Crossover iliofemoral bypass graft through tension-free abdominal wall-repair mesh.

INTRODUCTION: In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft). METHODS: In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years. DISCUSSION: Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia. CONCLUSIONS: The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk. KEY WORDS: Abdominal wall, Iliofemoral bypass, Vascular surgery.

Major vascular injuries complicating knee arthroscopy.

Starting with a case report, we made a detailed review of the literature, with the purpose of identifying and analyzing the type of iatrogenic vascular lesion following knee arthroscopy and the method of vascular repair. A PubMed literature search was undertaken to locate all reported cases of major vascular iatrogenic injuries during arthroscopic knee procedures. We identified 39 papers which report a total of 62 cases of major iatrogenic popliteal lesions after knee arthroscopy, between 1985 and 2014. The type of arthroscopic intervention performed, the type of iatrogenic vascular lesion encountered, the time passed until its discovery and treatment, the method of vascular reconstruction, and the postoperative course are presented. Postarthroscopy vascular complications are infrequent but potentially disastrous for the condition of the affected inferior limb. An early diagnosis and reintervention are mandatory for a good postoperative outcome.

Outcomes after transhiatal esophagectomies in an eastern-European low-volume center.

BACKGROUND: The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV). AIMS: Our analysis, which to the authors' knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania. STUDY DESIGN: Retrospective observational study. METHODS: In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%). RESULTS: The majority of cancer-group patients had T3/N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively. Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2-36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months. CONCLUSION: Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite being significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers.

Endoscopic ureteral procedures for one-step nephroureterectomy: experience in 100 cases.

BACKGROUND AND PURPOSE: Nephroureterectomy with perimeatal cystectomy is the gold standard for the treatment of urothelial upper urinary-tract carcinoma (UUTC). Ureteral endoscopic surgery has been proposed as a complementary step in nephroureterectomy, either open or laparoscopic, in order to obviate the low abdominal incision. Our goal was to establish the value of two techniques for endoscopic distal-ureteral management in one-step nephroureterectomy for UUTC. PATIENTS AND METHODS: Between June 1995 and January 2006, 100 nephroureterectomies with an endoscopic distal ureteral approach were performed for UUTC (stage pT(a) in 31 cases, pT1 in 27 cases, pT2 in 21 cases, pT3 in 18 cases, and pT(4) in 3 cases). The tumor was pyelocaliceal in 65 cases, ureteral in 18 cases, and both ureteral and pyelocaliceal in 17 cases. Among the patients, 72 underwent "pluck" transurethral detachment of the intramural ureter, and 28 were managed by ureteral stripping. The follow-up was performed by cystoscopy with urinary cytology, ultrasonography, and intravenous urography. The mean follow-up was 44 months (range 4-129 months). RESULTS: All but two of the procedures were completed successfully. In these two patients, ureteral stripping failed, and open surgery was performed. The complication rate was 2.8% for the pluck technique and 7.1% for ureteral stripping. During follow-up, 23 patients had bladder recurrences, 2 had renal fossa tumors, 3 had secondary lymph-node invasion, 2 had contralateral UUTC, and 1 had asynchronous liver metastases. The disease-specific mortality rate was 12%. CONCLUSIONS: The endoscopic approach to the terminal ureter is safe and effective as part of one-step nephroureterectomy. Differences between the techniques with regard to operative time, complications, and oncologic outcome were not significant.

[Reconstruction of incisional median hernia with retromuscular mesh and hernial sac]. / Posztoperatív medián sérvek rekonstrukciója retromuscularis helyzetû, sérvzsákkal borított hálóval.

INTRODUCTION: one of the most frequent complications of a laparotomy is the development of an incisional hernia. Proper surgical technique can somewhat reduce the incidence, but it still remains a common sequel. Application of prolene mesh for the reconstruction of the abdominal wall with tension-free methods has excellent results. PATIENTS AND METHODS: between 2001-2005, 50 abdominal wall reconstructions were performed using prolene mesh in sublay position including the peritoneal sac of the incisional hernia. RESULTS: postoperative complication was found in one case only, namely a haematoma was formed in the rectus sheat possibly due to an injury of a branch of the inferior epigastric artery. The haematoma was managed non-operatively by suction drainage. No postoperative respiratory problems were detected; all we noticed was minimal abdominal pain. Patients were mobilized shortly after the surgery. CONCLUSIONS: application of prolene mesh in sublay position including the hernia sac is an effective alternative procedure for preventing postoperative complications, when large incisional hernias are repaired in median laparotomy scars.