Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial.

OBJECTIVE: The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT). METHODS: A total of 246 patients, comprising 128 men (mean age, 54.28±16.48 years) and 118 women (mean age, 50.11±16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events. RESULTS: Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P<.001), and the circumference of the affected leg (P<.001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P<.001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P<.001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P<.001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications. CONCLUSION: Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline.

Direct CT venography for evaluation of the lower extremity venous anomalies of Klippel-Trenaunay Syndrome.

OBJECTIVE: Our aim was to describe the technique of direct CT venography and to describe various forms of venous anomalies detected with CT venography in patients with Klippel-Trénaunay syndrome. CONCLUSION: MDCT is helpful for visualizing the full length of extremities and for evaluating length and thickness on one image.

Surgical approach to the management of cardiovascular echinococcosis.

OBJECTIVE: Echinococcosis is a serious health problem in some regions of the world. Although cardiovascular hydatid cyst is rare, its early diagnosis and surgical management is important. METHODS: We reviewed 10 patients with cardiovascular hydatid cyst who underwent surgery in our department between January 1982 and 2007. Standard cardiopulmonary bypass and antegrade cardioplegia with aortic cross-clamping were used in all but one patient. After the cysts were removed, the cavity was cleaned and then obliterated with purse-string sutures. Albendazole was used in all patients. The mean follow-up was 4.5 years. RESULTS: The mean age was 27 years (range 12 to 76 years). Eight patients were men. The hydatid cysts were located on left ventricle (five patients), left atrium (two patients), right ventricle (three patients), right atrium (one patient), pericardium (one patient), and aorta (one patient). Except for two patients who died, all were discharged without postoperative complications. There was no late cardiac mortality or recurrence. CONCLUSIONS: Cardiac hydatid cyst should be treated surgically without delay. Although its surgical treatment carries a high complication rate, gentle handling of the heart during cardiopulmonary bypass minimizes operative risk.

Isolated penetrating gluteal injuries.

In the authors' institution, 27 patients with gluteal injuries were treated surgically during the past 17 years. All patients were males, and the mean age was 32.4 years. Most patients (89%) had stab wounds. The lesion was on the right buttock in 16 (59%) patients and on the left buttock in 11 (41%) patients. Bleeding was the most common presenting sign. The superior gluteal artery and its branches were the most commonly injured arteries (89%). Surgical procedure was arterial ligation alone in all but one case, whereas one patient underwent coil embolization. Mortality was 11% and included 1 death on arrival to the medical center and 2 intraoperative deaths. To achieve a low rate of morbidity and mortality with such injuries, careful physical examination and immediate surgical or endovascular treatment is needed.

The effect of high dose melatonin on cardiac ischemia- reperfusion Injury.

PURPOSE: Melatonin, the most potent scavenger of toxic free radicals, has been found to be effective in protecting against pathological states due to the release of reactive oxygen species. This study was performed to establish the effect of high dose melatonin on protection against ischemia- reperfusion (I/R) injury in rat hearts. MATERIALS AND METHODS: Forty male Sprague-Dawley rats were used in this study. They were separated into four groups of ten rats each. A left coronary artery occlusion was induced in the rats by ligating the artery for 20 minutes and then releasing the ligation (reperfusion) afterwards. The control group was Group A. Group B was subjected to myocardial ischemia-reperfusion without any treatment, while Group C underwent myocardial ischemia-reperfusion with a melatonin treatment before the ischemia. Group D was subjected to myocardial ischemia-reperfusion with a melatonin treatment before the reperfusion. After 20 minutes of reperfusion, blood samples were obtained from each group for biochemical studies, and the animals were sacrificed for histological and, immunohistochemical examinations of the myocardial tissue. RESULTS: We found that the cardiac troponin T(cTn-T) levels were significantly increased in Group B when all groups were compared. In the Group C rats treated with melatonin, the cTn-T values were significantly lower than those in Groups B and D. In addition, malondialdehyde (MDA) and antioxidant enzymes including, superoxide dismutase (SOD) and myeloperoxidase (MPO) were lower than those in Group B in the melatonin treated groups. The differences were statistically significant (p < 0.05). Histopathologic and immunohistopathologic studies also supported the effectiveness of melatonin. CONCLUSION: Our study suggests that high dose melatonin, appears to offer protection against cardiac ischemia-reperfusion injuries in rats by scavenging the free radicals and could have a potential clinical use in the management of myocardial ischemia.

Endovascular treatment of lower limb penetrating arterial traumas.

PURPOSE: The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma. MATERIALS AND METHODS: Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients. RESULTS: On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient. CONCLUSIONS: We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Angiomyolipoma with cavoatrial extension.

In this paper, we report a case of angiomyolipoma with cavoatrial extension in a 55-yr-old woman. Multislice computed tomography revealed a hypodense mass extending into the right atrium through the right renal vein and inferior vena cava without a renal mass. The patient underwent surgery, and right atrial mass was resected. Pathologic evaluation revealed a tumor consisting of mature adipose tissue, smooth muscle and vessels consistent with angiomyolipoma. Our case reminds us of the rare possibility that angiomyolipoma, which is classified as a benign tumor, may invade the inferior vena cava or right atrium.

Benefits of early aggressive management of empyema thoracis.

BACKGROUND: The end-target of the management of thoracic empyema is to obtain early rehabilitation by re-expansion of the trapped lung resulting from intrapleural infected material. Our aim was to shorten the hospitalization time and to prevent a possible thoracotomy by using video-assisted thoracoscopy initially. METHODS: Seventy patients with parapneumonic empyema were prospectively studied between January 1997 and June 2004. The patients were randomly divided into two groups. In group I (n = 35 patients), a chest tube was inserted into the patients after pleural content was evacuated and fibrins were debrided using video-assisted thoracoscopy. In group II (n = 35 patients), tube thoracostomy was carried out without using a video-assisted thoracoscope. Both groups were compared in terms of hospitalization time, open surgery for decortication and complications. RESULTS: There was no statistically significant difference between the groups from the point of view of age and sex (P > 0.05). In group I, 17.1% of the patients underwent open decortication, whereas in group II, 37.1% of the patients underwent the same procedure (P < 0.05). Whereas average hospital stay in group I was 8.3 days (range, 7-11 days), it was 12.8 days in group II (range, 10-18 days; P < 0.05). There was one bronchopleural fistula in group I, and there was one bronchopleural fistula and one death in group II. CONCLUSION: Video-assisted thoracoscopic evacuation and chest tube insertion in situ is a new therapeutic approach for pleural empyema that shortens hospital stay and reduces the necessity of open decortication.

Tumour cell frequency in pleural lavage in cases with stage I epidermoid lung cancer with no visceral pleural involvement.

BACKGROUND: The presence of tumour cells in the pleural lavage of lung cancer patients with no malignant pleural effusion is a negative prognosticator. In the present study we aimed to determine the lowest frequency of positive pleural lavage in lung cancer. METHODS: The study included 26 consecutive patients who underwent thoracotomy for curative resection for Stage I epidermoid lung cancer. The cases had neither visceral pleural involvement nor obstructive pneumopathy. The patients were applied pleural lavage cytology immediately after thoracotomy. RESULTS: The frequency of malignant cells in pleural lavage was 7.7% (Stage IA, n = 1, and IB, n = 1). CONCLUSION: Our series, in which we predicted the lowest probability of the presence of tumour cells in pleural lavage, had such a frequency of positive tumour cells that should'nt be neglected. The present study concluded that pleural lavage cytology before pulmonary resection should routinely be performed in 'all' lung cancers and that pleural lavage cytology may also be included in the current staging system.

Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases.

BACKGROUND: Post traumatic retained haemothorax (PRH) may cause pulmonary restrictions or septic pleural complications. Currently, minimally invasive procedures such as videothoracoscopy or intrapleural fibrinolysis have replaced open surgery in an effort to avoid these complications. OBJECTIVE: We have reviewed retrospectively our use of videothoracoscopy versus intrapleural streptokinase for the management of PRH over the last 10 years. PATIENTS AND METHOD: There were 56 males and nine females in the study. Thirty-one cases had been managed by intrapleural streptokinase (group I), and videothoracoscopy was performed on 34 cases (group II). Therapeutic results for both groups were determined by chest radiographs. RESULTS: In the population from which we drew our study group, retained haemothoraces occurred in 10.9% of 596 cases with traumatic haemothorax. In group I, 22 patients had radiological improvement; the others underwent thoracotomy. In this group, mean hospitalisation time was 14.5(+/-4.2) days, and three cases were complicated by empyema. In group II, all patients except four had complete radiological improvement; two of them required a decortication. In this group, mean hospital stay was 9.8(+/-3.7) days. There were no deaths in either group. The differences between group I and group II for length of hospital stay and number of thoracotomies was statistically significant. CONCLUSION: Videothoracoscopy is therefore a more effective procedure than intrapleural streptokinase for the management of PRH.

Modified pudendal thigh flap for perineoscrotal reconstruction: a case of Leriche syndrome with rapidly progressing Fournier's gangrene.

We present the first report of Leriche syndrome associated with Fournier's gangrene. We used a modified pudendal thigh flap in the treatment of an extensive perineoscrotal soft-tissue defect successfully. We propose this new robust flap as an addition to the existing reconstructive armamentarium and draw attention to the coexistence of Leriche syndrome and Fournier's gangrene.

Is capitonnage unnecessary in the surgery of intact pulmonary hydatic cyst?

BACKGROUND: Hydatid disease, a parasitosis, is still an important health problem in Turkey. Surgery is the choice of treatment for pulmonary hydatid cyst. In this study, cystotomy and capitonnage were compared to cystotomy. METHODS: Fifty-nine patients with 70 pulmonary intact hydatid cysts were surgically treated between 1993 and 1999. There were 11 females and 48 males (range 4-58 years). Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into two groups. In Group A (n = 32 patients, n = 38 cysts), the cavity was closed (capitonnage), and in Group B (n = 27 patients, n = 32 cysts) capitonnage was not performed. The patients treated by other surgical methods (pericystectomy, lobectomy, and others) were not included in this study. RESULTS: Prolonged air leak (> 5 days) was found in one patient in Group A, and in four patients in Group B. Atelectasis developed in one patient in Group A, and in three patients in Group B. Additionally, in Group B pseudocystic appearance occurred in two patients and empyema in one patient. The duration of hospitalization was 9.8 +/- 2.1 days for Group A, and 12.4 +/- 3.2 days for Group B. There was a significant difference between the groups for hospital time (p < 0.01). There was no mortality in either group. CONCLUSION: This study shows that capitonnage is a procedure that should not be easily abandoned, despite the current contrary opinions, because of its low complication rate.

Extrapleural regional versus systemic analgesia for relieving postthoracotomy pain: a clinical study of bupivacaine compared with metamizol.

BACKGROUND: The effects of a local anesthetic delivered through a catheter inserted in the extrapleural region by a surgeon and an analgesic agent given systemically on pain after thoracotomy were assessed. METHODS: The patients in group I (n = 25) had a catheter inserted between the parietal pleura and the endothoracic fascia by a surgeon, and 0.5% bupivacaine was given through this catheter. Another 25 patients (group II) had metamizol given intravenously. Respiratory function tests, arterial blood gases, range of shoulder motion, and postoperative pain were evaluated for each group. Bupivacaine and metamizol were given just before finishing the thoracotomy and then repeated every 4 hours for 3 days. RESULTS: There was no statistical difference in arterial blood gases between the groups (P >.05). There were statistically significant differences in the respiratory function tests, range of shoulder motion, and visual analogue scale (P <.05) between the groups. Group I had fewer complications than group II. There was no mortality in either group. CONCLUSIONS: Bupivacaine given through a catheter to the extrapleural region before finishing thoracotomy is substantially beneficial for the prevention of postoperative pain and reduction of postoperative complications.

The effect of standard posterolateral versus muscle-sparing thoracotomy on multiple parameters.

BACKGROUND: Different alternative approaches to thoracotomy have been developed because of the considerable morbidity associated with the standard posterolateral incision. METHODS: We studied a prospective, randomized, blinded study of 60 consecutive patients to compare surgical approach time, postoperative pain (quantitated by narcotic requirements and the visual analogue scale), pulmonary function, shoulder strength, and range of motion between standard posterolateral (group I) and muscle-sparing (group II) thoracotomy techniques. RESULTS: There were no differences in postoperative surgical time, pulmonary function, shoulder range of motion, mortality, or hospitalization time. There was significantly less postoperative pain in group II. In this group, narcotic requirement was less in the first 24 hours, and visual analogue scale scores were significantly lower (p < 0.05) throughout the first postoperative week. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 16.6% in the muscle-sparing group. CONCLUSIONS: We conclude that the muscle-sparing incision may be a sensible alternative to a standard posterolateral thoracotomy.

Multiple pellets expectoration: bronchial repair by using a costal cartilage graft.

Foreign body expectoration resulting from penetrating thoracic injury is an extremely rare condition. It requires bronchoscopy for diagnosis, and if there is a bronchial wound with a large tissue defect, costal cartilage grafting covered with a vascularized muscle flap is suggested as a good alternative for the treatment.

A technique facilitating muscle-sparing thoracotomy.

The muscle-sparing thoracotomy technique preserves the latissimus dorsi and serratus anterior muscles and provides excellent exposure for most thoracic and mediastinal operations. It also reduces postoperative pain and complications, and preserves pulmonary function. The technique has been developed further to facilitate subcutaneous dissection by insufflation of air from a syringe connected to a large-bore needle via a 3-way tap.