Voice and Swallowing Disorders After Thyroid Surgery.

OBJECTIVE: The aim of the study was to evaluate voice and swallowing function following thyroid surgery, to identify dynamic changes during the follow-up period of 12-18 month and to find possible indicative signs of permanent or temporary vocal fold palsy. METHODS: All participants (N = 110) were prospectively enrolled from the preoperative thyroid surgery patients between September 2013 and December 2016. All subjects underwent preoperatively, first week and 12-18 month postoperatively videolaryngostroboscopy, filled in subjective evaluation of voice (voice handicap index, [VHI]) and swallowing (swallowing impairment score) complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) measurement and perceptual voice evaluation were conducted. In the presence of laryngeal damage, additional first and sixth-month follow-up visits were planned. Patients, whom we suspected laryngeal nerve damage, underwent laryngeal electromyography 4 weeks after the operation. RESULTS: On first postoperative week evaluation, no objective voice changes within patients with postoperatively intact laryngeal nerves were found. Subjective evaluations showed decline in VHI physical domain and increased strain in postoperative voice. Patients with postoperative nerve damage had a drastic decline in subjective voice quality (VHI all subscales and total score), AVA parameter jitter, MPT and perceptual voice quality. Subjective evaluation of swallowing revealed disturbances in all patients regardless of the nerve damage. We noticed remarkable differences in first week and first month visits between patients with permanent and temporary palsy in VHI total score and physical domain, MPT and perceptual breathiness and asthenia in voice. Regardless of the nerve injury, by the end of the follow-up period all changes had become statistically insignificant with the exception of perceptual evaluation of voice quality. CONCLUSIONS: Patients with postoperative laryngeal nerve damage experience substantial deterioration of both subjective and objective voice quality with more extensive impairment in patients with permanent paralysis. Thyroid surgery causes subjective swallowing changes irrespective of laryngeal nerve damage. In patients without laryngeal nerve damage, swallowing function improves following thyroidectomy. Possible indicators for permanent paralysis are delayed recovery in the values of MPT and jitter and persistent perceptual breathiness and asthenia.

Cardiac Injuries at Estonian Major Trauma Facilities: A 23-year Perspective.

BACKGROUND AND AIMS: Cardiac injuries are highly lethal lesions following trauma and most of the patients decease in pre-hospital settings. However, studies on cardiac trauma in Estonia are scarce. Thus, we set out to study cardiac injuries admitted to Estonian major trauma facilities during 23 years of Estonian independence. MATERIALS AND METHODS: After the ethics review board approval, all consecutive patients with cardiac injuries per ICD-9 (861.0 and 861.1) and ICD-10 codes (S.26) admitted to the major trauma facilities between 1 January 1993 and 31 July 2016 were retrospectively reviewed. Cardiac contusions were excluded. Data collected included demographics, injury profile, and in-hospital outcomes. Primary outcome was mortality. Secondary outcomes were cardiac injury profile and hospital length of stay. RESULTS: During the study period, 37 patients were included. Mean age was 33.1 ± 12.0 years and 92% were male. Penetrating and blunt trauma accounted for 89% and 11% of the cases, respectively. Thoracotomy and sternotomy rates for cardiac repair were 80% and 20%, respectively. Most frequently injured cardiac chamber was left ventricle at 49% followed by right ventricle, right atrium, and left atrium at 34%, 17%, and 3% of the patients, respectively. Multi-chamber injury was observed at 5% of the cases. Overall hospital length of stay was 13.5 ± 16.7 days. Overall mortality was 22% (n = 8) with uniformly fatal outcomes following left atrial and multi-chamber injuries. CONCLUSION: Overall, 37 patients with cardiac injuries were hospitalized to national major trauma facilities during the 23-year study period. The overall in-hospital mortality was 22% comparing favorably with previous reports. Risk factors for mortality were initial Glasgow Coma Scale < 9, pre-hospital cardiopulmonary resuscitation, and alcohol intoxication.

Cold-Stored Venous Allografts In Different Preserving Solutions: A Study On Changes In Vein Wall Morphology.

BACKGROUND:: The saphenous vein is the most frequently used bypass conduit for vascular reconstructions, which may need to be stored for a prolonged time. The aim of this study was to compare the effect of different preservation solutions on the morphology of saphenous veins during the long-term cold storage. DESIGN:: An in vitro study. MATERIAL AND METHODS:: Saphenous vein samples, collected from 29 patients undergoing varicose vein surgery, were stored at +4°C in (1) 10% formalin, (2) isotonic saline with heparin and antibiotic, (3) phosphate-buffered saline, (4) 2.5% glutaraldehyde + phosphate-buffered saline, and (5) Custodiol (histidine-tryptophan-ketoglutarate). Changes in the vein wall were histologically investigated up to day 35. Possible retention of the capacity of endothelial function was evaluated by immunohistochemical detection of endothelial nitric oxide synthase. RESULTS:: Formalin as the control medium well preserved the vein wall morphology, but endothelial nitric oxide synthase immunostaining was very weak. Phosphate-buffered saline and isotonic saline with heparin and antibiotic poorly preserved vein wall morphology. Phosphate-buffered saline endothelial nitric oxide synthase staining decreased dramatically throughout the study period. Compared to phosphate-buffered saline, stronger isotonic saline with heparin and antibiotic endothelial nitric oxide synthase staining was noted at day 35 (p < 0.001). Custodiol and glutaraldehyde better preserved vein morphology compared to ISHA and PBS at day 5 and later (p < 0.001), but compared to stronger isotonic saline with heparin and antibiotic their endothelial nitric oxide synthase staining was weaker. CONCLUSION:: In terms of preserving the morphology of saphenous veins, phosphate-buffered saline and isotonic saline with heparin and antibiotic were the poorest, while Custodiol and glutaraldehyde were the best. Demonstrating good retention of endothelial nitric oxide synthase staining throughout the study period, isotonic saline with heparin and antibiotic seems to have the best potential to retain vein wall functionality, despite relatively poor morphological preservation.

Population-Based Autopsy Study of Traumatic Fatalities.

BACKGROUND: Injuries result in 5.8 million global fatalities annually and are the leading cause of death in younger individuals. Nevertheless, population-based autopsy investigations on traumatic deaths are scarce. We set out to study all consecutive autopsies on traumatic fatalities performed in a 5-year time segment in Estonia. METHODS: After the ethics review board approval, all consecutive autopsies after blunt or penetrating deaths occurring in prehospital or in-hospital settings between January 1, 2009, and December 31, 2013, were retrospectively reviewed using the National Forensic Medicine Database. Fatalities due to suffocation, intoxication, burns, or freezing were excluded. Data collection included demographics, mechanism of injuries, cause of death, and a detailed injury profile. Primary outcome was cause of death. Secondary outcomes included injury patterns. RESULTS: Overall, 1344 autopsies were included. 75.7% of deaths were following blunt trauma. Mean age was 50.4 ± 18.5 years, and 77.1% were male. A total of 71.8% of deaths occurred in the prehospital setting. Accidents, assaults, and suicides constituted 64.4, 20.5, and 15.2% of deaths, respectively. A total of 51.1% of injury fatalities had a positive blood alcohol level (BAL). Mean injury severity score was 39.7 ± 23.9. Most common cause of death was due to head injuries at 50.5% followed by hemorrhage at 30.4%. Cardiac and aortic injuries were the predominant cause of hemorrhage-related fatalities. CONCLUSIONS: The current population-based investigation documented brain injury as the predominant cause of death followed by cardiac and aortic injuries. High incidence of positive BAL among injury fatalities requires national initiatives for alcohol harm reduction and law enforcement efforts.

Evolution of severe trauma in Estonia comparing early versus established independence of the state.

PURPOSE: Trauma mechanisms and patterns of severe injuries during the Estonian independence have not been evaluated. The aim of the study was to compare the incidence and outcomes of severe injuries between time periods of early independence from the Soviet Union and the present time. METHODS: After the ethics review board approval, all adult trauma admissions to major trauma facilities in 1993-1994 and 2013-2014 with Injury Severity Score >15 were identified. Data collection included demographics, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes included incidence of penetrating trauma, hospital length of stay (HLOS), and in-hospital complications. Primary outcome difference comparing the two time segments was determined using logistic regression analysis. RESULTS: A total of 1064 patients were included, 593 and 471 from 1993-1994 to 2013-2014, respectively. Incidence of penetrating trauma during 1993-1994 was 11.1 % and in 2013-2014 at 6.4 % (p = 0.007). Gunshot injuries constituted 62.1 and 23.3 % of all penetrating trauma in 1993-1994 and 2013-2014, respectively (p < 0.001). The overall mean HLOS was 15.5 ± 19.8 days and did not differ between the periods. The rate of adjusted complications showed a trend for a decreased incidence (adj. p = 0.064). Adjusted mortality rate was 50.3 and 16.4 % during 1993-1994 and 2013-2014, respectively (adj. OR 7.01; 95 % CI 4.69-10.47; p < 0.001). CONCLUSIONS: Effective law enforcement, gun control, evolution of trauma system, and reduction of interpersonal violence have all contributed to a significant decrease in penetrating trauma incidence and all-cause adjusted mortality during the 20 years of Estonian independence.

Prospective study evaluating the impact of severity of chronic pain on quality of life after inguinal hernioplasty.

PURPOSE: The definition of chronic pain after inguinal hernioplasty and the methods of its assessment vary a great deal, which make it complicated to conduct meta-analyses. The primary aim of the present prospective study was to evaluate at which pain severity degree the quality-of-life scores will be reduced. METHOD: A prospective study of patients operated for inguinal hernia was conducted. A pain questionnaire and a quality-of-life (QoL) questionnaire were completed. RESULTS: Altogether, 370 patients were investigated and included in analysis. Of them, 33.8% experienced pain during different activities. Compared to the non-pain response group, significantly lower QoL scores for the Bodily pain domain were reported by patients who gave 1, 2, or 3 positive responses to the pain questionnaire. Patients with no pain as well as patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 had similar QoL scores for all domains. Patients who gave 1 positive response to the pain questionnaire and whose VAS score was >20, and patients who gave two or more positive responses to the pain questionnaire, showed significantly lower QoL scores in most of the domains compared with the non-pain group. When the patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 were excluded from the group of patients with pain, the rate of chronic pain was 19.7%. Considering the above result, the reduction in the rate of chronic pain from 33.8 to 19.7% was statistically significant. CONCLUSION: Pain scores 20 mm or less on the VAS (0 to 100 mm) have no impact on the patients' quality of life. Uniform assessment methods of chronic pain should be developed to improve the quality of research.

Three-Year Results of a Single-Centre Single-Blinded Randomised Study Evaluating the Impact of Mesh Pore Size on Chronic Pain after Lichtenstein Hernioplasty.

BACKGROUND AND AIMS: The aim of the present study was to determine whether usage of mesh with larger pores, compared with mesh with smaller pores, would result in a decreased rate of chronic pain at 3-year follow-up. According to earlier published short-term results, differences in mesh pore size do not influence the rate of chronic pain. MATERIAL AND METHODS: The patients were randomized into two study groups for which meshes with similar weight but different pore size were used: the UM group received Ultrapro mesh (pore size 3-4 mm) and the OM group received Optilene LP mesh (pore size 1 mm). Pain scores were measured on a visual analog scale. The feeling of a foreign body was a yes-or-no question. RESULTS: A total of 65 patients in the UM group and 63 patients in the OM group were included in analysis. Of the patients, 33.9% in the UM group and 15.9% in the OM group reported having experienced pain during different activities at 3-year follow-up (P = 0.025). Comparison with the results of 6-month follow-up (46.3% in the UM group, 34.3% in the OM group) showed that the rate of chronic pain had decreased significantly in the OM group (P = 0.009) but not in the UM group (P = 0.113). The feeling of a foreign body in the inguinal region was experienced by 23.1% of the patients in the UM group and by 15.9% in the OM group (P = 0.375). There was one hernia recurrence in the OM group. Severe preoperative pain and younger age were identified as risk factors for development of chronic pain. CONCLUSIONS: Mesh with larger pores, compared with mesh with smaller pores, has no advantages in reducing the rate of chronic pain. We speculate that the reason for the higher rate of chronic pain in the study group where the mesh with larger pores was used might have been the different composition of the meshes at implantation. Also, it is possible as development of chronic pain after inguinal hernia repair is multifactorial, we failed to find a plausible explanation for this difference. Low recurrence rates were achieved with both meshes used in our study.

Severe Trauma in Estonia: 256 consecutive cases analysed and the impact on outcomes comparing two regions.

PURPOSE: The purpose of this study was to investigate epidemiology of severe injuries in Estonia while comparing outcomes at regional trauma facilities. METHODS: After the ethics review board approval, all consecutive trauma admissions with Injury Severity Score (ISS) > 15 to North Estonia Medical Center/Tallinn Children's Hospital (NEMC + TCH) and Tartu University Hospital (TUH) were identified between 1/1/2013 and 31/12/2013. Data collection included demographics, admission data, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes were complications per Clavien-Dindo and hospital length of stay (HLOS). Logistic regression analysis was used to compare adjusted mortality between the two regional hospitals. RESULTS: A total of 256 patients met inclusion criteria. The mean ISS for the cohort was 23.6 ± 7.8, 13.3 % were hypotensive on admission, and 44.1 % had a Glasgow Coma Scale < 9. Overall rate of complications was 40.2 % that did not differ between the facilities. The mean HLOS at the NEMC + TCH and the TUH were 20.1 ± 25.1 and 10.5 ± 11.2 days (p < 0.001), respectively. Overall mortality was 20.7 % (n = 53). Mortality was 25.4 and 14.9 % for the NEMC + TCH and the TUH, respectively (p = 0.04). Logistic regression analysis resulted in comparable mortality at the regional trauma facilities (adj. OR 1.38; 95 % CI 0.66-2.92; p value 0.39). CONCLUSIONS: The annual incidence of injuries with ISS > 15 was 256 cases with overall mortality at 20.7 % in Estonia. We observed comparable adjusted outcomes at the major regional trauma facilities. This study contains benchmarking data on severely injured patients in Estonia providing potential for future trauma care evaluation and regional outcome comparisons.

Three-year results of randomised clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty.

PURPOSE: The aim of the present randomised study was to find out whether usage of lightweight mesh in inguinal hernia repair, compared with heavyweight mesh, results in decreased incidence of chronic groin pain and foreign body feeling, as well as to evaluate the risk factors for chronic pain development and hernia recurrences. METHODS: The patients were randomised into the heavyweight mesh (HW) group and lightweight mesh (LW) group. A tension-free mesh repair using the Lichtenstein technique was performed on all patients. Pain scores during different activities were measured on visual analogue scale. All patients underwent a clinical examination for any evidence of hernia recurrence. RESULTS: Of the patients, 17.2 % in the HW group and 29.3 % in the LW group reported that they experienced pain at 3-year follow-up (P = 0.1323). Pain was most often reported during physical activity. The median VAS score of all studied activities was 30.5 in the HW group and 30.0 in the LW group. There were more patients in the HW group than in the LW group who stated that they could feel the mesh in the groin (27.6 vs. 20.7 %, P = 0.3967). Among all patients, 42.9 % who had severe pain preoperatively also reported pain during different activities and 19.6 % of the patients who did not have severe pain preoperatively reported pain during different activities (P = 0.0481). At 3-year follow-up, there was 1 hernia recurrence in the HW group and 1 hernia recurrence in the LW group. CONCLUSIONS: Our study shows that compared with HW mesh, LW mesh has no advantage in reducing chronic groin pain and foreign body feeling at the operation site after inguinal hernioplasty at 3-year follow-up. Severe preoperative pain was correlated with the development of chronic pain. There was no difference between the two study groups in the recurrence rates.

Randomised clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty.

PURPOSE: The aim of the present randomised clinical study was to compare the incidence of post-operative chronic groin pain and the feeling of a foreign body after inguinal hernioplasty with lightweight (LW) and heavyweight (HW) mesh, as well as to evaluate the patient's quality of life after inguinal hernia repair. METHODS: A total of 135 patients were randomised into the HW mesh group (66 patients) and the LW mesh group (69 patients). A tension-free repair using the Lichtenstein technique was performed on all patients. Pain scores were measured on a visual analogue scale. To evaluate the patient's quality of life, the Medical Outcomes Study Short-Form (SF) 36 questionnaire was completed by the patient. RESULTS: There were significantly more patients with pain at rest in the HW mesh group than in the LW mesh group at 6 months follow-up (6.3 vs. 0%, P = 0.038). The feeling of a foreign body at the operation site was experienced by 32.8% of the patients in the HW group and by 20.9% of the patients in the LW group after 6 post-operative months (P = 0.123). There were no significant differences in any dimension of quality of life on the SF36 between the two study groups 6 months after surgery. CONCLUSIONS: Our study shows that, compared with HW mesh, LW mesh has some advantages in reducing chronic groin pain at the operation site after inguinal hernioplasty. According to our study, there was no difference in the feeling of a foreign body and in the quality of life between the two study groups.

Ten years experience of treating aorto-femoral bypass graft infection with venous allografts.

OBJECTIVE: The aim of the present study was to analyze our results of treating synthetic vascular graft infection in the aorto-femoral segment with venous allografts. PATIENTS AND METHODS: During 1997-2006 we treated 11 male patients with venous allografts for aorto-femoral segment prosthetic graft infection. Patients were followed postoperatively with patency assessment based on Doppler ultrasonography. RESULTS: The mean interval between the implantation of the synthetic vascular graft and the appearance of infection was 43+/-29 months (range 5 months-10 years). Overall primary patency of the venous allograft was 100%, 88% and 66% at 1, 6 and 36 months, respectively. Secondary patency rates of the venous allograft were 94% and 73% after 5 and 8 years, respectively. Overall survival rate was 100%, 64%, 46% and 27% after one month, 3, 5 and 8 years, respectively. Limb salvage rate was 100%, 94% and 73% after 1 month, 5 and 8 years, respectively. CONCLUSIONS: The use of in situ venous allograft for the treatment of synthetic graft infection in the aorto-femoral segment has led to favourable short- and long-term results.

Ligasure vessel sealing system versus conventional vessel ligation in thyroidectomy.

BACKGROUND AND AIMS: The Ligasure Vessel Sealing System (LVSS) is a new surgical technology which has been used to secure haemostasis in various fields of surgery. There is little information in the literature about the use of the LVSS in thyroid surgery and the results of these studies are controversial. The aim of this study was to report our experience with the LVSS in thyroid surgery and to compare it with our experience with conventional vessel ligation. PATIENTS AND METHODS: The non-randomized retrospective review included 403 consecutive patients who underwent primary thyroid surgery. A conventional suture-ligation technique was used in 199 patients (conventional group) and the LVSS was used in 204 patients (ligasure group). The following data were collected: patients' demographics, thyroid pathology, type of thyroidectomy, operating time and complications. RESULTS: The mean operating time for lobectomy, subtotal thyroidectomy and total thyroidectomy was significantly shorter in the Ligasure group compared with the conventional group. Average saving in operating time in the Ligasure group was 25.8 minutes (95% CI 19.5-32.2; p < 0.0001) with relative reduction being 26.6%. Among all types of complications only postoperative transient hypoparathyroidism demonstrated a significantly lower incidence in the Ligasure group (2.5% vs 7.0%; p = 0.022). CONCLUSIONS: We found that the LVSS is a safe method with minimal complications in thyroid surgery. Use of the LVSS for all types of thyroidectomy ensures a significantly shorter operating time.

Intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy: a prospective study of 413 consecutive patients.

BACKGROUND AND AIMS: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). MATERIAL AND METHODS: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2%) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. RESULTS: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58%) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9%) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9%) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5% were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5%); however, the supposed rate of residual stones was 2.4%. CONCLUSIONS: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.

Postoperative pain relief after laparoscopic cholecystectomy: a randomised prospective double-blind clinical trial.

BACKGROUND AND AIMS: The clinical value of infiltration of wounds with local anaesthetics (LA) and their intraperitoneal application for treating pain after laparoscopic cholecystectomy (LC) still remain controversial. In this study the use of intraincisional and intraperitoneal LA was evaluated. MATERIAL AND METHODS: Eighty patients were prospectively randomised into four groups. In the control group (G1) LA was not used. In G2 all wounds were infiltrated with 80 ml of 0.125 % Bupivacaine containing 5 mg of Phenylephrine. In G3 the wounds were infiltrated with 80 ml of 0.9 % NaCl. In G4, in addition to wound infiltration with Bupivacaine/Phenylephrine, 200 ml of normal saline, containing 0.15 % of Lidocaine, was left intraperitoneally under the right diaphragm. Postoperative abdominal and shoulder pain scores were recorded on a visual analogue scale (VAS) during 24 hours after LC. Narcotic analgesic consumption was also recorded. RESULTS: The mean abdominal pain scores were significantly lower in G2, compared with G3, 3 to 24 hours after operation, compared with G4, 3 to 6 hours and compared with G1, 3 to 24 hours (except at hour 12) after surgery. The incidence of shoulder pain was 30 %. There were no significant differences in the mean shoulder pain scores between the groups. The mean dosage and the total amount of Pethidine at 24 hours were significantly lower in G2 compared with G1. CONCLUSIONS: Intraincisional infiltration with a Bupivacaine/Phenylephrine mixture reduces significantly abdominal postoperative pain (for up to 24 h) and narcotic analgesic consumption after LC. An intraperitoneal subdiaphragmatic dilute solution of Lidocaine was not effective in reducing overall pain and shoulder pain after LC.

Sugiura procedure in the treatment of bleeding esophageal varices.

AIM OF THE STUDY: The aim of this study was to report our results and to make an attempt to define the possible role of Sugiura procedure in the treatment of variceal bleeding. MATERIAL AND METHODS: From January 1979 to December 1997, 39 patients with portal hypertension and acute variceal bleeding (17 patients) or previous variceal bleeding (22 patients) underwent Sugiura procedure. Operations were performed in two stages. When performed in an emergency situation (17 patients) thoracic operation was performed first. In elective cases abdominal operation was usually preferred. Complete two-stage operation was performed in 16 patients. Twenty-three patients did not undergo the second stage because of early postoperative death, deterioration of condition or refusal. There were 17 men and 22 women, aged 41.7 +/- 18.3 years (range 8-71 years). According to the Child--Turcotte classification of hepatic function there were 23 Child class A, 13 Child class B and 3 Child class C patients. SUMMARY OF RESULTS: Overall operative mortality was 10.3% (4 deaths per 39 patients with 54 operations), mortality in an emergency situation was 17.6% (3 deaths per 17 patients) and in elective cases 4.3% (1 death per 22 patients with 37 operations). Variceal rebleeding occurred in 4 survivors (11.4%) at an average follow-up of 6.1 +/- 4.3 years. Survival rate was 84.6% at 1 year, 71.8% at 5 years and 64.1% at 10 years. CONCLUSIONS: Sugiura operation carries low operative risk in an elective situation and results in an effective prevention of recurrent variceal bleeding.

Venous allografts for infrainguinal vascular bypass.

Between 1978 and 1993, 107 patients received venous allografts for infrainguinal revascularization because autogenous material was unavailable. These operations comprised 7.4% of 1442 reversed vein bypass procedures performed during the same period. Alloveins were harvested during varicose vein stripping and stored up to 10 days in saline solution containing heparin and antibiotics. Veins with or without minimal degenerative changes were used and when necessary segments were sutured end-to-end to obtain a convenient length. The patients comprised 95 men and 12 women of age range 44-87 years. All operations were performed for limb salvage (rest pain and gangrene); 40 femoropopliteal and 67 femorocrural bypasses were performed; 66 were primary reconstructions and 41 secondary reconstructions. The operative mortality rate was 3.7%. Early thrombosis occurred in 18 patients (16.8%), nine of whom were successfully reoperated upon. The cumulative patency rates for all bypass operations was 82.9%, 38.7% and 21.3% at 30 days, 3 and 5 years, respectively, the limb salvage rates being 84.8%, 48.0% and 29.2%, respectively. Allografts may have a place in lower-limb bypass surgery in the absence of veins, polytetrafluoroethylene or human umbilical vein.

Limb loss in association with vascular surgery--a five-year series of major lower-limb amputation.

OBJECTIVE: To evaluate the type, timing and number of vascular reconstructions that preceded amputation; to compare the characteristics of amputees who had had reconstructions with those of amputees who had not, and to compare the results of amputation. DESIGN: Retrospective study of case notes. SETTING: University hospital, Sweden. SUBJECTS: All 219 patients who underwent amputation between 1987 and 1992. MAIN OUTCOME MEASURES: Incidence of amputations; presenting features, and type and results of vascular reconstructions. RESULTS: The number of amputations decreased after 1988, and that of vascular reconstructions increased. 56 of the 99 who had amputations after reconstruction (57%) had had their last procedure within a month. This group had had a mean of three operations, had worse run-off as assessed by angiography, and 2 of them (5%) had amputations after failed suprainguinal reconstruction for claudication alone. 68 of the total (31%) had amputations without first being assessed by a vascular surgeon. 52 (24%) required reamputation. CONCLUSION: Better objective methods are needed for the assessment of patients before primary as well as secondary vascular reconstructions. All patients should be seen by a vascular surgeon before amputation is recommended.

[Sugiura's operation in the treatment of hemorrhage from esophageal varicose veins]. / Operatsiia Sugiura pri lechenii krovotechenii iz varikozno-rasshirennykh ven pishchevoda.

The authors have performed Sugiura's operation since 1979 in 17 patients in bleeding from varicose veins of the esophagus. The patient's ages ranged from 14 to 69 years. Portal hypertension was caused by hepatic cirrhosis in 14 and extrahepatic blockade in 3 patients. Emergency operations were carried out in 12 and planned interventions on 5 patients. The 3 patients with extrahepatic blockade and 7 patients with Groups A and B hepatic cirrhosis (according to Child's classification) recovered. Among 7 patients with group C 4 died (total mortality, 24%). Recurrent bleeding was not encountered in long-term postoperative follow-up periods of up to 10 years.

[Myoglobin level in patients with occlusive diseases of the lower extremities]. / Soderzhanie mioglobina u bol'nykh s obliteriruiushchimi zabolevaniiami nizhnikh konechnostei.

Serum myoglobin (MG) concentration was measured in 25 patients with obliterating atherosclerosis of the aorta and main arteries of the lower extremities and in 30 normal subjects. Serum MG levels were also measured repeatedly following aortofemoral bifurcation shunting. An original one-step enzyme (immunoassay technique was used to determine serum MG concentration. Serum MG was increased in patients with obliterating diseases of the lower extremities. There was marked myoglobinemia, reaching its peak within 8 to 10 hours after the reconstructive operations on the aorto-iliac segments.

[Electron microscopic studies of pseudointima in synthetic prostheses]. / Elktronno-mikroskopicheskoe issledovanie psevdointimy sinteticheskikh protezov.

Thirty one prostheses made of Lavsan (therylene) or teflon-lavsan that had been functioning in human patients for 16 months to 21 years were examined. No continuous endothelial lining was found present on the pseudointimal surface of any of the prostheses. The major cell types in a formed, well-vascularized pseudointima were fibroblasts and smooth-muscle cells. Cells of the macrophage series were involved in forming the granulation tissue seen around fibers of the prostheses.