An original external iliac artery reconstruction with internal iliac artery translocation in a blunt injury of the pelvic vessels in a 4-year-old child: A 12-year follow-up study.

A 4-year-old child presented to the emergency department with an open-book pelvic fracture, blunt trauma to the right external iliac artery and vein, and contaminated abdomen due to jejunal tear. Arterial reconstruction with polytetrafluoroethylene was not considered because of caliber discrepancy of 6 mm compared with 3 mm of the child's external iliac artery and a 40% probability of graft infection. We used the ipsilateral internal iliac artery, which was dissected for 7 cm; the distal artery was translocated and anastomosed to the distal external iliac artery. At 12 years of follow-up, the artery grew with the patient, with no need for replacement.

A New Modified Surgical Technique of In Situ Reverse Arterialization: Leaving the Distal Saphenous Side Branches Open of Nonreconstructable Ischemic Leg Leads to Full Recovery.

BACKGROUND: Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. METHODS: A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. RESULTS: Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO2 level of the foot increased up to 76 mm Hg. CONCLUSIONS: This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO2 and reduced flow, leading to full recovery of the ischemic foot.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery.

BACKGROUND: The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. METHODS: A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. RESULTS: The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months.Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. CONCLUSIONS: In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Preprogrammed oscillations improve lower limb blood flow and walking distance in patients with peripheral arterial disease.

BACKGROUND: Claudication is one of the sequelae of peripheral arterial disease (PAD). To date, no effective treatment has been found for this condition. OBJECTIVES: To investigate a new device to treat PAD. The device administers pre-programmed protocols of oscillations to the foot. METHODS: Fifteen patients aged 40-70 years who suffered from intermittent claudication secondary to PAD were recruited to an open prospective study. Each patient was treated once for 30 minutes. The following parameters were evaluated: pain-free and maximal walking distances, skin blood flux by laser-Doppler, skin temperature, ankle-brachial and toe-brachial indices, transcutaneous oxygen pressure (tcpO2) and transcutaneous carbon dioxide pressure (tcpCO2). Non-parametric signed-rank test was applied for testing differences between baseline assessment and post-treatment assessments for quantitative parameters. RESULTS: Mean pain-free walking distance was 122 +/- 33 m and increased to 277 +/- 67 m, after the treatment session (P = 0.004). Mean maximal walking distance was 213 +/- 37 m and it increased to 603 +/- 77 m (P < 0.001). Foot skin perfusion also improved, as demonstrated by an increase in tcpO2 by 28.6 +/- 4.1 mmHg (P < 0.001), a decrease in tcpCO2 by 2.8 +/- 1.3 (P= 0.032), and up to twofold improvement in blood flux parameters, and an increase in skin temperature by 1.9 +/- 0.5 degrees C (P < 0.001). Ankle-brachial index increased by 0.06 +/- 0.01 (P = 0.003) and toe-brachial index by 0.17 +/- 0.02 (P < 0.001). CONCLUSIONS: Preprogrammed oscillations applied to the foot had a positive effect on microcirculation, tissue oxygenation and CO2 clearance; they had a smaller though significant effect on arterial blood pressure indices, and the change in the arterial-brachial index correlated with the change in the pain-free walking distance.

Tumor differentiation as related to sentinel lymph node status in gastric cancer.

AIM: To investigate the influence of tumor grade on sentinel lymph node (SLN) status in patients with gastric cancer (GC). METHODS: We retrospectively studied 71 patients with GC who underwent SLN mapping during gastric surgery to evaluate the relationship between SLN status and tumor grade. RESULTS: Poorly differentiated tumors were detected in 50/71 patients, while the other 21 patients had moderately differentiated tumors. SLNs were identified in 58/71 patients (82%). In 41 of the 58 patients that were found to have stained nodes (70.7%), the tumor was of the poorly differentiated type (group I), while in the remaining patients with stained nodes 17/58 (29.3%), the tumor was of the moderately differentiated type (group II). Positive SLNs were found in 22/41 patients in group I (53.7%) and in 7/17 patients in group II (41.2%) (P = 0.325). The rate of positivity for the SLNs in the two groups (53.7% vs 41.2%) was not statistically significant (P = 0.514). CONCLUSION: Most of our patients were found to have poorly differentiated adenocarcinoma of the stomach and there was no correlation between tumor grade and SLN involvement.

Effect of arteriovenous hemodialysis shunt location on cardiac events in patients having coronary artery bypass graft using an internal thoracic artery.

The possibility of developing coronary steal in patients having coronary artery bypass graft (CABG) using internal thoracic artery (ITA) and ipsilateral upper extremity arteriovenous (AV) hemodialysis shunt has been reported. The impact of this phenomenon on clinical outcomes is uncertain. The aim of this study was to investigate an association between the AV dialysis shunt location regarding the side of the ITA CABG and clinical outcomes. This retrospective cohort study included chronic hemodialysis patients having ITA CABG and upper extremity AV shunt. The patients were divided into two groups: those with ipsilateral and those with contralateral location of ITA CABG and AV shunt. The outcomes were: death from any cause, cardiac death and a first cardiac event. In a group of 112 chronic hemodialysis patients having CABG, 32 had an ipsilateral and 25 had a contralateral location of ITA CABG and an upper extremity AV shunt. Significantly more cardiac events occurred in the group with an ipsilateral compared to a contralateral location of ITA CABGs and dialysis AV shunts (hazard ratio, 2.16 [95% CI, 1.11 to 4.19], P = 0.023). There was no difference between the groups in the all cause mortality risk (hazard ratio, 1.005 [95% CI, 0.43 to 2.37], P = 0.990) or the risk of cardiac death (hazard ratio, 2.43 [95% CI, 0.64 to 9.17], P = 0.191). The ipsilateral location of a CABG with the use of ITA and upper extremity AV hemodialysis shunt may be associated with increased risk of cardiac events.

Effect of timing of thrombectomy on survival of thrombosed arteriovenous hemodialysis grafts.

BACKGROUND: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts. METHODS: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups. RESULTS: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups (P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% (P = .038). CONCLUSIONS: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.

Effect of timing of the first cannulation on survival of arteriovenous hemodialysis grafts.

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12-month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty-eight patients with 64 newly-created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.

Comparative study of the pathological characteristics of gastric stump carcinoma and carcinoma of the upper third of the stomach.

BACKGROUND: Gastric stump cancer is often described as a tumor with a poor prognosis and low resectability rates. OBJECTIVES: To compare the pathological characteristics of gastric stump cancer patients with those of patients with proximal gastric cancer. METHODS: This retrospective study was based on the demographic and pathological data of patients diagnosed with gastric cancer and treated at Assaf Harofeh Medical Center during an 11 year period. The patients were divided into two groups: those undergoing proximal gastrectomy for proximal gastric cancer and those undergoing total gastrectomy for gastric stump cancer. RESULTS: Patients with gastric stump cancer were predominantly male, older (P = 0.202, not significant), and had a lower T stage with less signet-ring type histology, fewer harvested and fewer involved lymph nodes (P = 0.03, statistically significant) and less vascular/lymphatic involvement than patients with proximal gastric cancer. CONCLUSIONS: The lower incidence of involved lymph nodes and lymphovascular invasion in gastric stump cancer as compared to proximal gastric cancer in this study may imply that the prognosis of gastric stump cancer may be better than that of proximal gastric cancer. However, to verify this assumption a study comparing patient survival is required.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome.

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

The accuracy of sentinel node mapping according to T stage in patients with gastric cancer.

BACKGROUND: Sentinel lymph node (SLN) mapping has been recently introduced to the field of gastric cancer. To the best of our knowledge, no study has dealt with the accuracy of SLN mapping according to the T stage of the primary tumor. The aim of the present study was to evaluate SLN status according to the T stage of the primary tumors. METHODS: Eighty patients with gastric cancer underwent SLN mapping with patent blue dye during gastric resection. RESULTS: Forty-seven patients underwent distal subtotal gastrectomy; 17 patients, proximal gastrectomy; 14, total gastrectomy; and 2, gastric stump resection. SLNs were stained in 61/80 patients (76.3%). The number of stained SLNs varied from 1 to 16 (mean, 3.3). Patients undergoing proximal gastrectomy had a mean of 3 stained SLNs, whereas patients undergoing distal subtotal gastrectomy had a mean of 2.8 stained SLNs. In 55/61 patients (90.2%) with stained SLNs a positive correlation was found between the presence of metastases and stained or non-stained SLNs. Ten out of 11 patients (90.9%) with T1 tumors (mean, 3.27 SLNs per patient) and 15/17 patients with T2 tumors (88.2%; mean, 3 SLNs per patient) had stained SLNs as compared to only 33/48 (68.8%) of patients with T3 tumors (mean, 3.3 SLNs per patient). The positive predictive value of the SLN mapping was 100%, the negative predictive value was 76.9%, and sensitivity was 85.4%. CONCLUSION: While in T1 and T2 tumors sentinel node mapping may be of assistance in the decision-making process regarding the extent of lymphadenectomy (sensitivity, 100%; negative predictive value, 90%-100%), SLN mapping in patients with T3 tumors will be misleading in a third of the patients and should not be attempted.

The role of diagnostic laparoscopy in the management of patients with gastric cancer.

BACKGROUND: Gastric cancer continues to be a leading cause of cancer death. The treatment approach varies, and preoperative staging is therefore crucial since an exploratory laparotomy for unresectable gastric cancer will be followed by an unacceptably high morbidity and mortality rate. OBJECTIVES: To assess the added value of diagnostic laparoscopy to conventional methods of diagnosis such as computed tomography in avoiding unnecessary laparotomies. METHODS: We conducted a retrospective study on 78 patients scheduled for curative gastrectomy based on CT staging. DL was performed prior to exploratory laparotomy. RESULTS: In 23 of 78 patients (29.5%) unexpected peritoneal spread not detected on preoperative CT was found. Fifty-five patients underwent radical gastrectomy, 15 patients were referred for downstaging and 8 patients underwent a palliative procedure. CONCLUSIONS: Based on our results, DL should be considered in all gastric cancer patients scheduled for curative gastrectomy.

Gastrointestinal stromal tumors: a 19 year experience.

BACKGROUND: Gastrointestinal stromal tumors are the most common mesenchymal neoplasms of the human gastrointestinal tract. OBJECTIVES: To review our accumulated experience using surgery to treat gastrointestinal stromal tumors. METHODS: We reviewed all patient charts and histological diagnoses of leiomyomas, leiomyosarcomas, leiomyoblastomas and schwannomas. Only tumors that displayed c-kit (CD117) immunopositivity were defined as GISTs. RESULTS: The study group comprised 40 female and 53 male patients (age 26-89 years); 40.8% of the tumors were classified as malignant, 39.8% as benign, and 19.4% as of uncertain malignancy. Fifty-six GISTs were located in the stomach (60.2%), 29 in the small bowel (31.2%), 4 in the duodenum (4.3%), 2 in the colon (2.1%) and 2 in the rectum (2.1%). Incidental GISTs were found in 23.7% of our patients. Mean overall survival time for malignant gastric GISTs was 102.6 months (95% confidence interval 74.2-131.1) as compared to 61.4 months mean overall survival for malignant small bowel GISTs (95% CI 35.7-87) (P = 0.262). The mean disease-free survival period for patients with malignant gastric GISTs was 97.5 months (95% CI 69.7-125.2) as compared to only 49.6 months (95% CI 27.4-71.7) for patients with small bowel malignant GISTs (P = 0.041). CONCLUSIONS: We found a high percentage of incidental GISTs. Gastric GISTs are more common than small bowel GISTs. Patients with malignant gastric GISTs have a significantly better prognosis than patients with malignant small bowel GISTs. A statistically significant correlation was found between age and malignant potential of the GIST.

Sentinel node mapping for gastric cancer.

BACKGROUND: Sentinel lymph node mapping is the standard of care for patients with malignant melanoma and breast cancer. Recently, SLN mapping was introduced to the field of gastric cancer. OBJECTIVES: To evaluate SLN mapping in patients with gastric cancer. METHODS: In 43 patients with gastric cancer, open intraoperative subserosal dye injection in four opposing peritumoral points was used. Ten minutes following dye injection, stained LNs were located, marked and examined postoperatively from the surgical specimen. RESULTS: SLN mapping was performed in 43 patients with gastric cancer; 782 lymph nodes were harvested and evaluated. SLNs were stained in 34 of the patients (79.1%) with a mean of 2.85 SLNs per patient. The false negative rate was 20.9%, the positive predictive value 100%, the negative predictive value 78.6% and the sensitivity 86.9%. CONCLUSIONS: SLN mapping in patients with gastric cancer is feasible and easy to perform. SLN mapping may mainly affect the extent of lymph node dissection, and to a lesser degree gastric resection. However, more data are needed.