distal extension. We must to do everything to prevent--or to diagnose and treat--bowel necrosis. The mortality rate of aortoiliac occlusions causing acute ischaemia is high, therefore we must consider the adoption of extraanatomical bypasses.

[Chronic pancreatitis combined with obliterative arterial disease]. / Chronicus pancreatitis és obliteratív veróérbetegég együttes elófordulása.

We performed a prospective study at the 1st Surgical Department, Semmelweis University Budapest between 1996 and 2000, in which we examined the common occurrence of chronic pancreatitis and obstructive vascular disease in patients admitted to our department because of either of these illnesses. There were 37 patients suffering from both diseases, all are included in our trial. Control groups were set up of 50 consecutive chronic pancreatitis patients and 50 consecutive vascular patients. In all patients with two disease chronic pancreatitis developed earlier than vascular disease. Occurrence of vascular disease is twice as common among patients with chronic pancreatitis as in normal population. Risk factors like smoking, coffee-abuse and alcohol, which might trigger both diseases, didn't vary in the three groups. This combination of diseases usually starts in the young, and causes severe and progressive deterioration in the quality of life. In four patients after operations performed because of chronic pancreatitis, peripheral arterial operation was also necessary. Operative mortality rate in the chronic pancreatitis group was 2%, in vascular patients 4% and in the group with both diseases it was 16%. We found in our study that there is relation between chronic pancreatitis and peripheral obstructive vascular disease. Further examinations are necessary to examine the etiology. In patients with chronic pancreatitis we must always think of the possibility of later obstructive vascular disease.

[Role of extra-anatomical bypasses in the treatment of aorto-iliac occlusion]. / Az extraanatomicus áthidalások szerepe az aortoiliacalis veróér elzáródás kezelésében.

In the last six years we have performed 468 operations because of aortoiliac occlusion or septic complications of these arteries. 410 (87.6%) of these operations were anatomical reconstructions, in 58 (12.4%) patients we performed extra anatomical bypasses. The distribution of the operations was the following; 12 obturator, 23 femoro-femoral crossover, 13 axillofemoral and 10 axillobifemoral bypasses. The indication for extra-anatomical reconstruction in 24 (41.4%) patients was septic complication (EABS), and in 34 cases (58.6%) poor general condition or difficulties during surgery. The average age of the patients with non-septic indication (EABNS) was significantly higher than the average age of the patients treated with anatomical reconstruction (AR) (66.3 vs. 60.9 year, p < 0.01). There were more REDO operations in the group EABNS then in the AR group (35.3%/11.7% p < 0.02). Despite of the high operative risk, the rate of early complications (EABNS 13.8%, AR 10%) and postoperative mortality (EABNS 3.7%, AR 4.0%) was not statistically different between the two groups. If the indication was aorto-duodenal fistula (6 patients) or acute limb ischaemia (7 patients), the mortality was significantly higher compared to other extra-anatomical operations (46.2% vs. 4.4%, p < 0.01). The postoperative mortality after EABNS and EABS operations was similar (11.7% vs. 16.6%), but we performed more reoperations after EABS operations (10/24 vs. 2/34, p < 0.05). According to our early postoperative results elective extra-anatomical bypasses are suitable for the treatment of aortoiliac occlusion in high risk patients, with poor life expectancy. Extra-anatomical bypasses are performed because of acute ischemia or septic complications which are life or limb threatening complications, so early results must be validated concerning this fact.