Prevotella intermedia infection causing acute and complicated aortitis-A case report.

INTRODUCTION: Aortitis is a general term that refers to all conditions involving an inflammation of the aortic wall. This case report describes the surgical approach of a patient with infectious and symptomatic aortitis caused by the rare vector Prevotella intermedia. PRESENTATION OF CASE: A 44-year old male patient was admitted with fever and general discomfort after a period of sore throat in a non-teaching hospital. After two weeks he developed acute abdominal and back pain accompanied by sweating and elevated infection parameters. Computed tomography angiography revealed atherosclerotic changes of the infrarenal aorta with a locally contained rupture of the aorta alongside peri-aortal signs of inflammation (and aortitis aspects). An urgent aortic reconstruction was performed according to Nevelsteen. The blood cultures turned out positive for Prevotella intermedia. Postoperatively the patient received antibiotics for six weeks. The patient recovered uneventful from this infection and surgical procedure. DISCUSSION: A complicated and acute aortitis is a rare but potentially life-threatening disease. The aetiology can be ordered into two main groups; inflammatory and infectious. Diagnosis is based upon symptoms, biochemical values, microbiological results and imaging modalities. Treatment depends on aetiology and should be discussed in an experienced multidisciplinary setting. Infectious aortitis should be treated with antibiotics for at least six weeks with close monitoring of the patient's clinic and biochemical values, even after surgery. CONCLUSION: Prevotella intermedia is a rare causative agent for aortitis. Acute aortitis is a challenging clinical entity which should be managed in an equipped medical center by an experienced multidisciplinary team.

Circumferential suction-assisted lipectomy for lymphoedema after surgery for breast cancer.

BACKGROUND: The incidence of arm lymphoedema after treatment for breast cancer ranges from 1 to 49 per cent. Although most women can be treated by non-operative means with satisfying results, end-stage lymphoedema is often non-responsive to compression, where hypertrophy of adipose tissue limits the outcome value of compression or massage. METHODS: This was a prospective study of 37 women with unilateral non-pitting lymphoedema. After initial conservative treatment for 2-4 days, circumferential suction-assisted lipectomy was used to remove excess volume. Limb compression was resumed after surgery with short-stretch bandages, followed by flat-knit compression garments. RESULTS: The mean preoperative excess arm volume was 1399 ml. The total aspirate volume was 2124 ml with 93 per cent aspirate adipose tissue content. After 12 months, the mean reduction in excess volume was 118 per cent. The percentage reduction in excess volume after 12 months was linearly related to the preoperative excess volume but showed no linear relationship with the duration of lymphoedema or surgeon experience. CONCLUSION: Circumferential lipectomy combined with lifelong compression hose is an effective technique in end-stage lymphoedema after treatment for breast cancer.

[New surgical options for patients with secondary lymphedema of the arm who no longer benefit from regular treatment]. / Nieuwe chirurgische mogelijkheden voor patiënten met uitbehandeld secundair lymfoedeem van de arm.

Three patients are described who developed irreversible lymphedema of the arm following mastectomy because of breast cancer. Despite maximal conservative treatment, a difference in volume between the affected arm and the healthy arm remained (900-1500 ml). The patients underwent reductive surgery by means of circumferential suction assisted lipectomy, involving removal of hypertrophied adipose tissue. This was the first experience with this procedure in the Netherlands. The differences in arm volume were neutralised completely with a significant improvement of the shoulder function. In order to make the results lasting, the patients have to wear medical elastic stockings day and night for the rest of their lives. Long-term volume measurements are essential.

Saphenous vein versus PTFE for above-knee femoropopliteal bypass. A review of the literature.

The autogenous saphenous vein is considered the best bypass graft material for arterial bypasses below the inguinal ligament. However, a synthetic graft or prosthesis is considered an acceptable alternative, especially when the distal anastomosis is situated above the knee. Some studies even suggest that patency rates for vein and synthetic grafts are comparable, whereas others indicate that a vein graft is superior to a prosthetic graft, even above the knee. To test the hypothesis that both vein grafts and synthetic prostheses are equally beneficial in the above-knee position, we performed a systematic review of available studies comparing the patency of saphenous vein and polytetrafluoroethylene (PTFE) as bypass material. English and German medical literature from 1966 to 2002 was searched using Medline, and 25 articles meeting our inclusion and exclusion criteria were selected. The patency of venous bypasses was superior to that of PTFE bypasses at all time intervals studied. After 2 years, the primary patency rate of venous bypasses was 81% as compared to 67% for PTFE bypasses, and after 5 years it was 69 and 49%, respectively. After 5 years, the secondary patency of PTFE bypasses reached 60%. When only randomized trials were considered, venous bypasses were again superior to PTFE bypasses at all intervals studied. After 2 years, the primary patency rate of venous and PTFE bypasses was 80 and 69%, respectively, and after 5 years it was 74 and 39%, respectively. Since both randomized and retrospective studies comparing venous with PTFE bypasses showed that vein grafts were 'better' than PTFE prostheses, the null hypothesis that there is no difference between the two types of graft material was rejected (p=0.008). We conclude from this systematic review that if a saphenous vein is available, a venous bypass should be chosen at all times, even if patients have an anticipated short life expectancy (<2 years). If the saphenous vein is absent or not suitable for bypass grafting, PTFE is a good alternative as bypass material.

Polytetrafluoroethylene femorotibial bypass grafting: 5-year patency and limb salvage.

For a femorotibial bypass graft the material of choice is autologous vein. The question remains whether prosthetic material is a reasonable alternative for limb salvage, if autologous vein is not available. From 1991 to 1998, 83 consecutive femorotibial bypass procedures were performed in 70 patients. Thin-walled, ringed 6-mm polytetrafluoroethylene (PTFE) was used, as autologous vein was not available. The indication for the femorotibial bypass was critical ischemia due to atherosclerotic occlusive disease in all cases. Three patients died in the hospital or within 30 days of the operation, resulting in a perioperative mortality rate of 3.6%. After 5 years, 33 patients had died (40%) and 3 patients were lost to follow-up (3.6%). Primary patency was 64.2% after 6 weeks and 18% +/- 5% after 5 years. Secondary patency was 74.1% after 6 weeks and 22.3% +/- 6% after 5 years. When we compared primary and secondary patency for distal anastomosis, there was no difference between the three crural arteries. The limb salvage rate was 61.9% +/- 7% after 5 years. From these results we conclude that, with a limb salvage of 61.9%, PTFE is an acceptable alternative for a femorotibial bypass graft in patients with critical ischemia, if autologous vein is not available.

Complication registration in patients after peripheral arterial bypass surgery.

The objective of this study was to describe the kinds of complications and their incidence after peripheral vascular surgery of the lower limb, coding for causes and effect on the patient. In this prospective study, a standardized complication registration system was used at the Red Cross Hospital, The Hague. All patients (n = 373) receiving an infrainguinal bypass graft during the period January 1, 1996 to December 31, 1999 were included. All postoperative complications occurring during admission were coded. In 29% of the patients 153 complications were coded. Early occlusions of the graft occurred 36 times, wound infections 21 times and postoperative hemorrhages 20 times. Postoperative retention of urine was seen most frequently of all nonspecific complications (n = 22). In 43 cases the patient needed medication or a blood transfusion for his complication. In 42 cases a re-intervention was necessary. Complications led to a prolonged stay in the hospital in 20 cases. Six patients died during admittance (mortality 1.6%). An error in surgical therapy and error in nonsurgical therapy were the cause of the complication in 108 cases (out of 153). The advantage of this complication registration is that it describes all complications, not just the specific ones. Furthermore, by categorizing all complications we force ourselves to look for errors in nonsurgical therapy and surgical technique and to describe the effect of the complication.

[Acute renal insufficiency caused by bilateral ureteral obstruction after appendectomy in a 6-year old boy]. / Acute nierinsufficiëntie door bilaterale ureterobstructie na appendectomie bij een 6-jarige jongen.

A 6-year-old boy developed macroscopic haematuria on the 4th day after appendectomy for acute appendicitis, at which the appendix was found to be perforated. During the next few days the urine secretion decreased and malaise, pain in the lower abdomen, nausea and vomiting occurred. On a management of ample fluid administration, the urine secretion recovered and the symptoms subsided in a few days. In the early postoperative stage after appendectomy in children the possibility should be kept in mind of the development of acute renal insufficiency due to bilateral ureteral obstruction as a result of oedema of the posterior bladder wall, even if by means of ultrasonography only mild to moderate abnormalities are noted. Awaiting decompression by means of the introduction of bilateral ureteric stents, in order to prevent irreversible renal damage, supportive therapy with fluid administration depending on the diuresis seems indicated.

Combined therapy in the treatment of gastric epithelioid leiomyosarcoma.

In recent years it has been reported that the chemotherapeutic CYVADIC regime has contributed well to the treatment of advanced soft tissue sarcomas. We treated a patient with a large gastric epithelioid leiomyosarcoma with a combination of surgery and the CYVADIC regime. We believe that our result warrants further investigation in this field.