Resection for progressively growing giant hemangioma of anterior abdominal wall.

Hemangioma is a benign vascular malformation and generally diagnosed in childhood. This pathology frequently shows regression within the first decade of life, but it rarely presents in young adults beyond 12 years of age. When progressive growth of the tumour leads to a giant hemangioma with clinical symptoms, surgical resection can be reasonable despite its high risk of complications such as intractable bleeding or recurrence. Selective angiography for assessment of the blood supply to hemangiomas is a guide for the surgeon to remove the lesion safely. We present the case of a 20-year-old patient, who underwent successful surgical treatment for a giant hemangioma that showed progressive enlargement in the abdominal wall.

Prosthetic aortic valve endocarditis due to Stenotrophomonas maltophilia complicated by subannular abscess.

Annular abscesses are serious complications of infectious native and prosthetic valve endocarditis. In this patient, we isolated Stenotrophomonas maltophilia, a rare cause of subaortic abscess with high mortality/morbidity rates although virulent gram-positive cocci, S. Aureus in particular, have been the most commonly isolated agents. We treated this case of endocarditis and the subannular abscess observed 1 year after the initial operation by aortic root replacement with resternotomy in addition to appropriate antibiotics.

Thoracic endoscopic surgery for hyperhidrosis: comparison of different techniques.

BACKGROUND: Hyperhidrosis is pathological perspiration in palmar, plantar or axillary surfaces. Video-assisted thoracic surgery (VATS) is currently the most commonly used therapy for hyperhidrosis. Blockage of sympathetic ganglia is achieved by segmental resection, transection and/or cauterization, and clipping of the chain. We aimed to compare the efficacy of these methods with respect to patient satisfaction, recurrence of symptoms and complications. METHODS: Eighty male patients with a mean age of 22.02 +/- 2.61 years undergoing bilateral thoracoscopic sympathectomy or sympathetic blockage to treat primary hyperhidrosis were included in this randomized study. The patients were divided into four groups depending on the technique used for sympathetic blockage; techniques included resection (n = 20), transection (n = 20), ablation (n = 20), and clipping (n = 20). RESULTS: The primary success rate for isolated palmar hyperhidrosis was 96.3 %; for palmar and axillary hydrosis it was 95.7 % and for palmar and face/scalp hyperhidrosis it was 66.7 %. No recurrence was observed. The overall success rate of the operation was 95 % and the differences between the four groups were not statistically significant. In the clipping group, the duration of the surgical procedure was significantly shorter than in the other groups. Complication rates were similar among the groups. The postoperative chest roentgenogram revealed pneumothorax in nine patients, but none of them required intervention. CONCLUSION: Thoracic endoscopic sympathetic blockage yields similar results irrespective of the surgical technique adopted.

[Aortoduodenal fistulae: about two cases]. / Fistule aortoduodénale: à propos de deux cas.

Aortoduodenal fistulae are an unusual complication of aortic pathology or surgery and a life-threatening entity. The results of surgical treatment may be disappointing because of postoperative complications. We report here two cases and discuss the diagnostic investigations and characteristics of aortoduodenal fistulae.

Does direct visualization of peripatch areas in beating heart eliminate the risk of residual ventricular septal defect in adult patients?

AIM: Although the incidence of residual ventricular septal defect (VSD) following surgical therapy in the modern series is very low, especially the risk of hemodynamically insignificant shunt still exists. Intraoperative assessment of residual shunt is useful in identifying patients at risk of having subsequently required reoperation and reintervention for residual VSD before chest closure. METHODS: In 87 patients who were operated because of isolated VSD (Group I), VSD was closed under cardioplegic arrest and right atriotomy or right ventriculotomy were closed in the beating heart after aortic cross-clamp removal. The VSD patch was watched out for residual shunt and additional sutures were placed if it existed. Results of this technique have been compared with the other 216 (Group II) in which all procedures of the VSD closure were performed under cardioplegic arrest. Transosephageal echocardiography (TEE) was performed for evidence of residual shunting intraoperatively and postoperatively in all patients. RESULTS: In group I, additional sutures were placed for residual shunt in 14 patients (16.1%), and insignificant residual shunt was detected in only one (1.1%) patient at early postoperative period (p<0.05, according to group II). In group II, there was hemodynamically insignificant residual shunt in 31 patients (14.5%), and 9 patients (4.2%) were reoperated for significant shunt (p<0.05). CONCLUSION: Transatrial or transventricular inspection to peripatch areas in the beating heart is a safe technique to detect a residual shunt, an observation that may eliminate reoperation.

Extended use of radial artery with Y-graft technique for complete arterial revascularization.

One of the biggest problems encountered during complete arterial revascularization is difficulty obtaining sufficient graft length to perform multiple distal anastomoses. We describe a technique of dividing the radial artery during harvest and forming one or more composite Y-grafts to allow end-to-side rather than sequential anastomoses without substantially decreasing usable conduit length. This approach has merit and may be helpful in some patients who require complex arterial grafting.

Removal of the thrombosed prosthetic axillofemoral graft.

Late thrombosis of prosthetic graft material is rarely managed successfully by simple thrombectomy or thrombolytic therapy. Replacement with a new graft may be necessary. Although several techniques have been described, mobilizing and removing an old thrombosed prosthetic graft is usually extremely difficult because of a firm attachment to its tunnel. This attempt is more difficult especially for ringed grafts. We describe a simple technique of using an internal varicose vein stripper for the removal of such a late thrombosed axillofemoral spiral polytetrafluoroethylene graft and positioning a new graft into the old tunnel.

Surgical approach to military vascular injuries.

PURPOSE OF THIS STUDY: Vascular injuries caused by high-velocity military missiles are associated with bone fracture, soft-tissue, nerve and tendon injuries. In this study we will discuss the surgical strategy and results of vascular injuries, which require a different approach from primary and elective surgical procedure. BASIC METHODS: Surgical interventions were performed in 116 patients. Vascular lesions were localized on the lower extremity in 53, upper extremity in 55, and nine were in other regions. Vascular injuries were concomitant with bone fracture in 46 and nerve injuries in 36 patients. Vascular repair was performed after orthopedic stabilization in vessels with an ischemic period of less than 4 hours. PRINCIPAL FINDINGS: Fasciotomy was performed after vascular repair in the 22 cases that had arrived after 8 hours. Amputation was required in two cases. There was one mortality. CONCLUSIONS: The best results are obtained when a multidisciplinary and emergency approach are used by the team of vascular, orthopedic, plastic and neurosurgeons who are experienced in military injuries.

Long-term prevention of atrial fibrillation after coronary artery surgery.

UNLABELLED: We researched the necessity of quinidine fumarate or acebutolol prophylaxis in patients in whom atrial fibrillation occurred in the postdischarge period and returned to sinus rhythm after coronary artery surgery. DESIGN: Prospective review. PATIENTS: Since 1992, 60 patients were chosen in whom atrial fibrillation occurred in early postoperative period. There were no significant differences between them and they were separated into 3 groups. In group I (20 patients) we did not give any drug, in group II (20 patients) quinidine fumarate was given and in group III (20 patients) acebutolol was given and patients were controlled for 90 days. RESULT: Atrial fibrillation occurred in one patient in group I, (5%), two in group II (10%) and two in group III (10%), (p < 0.05). Different from the other groups, atrial fibrillation was asymptomatic with low ventricular response in group III. CONCLUSIONS: There were no significant differences among three groups statistically, so we suggested that long-term prevention of atrial fibrillation with quinidine fumarate or acebutolol was not necessary after coronary artery surgery.

[Turkish immigrants in ambulatory psychiatric treatment]. / Immigranten aus der Türkei in ambulanter psychiatrischer Behandlung.

Socio-demographic and migration-specific particularities of first generation immigrants from Turkey (n = 133) treated at the Psychiatric Outpatient Department of the University Hospital, Basel were examined. 65.4% of the immigrants were men, 34.6% women. Women were significantly more often (p = 0.01) analphabetic than men and more often admitted as emergencies (p = 0.002). 66.7% of the married women and 57.8% of the married men were separated from their partners for more than one year because of migration. Adjustment disorder was the most frequent diagnosis in both genders. Opiate-dependency was not found in both genders, and none of the women were alcohol-dependent. The data are discussed on the background of socio-demographic characteristics of the Turkish immigrant population living in Basel and compared to studies made in Turkey.

Aneurysms of the sinus of Valsalva.

OBJECTIVE: To evaluate the properties of the coexistent cardiac anomalies associated with the aneurysm of sinus of Valsalva (ASV) and examine the long-term surgical results after operation. PATIENTS: From 1980 to 1994, nine patients (median age 22 years) underwent surgical correction of ASV. Aneurysms originated from the right (n = 5), noncoronary (n = 3) and left coronary sinus (n = 1) and entered into right ventricle (n = 5), right atrium (n = 3). In one patient, ASV originated from the left coronary sinus and unruptured. Coexistent cardiac lesions were aortic valve insufficiency (n = 4), ventricular septal defect (n = 5), patent foramen ovale (n = 1), right ventricular outflow tract obstruction (n = 1) and coronary artery anomaly (n = 2). All patients were symptomatic (sudden onset of symptoms in 3, gradual onset in 6). INTERVENTIONS: Ruptured ASVs were repaired by double approach in which both the involved chamber and the aortic root. Concomitant aortic surgery was performed in four patients (2 replacement, 2 valvuloplasty). VSDs were closed by patch in 4 and by direct suture in 1. RESULTS: The incidence of coexisting coronary artery anomaly was 22.2%. There was no hospital and late mortality. The mean follow-up period was 6.8 years (range 1 to 14 years). There were no reoperation for leaks of VSD, recurrence of aneurysm and aortic regurgitation. Eight patients were found to be in New York Heart Association class I, one patient in class II. CONCLUSION: The risk of the recurrent fistula or VSD is prevented by double approach technique, and also this approach reduces the incidence of late aortic insufficiency. Routinely preoperative coronary angiography must be performed for determine of coronary anomaly.

Missed arterial injuries in military patients.

BACKGROUND: Military vascular injuries frequently result from fragment wounds while civilian vascular injuries usually are caused by gunshot wounds. The natural history of untreated major injuries by small low velocity fragments is not well known. This study evaluated the nature of these wounds. METHODS: From 1990 to 1995, 40 patients with a delayed diagnosis of an arterial injury in the extremity, abdomen, or neck were treated. The median delay between injury and diagnosis was 60 days. All patients had been seen at other military hospitals immediately after trauma. RESULTS: During initial hospitalization, immediate exploration had been performed in 23 patients and arteriogram in 3 patients. According to analysis of the records of patients, none of them had hard signs of vascular injury at the time of initial evaluation after trauma. Complications of missed arterial injuries included the following: false aneurysm, 21 (52.5%); arteriovenous fistula, 14 (35%); and occlusion, 5 (12.5%). The superficial femoral artery (n = 11) was the most commonly injured vessel. The remaining arteries included the following: carotid, 2; vertebral, 1; subclavian, 5; axillary, 2; brachial, 3; radial or ulnar, 2; internal iliac, 2; common femoral, 1; profunda femoris, 2; popliteal, 1; tibioperoneal, 8. Thirty-eight patients had penetrating wounds (21 fragments, 9 gunshot, 3 shotgun, 5 stab wounds), and only 2 patients had blunt trauma. All patients underwent surgery. There were no deaths and no loss of extremity, but 10 patients had fair results and only 4 patients required later reoperation. CONCLUSION: Traumatic arterial injuries that particularly are caused by low-velocity small fragment wounds can result in serious delayed complications months or even years after the injury. Patients with penetrating injuries must be closely monitored, and arteriography is recommended to evaluate the conditions of patients with potential vascular injury even when overt clinical signs or symptoms of vascular injury are absent.

Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect.

OBJECTIVE: The aneurysm of the membranous septum (AMS) has often been considered as benign in the minds of many previous investigators. We have analyzed the complications with AMS in adult patients. METHODS: Fifty-one cases (20%) of AMS in 254 adult patients with perimembranous ventricular septal defect (VSD) are described. The diagnosis of AMS was based on angiographic criteria. Thirty-nine (76.5%) of the 51 patients with AMS were aged between 20 and 29 years. All patients but one with AMS had a pulmonary-to-systemic flow (Qp/Qs) of less than 2.3 (range 1-2.1, mean 1.4). In a patient who had a ruptured aneurysm, the Qp/Qs was 2.7. There were six main complications affected by AMS and/or VSD; aortic valve prolapse in 24 patients (47%), aortic regurgitation in 15 (29.4%), tricuspid insufficiency in nine (17.6%), right ventricular outflow tract obstruction in two (4%), and rupture of the aneurysm in one patient (2%). Seven patients (13.7%) had prior bacterial endocarditis. All patients underwent surgery. Aneurysm and VSD were closed by direct suture in nine and with a patch in 42 patients. Aortic valve repair was performed in 13 patients in whom regurgitation was mild to moderate, and replacement was required in two patients with severe aortic regurgitation. RESULTS: There were no early or late deaths. Residual communication and recurrence of the aneurysm was noted three and seven years postoperatively in two patients where VSD had been closed by direct suture. CONCLUSIONS: According to present data, aneurysm formation functionally reduces the VSD size, but it has the potential consequence of promoting tricuspid insufficiency, aortic valve prolapse, right ventricular outflow tract obstruction, rupture and bacterial endocarditis. Therefore, we recommend that AMS should be resected completely and the defect produced closed with a patch in order to prevent further enlargement and consequent complications even if there are no cardiac symptoms.

[Violence in partnership of immigrant women from Turkey]. / Gewalt in der Partnerschaft bei Immigrantinnen aus der Türkei.

Forty-one female immigrants from Turkey, who were victims of violence in their relationships and diagnosed with "reaction to severe stress and adjustment disorders" (F43, ICD-10) were compared with a controle-group of the same origin, sex, age and diagnosis who had not suffered from such violence. The frequency of emergency treatment and suicide attempts (in the last month before the first consultation) of the victims of violence were higher than in the controle-group. The victims of violence less frequently live in large families and were more often employed than the controle-group. The duration of time until the immigration of the partner was significantly higher in the group of victims than in the controle-group. The results are discussed with regard to studies concerning other ethnic groups and specific aspects of psychodynamics and migration.

Late posterior cardiac tamponade after open heart surgery.

OBJECTIVE: Late cardiac tamponade after open heart surgery is a relatively uncommon, but potentially serious complication. We retrospectively analyzed 14 patients who had posterior cardiac tamponade 13 to 210 days after open heart surgery. PATIENTS: Between May 1988 and July 1995, 3150 adult patients underwent open heart surgery at the Gülhane Military Medical Academy. In 35 of 3150 patients (1.11%) late pericardial effusions developed, and in 14 (0.44% of 3150 consecutive open heart surgery performed on adult patients in our center) of these patients had posterior tamponade. There were moderate symptoms including fatigue, malaise, and dyspnea on exertion in all patients. The diagnosis was made by echocardiography in 13 patients, and by tomographic scanning in 1 patient. Analysis of these 14 patients revealed that all of them had hemodynamic criteria consistent with tamponade physiology on right heart catheterization with Swan-Ganz catheters. RESULTS: Echocardiography guid pericardiocentesis through the left anterior axillary line was effective in decompressing of posterior cardiac tamponade in 10 of 14 patients. Three patients required operative surgical drainage after unsuccessful pericardiocentesis through subxiphoid area. Two patients who underwent surgical drainage died, and in one patient surgical pericardiotomy had complete evacuation of posterior pericardial fluid with major complication. CONCLUSIONS: 2-D echocardiography guid pericardiocentesis through left anterior axillary line was found to be a useful, safe, and simple technique. It can be used as an alternative treatment to surgical pericardiotomy for posterior cardiac tamponade after open heart surgery.

Coronary artery aneurysm associated with adult supravalvular aortic stenosis.

Two patients, aged 20 and 21 years, with supravalvular aortic stenosis and aneurysms of the coronary arteries are described. In supravalvular aortic stenosis, dilatation of the sinuses of Valsalva and multiple abnormalities of one or both coronary arteries are common. Aneurysm of coronary artery has not been well recognized as a lesion associated with supravalvular aortic stenosis. The operation in these patients was limited to relief of the supravalvular obstruction.

Repair of the left AV valve in atrioventricular septal defect in adults.

BACKGROUND: This study examined the septal cleft and septal commissure of the left atrioventricular (AV) valve, which are two different anatomical structures. METHODS: We presented 36 cases of adult partial atrioventricular septal defect. A distinction was made between patients based on the anatomy of the anterior leaflet of the left AV valve. The left AV valve appeared to be normal or to have minimal radial openings from the free edge of the anterior leaflet of the left AV valve in 10 patients (28%). There was a septal commissure structure in 8 (22%), and a septal cleft structure in 18 (50%) patients. In the commissure type anatomy, leaflet coaptation was usually adequate and no or mild degree of left AV regurgitation existed preoperatively. Cleft type structure usually was associated with some degree of left AV regurgitation. Attempts were made to close the septal clefts and leave the septal commissures unsutured during the repair of the partial AV septal defects. RESULTS: We have not found any increase of left AV regurgitation in patients with commissures during the follow-up period. Closure of the cleft successfully eliminated regurgitation. Long-term results for septal cleft and septal commissure after repair of partial AV septal defect were excellent with survival of 100% and freedom from reoperation of 100% at mean 6.5 years. CONCLUSIONS: Septal cleft and septal commissure should be considered two different structures. Repairing procedures for left AV valve abnormalities associated with partial AV septal defect should only be done in patients who have cleft type of leaflet structure.

[Opiate dependence in immigrant from Turkey]. / Opiatabhängigkeit bei Immigranten aus der Türkei.

A group of Turkish drug-addicted out-patients (n = 34) is compared to a group of Swiss opiate-addicted outpatients (n = 145) with respect to age, sex, social status, the number of offspring, the age of initiation of drug addiction and the type of the drug used. The results revealed that the Turkish population showed a better prognostic profile when the age of initiation of drug addiction, the familial integration and multiple addiction are taken into account, 97.1% of the Turkish opiate-addicted patients belonged to the second-generation immigrant population. In this group, the median age at immigration to Switzerland was 14.2 +/- 2.1 (excluding the three patients born in Switzerland). The conflict between the group-oriented expectations of their families and the individual-oriented life style of the peer group is the main reason for social role confusion, identity disturbances, for feelings of guilt because of separation or for shame because of dependence from the family. Confusion in social roles as well as in the interpretation of identification and the development and integration of identity permitting the coexistence of both cultures are the main topics of psychotherapy of drug-addicted Turkish immigrants.

Long-term prevention of atrial fibrillation after coronary artery bypass surgery: comparison of quinidine, verapamil, and amiodarone in maintaining sinus rhythm.

AIM OF STUDY: To evaluate the necessity and efficacy of quinidine fumarate, verapimil, or amiodarone prophylaxis for sinus rhythm maintenance in patients who experienced atrial fibrillation after coronary artery bypass surgery. METHODS: Between 1992 and 1995, this prospective, randomized, placebo-controlled study examined 120 patients in whom atrial fibrillation occurred and was restored to sinus rhythm by pharmacological therapy or direct current cardioversion in the immediately postoperative period after coronary artery by-pass surgery. There were no significant differences in perioperative characteristics among the patients, who were randomly separated into four groups in the course of discharge. In group 1 (n = 30), patients did not receive antiarrhythmic drugs. Quinidine fumarate was given in group 2 (n = 30), verapimil in group 3 (n = 30), and amiodarone in group 4 (n = 30). Patients were monitored six times over a 90-day postoperative period by 24-hour Holter monitoring and routine examination. RESULTS: The recurrent atrial fibrillation usually developed within 15 days of discharge. Atrial fibrillation occurred in one patient (3.33%) in group 1, and two each (6.66%) in groups 2, 3, and 4. Atrial fibrillation was asymptomatic and occurred with slow ventricular response in groups 3 and 4. Side effects occurred in 5 patients (16.6%) given quinidine, 1 patient given amiodarone, but in no patient given verapimil. CONCLUSIONS: There were no significant differences in the maintenance of sinus rhythm among the four groups, so we suggest that long-term prevention of atrial fibrillation in patients with coronary artery bypass grafting was not necessary at the postdischarge period.