The value of extended preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to surgical treatment.

AIM: Ovarian cancer (OC) is associated with a high risk of venous thromboembolism (VTE) in both, pre- and postoperative period. The aim of the study was to analyse the efficacy and the safety of an early prophylaxis with dalteparin in patients with OC qualified to surgery. METHODS: The prospective, non-randomized study was performed in the group of OC patients qualified to surgical treatment. The study group (SG) consisted of 37 patients with OC in whom thromboprophylaxis was started at the moment of qualification to the surgery (mean 16,1 days ± 11,32 SD before procedure). The control group (CG) consisted of 61 patients with OC qualified to surgery in whom thromboprophylaxis was started 12 hour before surgical treatment. The duration of postoperative prophylaxis was 4 weeks in both groups. Dalteparin 5000 U/day was used in both groups. The primary end points were occurrence of VTE and major bleeding. The patients underwent color Doppler US and D-dimer (DD) assessment at the moment of qualification for surgery, 1 day before and 7, 14, 28 days and 3 months after procedure. RESULTS: The total duration of thromboprophylaxis was 45.3 ± 10.7 days in SG and 27.9 ± 3.7 days in CG (P < 0.0001). The deep venous thrombosis rate was 2,7% in SG and 16.4% in CG (P = 0.042). Neither pulmonary embolism, nor major bleeding were observed. Median preoperative DD concentration in all patients was 1700 ng/ml and was significantly higher in patients who developed postoperative DVT when compared to those who did not, 2556.8 and 1691.0 ng/mL respectively (P = 0.0009). CONCLUSION: Prolonged preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to the surgical treatment is safe, decreases the risk of thromboembolic complications. To determine indication, dosage and timing of such thromboprophylaxis in this group of patients further studies are required.

Sulodexide modifies intravascular homeostasis what affects function of the endothelium.

PURPOSE: Sulodexide is a mixture of heparin and dermatan sulphate which has an antithrombotic action. It was shown that it has also direct effect on the endothelial cells. We tested the effect of sulodexide on the intravascular homeostasis in patients with peripheral vascular disease. METHODS: Sulodexide was infused iv. at a dose of 1200 Lipoprotein Lipase Releasing Units (LRU) in 10 patients with peripheral vascular disease. Blood samples were collected before the infusion and 1, 6 and 24 hours after the infusion. Inflammatory and fibrinolytic parameters were studied in the collected serum samples. Additionally, ex-vivo effect of the serum samples on in vitro function of the endothelial cells was studied. RESULTS: Infusion of sulodexide caused acute and transient peak of the Hepatocyte Growth Factor (HGF) concentration in blood and decrease of the Vascular Endothelial Growth Factor (VEGF) level, what, as we found in in vitro experiments, was due to adsorption of VEGF to endothelium. We found that HGF enhanced in vitro stimulating effect of VEGF on proliferation of the endothelial cells. Serum level of interleukin-6 was gradually decreased, whereas fibrinolytic activity of serum, reflected by t-PA/PAI-1 ratio, increased. Serum samples obtained from the studied patients suppressed oxidative stress and release of interleukin-6 in endothelial cells maintained in in vitro culture. CONCLUSION: Sulodexide reduces intravascular inflammation and suppresses inflammatory reaction in the endothelial cells; both effects are desirable in patients with peripheral vascular disease.

The influence of elastic components of the venous wall on the biomechanical properties of different veins used for arterial reconstruction.

OBJECTIVE: To evaluate the relationship between the biomechanical properties and the structure of elastic components in different veins used for vascular reconstruction. DESIGN: In vitro experimental study. MATERIAL AND METHODS: Groups of 30 samples of incompetent saphenous veins (rSV), competent saphenous veins (cSV) and femoral veins (FVs) were compared following immunohistochemical staining for the presence of collagen types I, III and IV and elastin. The percentage area of transverse section of veins occupied by each type of collagen and elastin was measured using a computer-image-analysis system connected to a microscope. For all three groups of veins, the storage modulus, E', and the loss modulus, E'', were measured with a mechanical analyser, DMA-242, and changes in the function of temperature and frequency, and duration of exposure to the applied force were determined. RESULTS: The rSV showed the highest percentage share of collagen I and the lowest percentage share of collagen IV. These samples also showed the greatest expression of elastin and the highest elastin to collagen ratio. The rSV were also found to have the highest E' and E'', and during the long-term exposure achieved maximum stiffness in the least time as compared to cSV and FV. CONCLUSION: The histological structure directly influences the biomechanical properties of venous wall with rSV showing least compliance and cSV the greatest compliance.

Endovascular treatment of intramural hematoma of internal carotid artery after blunt trauma of neck inflicted with the seatbelt.

Blunt trauma of the neck caused by a seatbelt may cause dissection with intramural hematoma of the internal carotid artery. The following case report discusses the differential diagnosis and the potential of endovascular treatment of symptomatic intramural hematoma of the internal carotid artery.

The importance of ceruloplasmin oxidase activity in patients with chronic lower limb atherosclerotic ischemia.

AIM: Inflammatory reactions accompanying ischemia increase the cytokine synthesis what leads to the increase in serum ceruloplasmin (Cp) concentration and activity. The aim of the study was to evaluate the association between serum Cp oxidase concentration and activity and the grade of lower extremity ischemia. Moreover, the correlation of Cp concentration and activity with the levels of interleukin 6 (IL-6), C-reacting protein (CRP), and a-1-acid glycoprotein (AGP) in serum was studied. METHODS: Two groups of patients were examined: 15 patients with moderate (MI) and 32 patients with critical ischemia (CI) of the lower extremities. Cp oxidase activity was measured spectrophotometrically, after incubation with o-dianisidine. The concentration of IL-6 was measured with the ELISA method, and Cp, CRP and AGP concentration by rocket immunoelectrophoresis. RESULTS: Significant increase in Cp oxidase concentration and activity was observed in patients with critical limb ischemia (median: 164.8 U/L), especially in patients with necrotic changes (median: 216.6 U/L). Cp oxidase activity was dependent on its concentration in patients with critical limb ischemia with necrotic changes (r=0.56; P<0.01). In patients with critical limb ischemia, the increase in Cp concentration and activity correlated significantly with CRP concentration (r=0.46; P=0.0007) (r=0.62; P=0.0001), respectively. CONCLUSION: Concentration and the oxidase activity of Cp depend of the degree of lower extremity ischemia and correlates with the major markers of inflammation, such as CRP. Critical limb ischemia induces the inflammatory reaction triggering the increase in IL-6 and of acute phase protein production. These processes lead to the increase in Cp oxidase activity dependent of Cp and CRP concentration.

Time to reconsider saline as the ideal rinsing solution during abdominal surgery.

BACKGROUND: Peritoneal mesothelial cells lining the peritoneal cavity play a primary role in prevention of formation of peritoneal adhesions, which depends mainly on their fibrinolytic activity. During surgical procedures, the abdominal cavity is in most cases rinsed with normal saline solution, which may modify the fibrinolytic activity of the peritoneal mesothelium and predispose to formation of adhesions. The goal of our experiments was to evaluate how normal saline and other solutions affect the fibrinolytic properties of the peritoneal mesothelial cells. MATERIAL AND METHODS: Experiments were performed on in vitro cultures of human peritoneal mesothelial cells. Mesothelial monolayers were exposed during 6 hours to the following solutions: culture medium (control), .9% NaCl, Hanks solution, Earles solution, new peritoneal dialysis fluid with low glucose degradation products (GDP) concentration (PDF), and peritoneal dialysis fluid with high concentration of GDP (PDF-GDP). Afterwards, morphology of the cells as well as leakage of lactate dehydrogenase (LDH) from their cytosol were evaluated. During the next 24 hours when the cells were cultured in standard medium synthesis of interleukin-6 (IL-6), tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) were studied. RESULTS: Mesothelial monolayers exposed to .9% NaCl or to PDF-GDP showed destruction of their morphology after 6 hours incubation and in case of PDF-GDP release of LDH from the cytosol was increased by 275% versus the control (P<.05). During subsequent culture of all cells in standard medium, the release of IL-6 was decreased in cases of cells pretreated with .9% NaCl (-58%, P<.05) or PDF-GDP (-93%, P<.001). The release of t-PA was also reduced from cells pretreated with .9% NaCl (-71%, P<.01) or with PDF-GDP (-74%, P<.01) but increased after exposure of these cells to PDF (+35%, P<.05). Statistically significant decrease of PAI-1 synthesis was observed in cells preexposed to .9% NaCl (-69%, P<.01) or to PDF-GDP (-82%, P<.05). When changes in the PAI-1/t-PA ratio were calculated, a strong tendency for increase of that value was seen in cells pretreated with .9% NaCl or Earles salts solution but not with PDF. However, in cases of Hanks solution, a significant increase in the PAI-1/t-PA ratio was observed (+104%, P<.01). CONCLUSION: Exposure of the peritoneal mesothelial cells to .9% NaCl, Hanks, Earles salts solution, or PDF-GDP results either in reduction of their viability or in loss of their fibrinolytic activity. Peritoneal dialysis fluid with a low content of glucose degradation products appears to be the optimal solution causing the least damage to mesothelial cells and therefore may be the ideal solution for rinsing the abdominal cavity with low risk of inducing deterioration of the mesothelial cells fibrinolytic activity and formation of adhesions. We postulate therefore that such hypertonic peritoneal dialysis fluids should be used not only during peritoneal dialysis but also for rinsing the abdominal cavity during any surgical procedures.

[Vaginal evisceration with secondary torsion of small intestine]. / Wytrzewienie przez pochwe z wtórnym skretem jelita cienkiego.

The case of vaginal evisceration in 87 year old woman is described. The evisceration occurred on a day preceding the admission of the patient to the hospital. On admission the intestinal ischemia due to torsion of the bowel loop was noticed and was immediately reversed in emergency room. On laparotomy the viability of the intestine was confirmed and repair of vaginal tear was performed. The brief review of the literature is also presented.

The value of quantitative bacteriological investigations in the monitoring of treatment of ischaemic ulcerations of lower legs.

The quantitative and qualitative bacteriological investigations of 63 patients were done on ischaemic ulcerations before reconstructive vascular surgery and at 7 day intervals after the operation. Among the isolated bacteria the most common were Gram positive (62.9%), especially Staphylococcus aureus. Amputations due to non-healing ulcers were performed on 8 patients, who had ankle brachial index (ABI) lower than 0.47. In 55 patients with ABI higher than 0.47 (with the exception of one case) free skin grafts were applied to reduce the time of the ulcers healing. Primary healing of ulcers covered with free-skin grafts was achieved in 44 out of 55 patients (80%). In 11 patients, were free-skin grafts had failed, ulcerations were healed following the repetition of the free-skin grafts. The healing results of skin grafts statistically were significantly better in the group where the number of bacteria in 1 cm2 of ulceration was lower than 50.000. The severity of infections in ulcers makes the healing process of skin grafts impossible. Quantitative bacteriology additionally helps in objective evaluation of granulating tissue and facilitates choice of proper skin grafting time. This study has shown the usefulness of quantitative bacteriology for the determination of the severity of infections in ulcers.

C-reactive protein and alpha-1-acid glycoprotein in monitoring of patients with chronic arterial occlusion of the lower limbs.

C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) levels were studied in the sera of 107 patients with chronic arterial ischaemia of the lower limbs. Depending on the degree of ischaemia, patients were divided into four groups: (i) intermittent claudication--20 patients; (ii) rest pain and ankle pressure above 50 mmHg--12 patients; (iii) rest pain and ankle pressure below 50 mmHg--25 patients; (iv) peripheral necrosis--50 patients. Reconstructive surgery was performed in 84 patients and primary major amputation in 23 cases. Levels of CRP and AGP increased with the severity of ischaemia. In uncomplicated cases, CRP and AGP concentrations decreased to normal values 7-10 days after surgery. In a group of 23 patients with postoperative necrotic complications, significant increases in CRP and AGP levels were found 7-10 days after surgery. These proteins, especially CRP, may be clinically useful in monitoring patients during the postoperative period with a CRP level greater than 50 mg/l predictive of complications with a sensitivity of 83% and a specificity of 94%.

C-reactive protein and alpha 1-acid glycoprotein in monitoring of patients with acute arterial occlusion.

C-reactive protein (CRP) and alpha 1-acid glycoprotein (AGP) levels were studied in sera of 75 patients with acute arterial occlusion. Depending on the degree of ischaemia, patients were divided into two groups: grade I--26 patients--and grade II--49 patients. All patients were treated surgically; 42 embolectomies, 17 endarterectomies and 16 bypasses were performed. After surgery in 19 patients various complications were observed. The concentration of both proteins at the time of admission was higher in the serum of patients with grade II than with grade I ischaemia. Similarly the concentration of both proteins was significantly higher in the sera of the patients admitted after 8 h than in patients admitted within 8 h of the onset of ischaemia. CRP and AGP levels were significantly higher in the serum of patients with ischaemia of the lower limb than in those with ischaemia of the upper limb. In all patients 2-3 days after surgery a significant increase in serum CRP and AGP was observed. In uncomplicated cases on days 7-10 the values of both proteins decreased below the level observed at the time of admission. However, in patients who experienced postoperative complications high levels of both serum proteins (especially CRP) were found on days 7-10. Complications were detected with a sensitivity and specificity of 84 and 95%, respectively, using a CRP level of 49 mg l-1 as the cut-off point.

Morphological aspects of the aortofemoral graft thrombosis.

Sixty seven patients underwent aorto-femoral double velour grafting for aortoiliac occlusive disease and 38 patients were treated for recurrent lower limb ischemia following aortofemoral grafting. Apart from various clinical examinations the patients underwent angiography as well as the morphological investigation of specimens obtained from abdominal aortae, common femoral arteries and from grafts implanted into the aorto-femoral section. The examinations showed that diffuse intimal thickening may, in the course of atherosclerosis, convert itself into uncomplicated fibrous and further into complicated plaques impairing mainly graft outflow. The drawbacks of grafts are: 1) persistens of fibrin deposits on the luminal surface of the prosthesis which may contribute to thrombosis development, 2) appearance of foci or bands of hyalinized connective tissue causing the stiffening of the graft, 3) development of lesions resembling atheromatous changes at the anastomotic areas and, 4) anastomotic hyperplasia which may contribute to stenosis at the femoral implantation site.