Preoperative duplex vein mapping (DVM) reduces costs in patients undergoing infrainguinal bypass surgery: results of a prospective randomised study.

OBJECTIVES: Surgical site infections (SSIs) after bypass procedures provoke major costs. The aim of this prospective randomised trial was to assess if preoperative duplex vein mapping (DVM) reduces costs generated by SSI. MATERIALS/METHODS: Patients undergoing primary infrainguinal bypass were randomised to DVM of the ipsilateral greater saphenous vein (group A) or none (group B). Costs were calculated by the hospital's accounting department. RESULTS: From December 2009 to April 2011, 130 patients (65 each group) were enrolled. Both cohorts were equal regarding demographics, risk factors and costs for primary bypass surgery, respectively. SSIs were classified minor (A: n = 13 vs. B: n = 13, P = n.s.) and major (A: n = 1 vs. B: n = 12, P = .0154). Preoperative DVM was the only significant factor to prevent major SSI (P = .011). Theatre costs for SSI: A: 537 € versus B 6553 € (P = .16). Recovery room/intensive care unit (ICU) costs for SSI: A: 0 € versus B: 8016 € (P = .22). Surgical ward costs for SSI: A: 2823 € versus B: 22 386 € (P = .011). Costs for outpatient visits due to SSI: A: 6265 € versus B: 12 831 € (P = .67). Total costs of patients without SSI: 8177 € versus major SSI: 10 963 € (P < .001). CONCLUSION: DVM significantly reduces costs generated by re-admission in patients suffering from major SSI.

Proximal common carotid artery lesions: endovascular and open repair.

OBJECTIVES: Management of proximal common carotid artery (pCCA) lesions is infrequently reported. We described open and endovascular treatment with regard to the neurological outcome and patency in patients suffering from atherosclerotic pCCA lesions. METHODS: Data were collected prospectively and analysed in a retrospective manner. RESULTS: From November 1991 to January 2010, 52 procedures, 24 surgical (11 bypasses, 12 transpositions and retrograde endarterectomy) and 28 endovascular (13 open transcervical and 15 transfemoral stent implantations) were performed (40.4% female, mean age 62.3 years, 65.4% left-sided). A total of 25 lesions (48.1%) were symptomatic (13 stenoses and 12 occlusions); 27 (51.9%) lesions were asymptomatic (22 stenoses and five occlusions). Two bypasses occluded within 30 days. Two early ipsilateral strokes were observed (3.8%). There was one perioperative death due to myocardial infarction after transcervical stent (1.9%). Mean follow-up was 61 months. In one transposition and two stent implantations, late redo interventions were performed. Fourteen of 48 patients died during follow-up. CONCLUSION: pCCA repair for atherosclerotic lesions is associated with a substantial perioperative risk (combined stroke/death rate: 5.7%). Endovascular intervention is the preferred invasive treatment option in patients suffering from stenotic pCCA lesions. In cases of pCCA occlusion, open surgery is a valid alternative. Late survival in patients suffering from pCCA lesions is poor.

Subclavian to carotid artery transposition: medial versus lateral approach.

INTRODUCTION: Subclavian to carotid transposition (SCT) is gaining importance as an adjunct for thoracic endovascular aortic repair (TEVAR). Two different anatomical approaches are described. We reviewed our experience with both approaches to evaluate the occurrence of complications and long-term outcome. MATERIALS/METHODS: We report the outcome of 150 SCTs carried between October 1979 and April 200710/79 at 2 university based tertiary care centers. Independent neurologic evaluation was performed. RESULTS: Lateral and medial approaches were used in 83 (55.4%) and 67 (44.6%) cases, respectively. The internal thoracic artery and the thyrocervical trunk were sacrificed more frequently when the lateral approach was used (1.5% vs 39.8%; p=0.0001 and 1.5% vs 49.4%; p=0.0001, respectively). The medial approach was associated with significantly less complications (8, 11.9%, compared to 24, 28.9%, p=0.012). Thirty day mortality was 0.7%. Median follow-up was 36 months (1-227), and no subclavian artery occlusions were identified. CONCLUSIONS: SCT is a durable procedure for the management of occlusive pathologies of the proximal subclavian artery occlusion. The medial approach is associated with significantly fewer complications.

Endovascular management versus surgery for proximal subclavian artery lesions.

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Bacterial translocation in short-bowel syndrome in rats.

Massive intestinal resection results in short-bowel syndrome (SBS) and is associated with an increased risk of infectious complications mainly caused by the egress of intestinal bacteria to distant organs, a process termed bacterial translocation (BT). The purpose of this experimental study in rats was to investigate in different models of SBS the impact of the type of intestinal resection on bacterial growth in the residual small bowel and on the occurrence of BT. SBS was created in 30 rats either by jejunal resection (JR), by ileal resection (IR) or by ileal resection including the ileocecal valve (IR+ICV). 10 animals underwent only a sham laparotomy (SL) and served as controls. Two weeks after the operative procedure, intestinal bacterial colonization and BT to the portal vein, vena cava, mesenteric lymph nodes, liver and spleen were determined. All resected animals showed a decreased weight gain and a significant bacterial overgrowth in the residual small bowel compared to the SL group. BT occurred after SL in 12%, after JR in 70%, after IR in 58%, and was significantly less frequent (35%) after IR+ICV, respectively. These experimental findings suggest that BT in SBS might be promoted by the intestinal bacterial overgrowth in the residual bowel, and the incidence of BT seems to be related to the presence or absence of the ileocecal valve.

[Apophyseal fractures of the pelvis and trochanter minor in 20 adolescents and 2 young children]. / Apophysenfrakturen des Beckens und des Trochanter minor bei 20 Adoleszenten und 2 Kleinkindern.

From 1978 to 1999, 22 patients (17 male, 5 female) who suffered apophyseal fractures of the pelvis and femoral lesser trochanter (18 patients by avulsion, 4 patients by direct trauma) were treated. The median age of the patients was 12.5 years (range, 1-16 years). Eighteen patients were injured during sports activities. Predominantly the anterior inferior iliac spine (n = 9) was affected, followed by fractures of the femoral lesser trochanter (n = 3), periacetabular rim (n = 3), anterior superior iliac spine (n = 2), and iliac crest (n = 2), retrospectively. The diagnosis was established using plain x-ray films. The treatment was conservative in 21 patients (95%) and operative in one (5%). Of the patients, 20 (91%) were followed-up for a median interval of 12 months (3 weeks to 84 months). At follow-up, 15 patients (75%) reported that they were free of pain during sport activities, while five patients (25%), at an average time of 33 months after accident, complained of pain at the former fracture site when exercising vigorously during sport. At clinical examination no patient was found suffering from limitation of ROM (range of motion), adjacent joints, or muscular insufficiency. Plain [not readable: see text]

Nephron-sparing procedures in 11 patients with Wilms' tumor.

PURPOSE: In unilateral Wilms' tumor (WT), tumor nephrectomy is the standard surgical approach, whereas partial nephrectomy (PN) is controversially discussed. The aim of our retrospective study was to show that in selected cases of unilateral WT kidney-sparing operations could be a reasonable alternative to nephrectomy and to discuss the results of patients with bilateral WT treated by tumor enucleation. MATERIALS AND METHODS: From 1981 to 1998, seven patients with unilateral nephroblastoma (four stage I, one stage III and two stage IV) had tumor resection by PN (five right side, two left side), which was planned when the tumor volume was reduced after 4 to 6 weeks of chemotherapy by at least 50%, when the tumor occupied one pole or was easily resectable, when 50% or more of the kidney tissue remained and when paraaortic lymph nodes were free by intraoperative histological examination. In four patients with bilateral WT (stage V) bilateral tumor enucleation was carried out-except in one patient in whom the contralateral kidney had to been removed because of extension of the tumor via the inferior vena cava to the right atrium. All patients ( n = 11) received pre- and postoperative chemotherapy followed by radiotherapy in four patients. RESULTS: All patients with unilateral WT ( n = 7) are still alive and disease free (follow-up time: mean 6.6 years, range: 28 months to 11 years) with normal renal function, although two patients with secondary nephrectomy revealed creatinine clearance levels at the lower range. In six patients primary PN was performed successfully. In a stage III tumor patient (intraperitoneal metastasis, free lymph nodes), secondary nephrectomy was necessary due to renal arterial thrombosis 2 days after PN. In one stage IV tumor patient (lung metastasis, free lymph nodes), the primary resection was not far enough away from the tumor margin so that an additional slice of tissue with then tumor-free margins had to be resected. This patient evolved a local relapse 19 months after PN and had to be nephrectomised thereafter. In the group of bilateral WT patients ( n = 4), one child died 2 months after surgery during chemotherapy because of central venous line sepsis. One patient who additionally suffered from inferior vena cava tumor thrombosis extending to the right atrium making nephrectomy of the right kidney necessary developed chronic renal failure 4.7 years postoperatively. The other two stage V tumor patients have creatinine clearance levels within the normal range. CONCLUSIONS: Kidney-sparing procedures remain the operative approach of choice in patients with bilateral WT, but bear the risk of chronic renal failure when one kidney has to be removed. PN in children with unilateral WT, carried out by an experienced surgeon, is a reasonable alternative to nephrectomy if strict guidelines such as excellent tumor response to preoperative chemotherapy and easy resectability far away from the tumor margins through healthy kidney tissue are followed. Paraaortic lymph nodes must be free of tumor invasion in order to avoid local radiotherapy. PN prevents the patient from having to have dialysis in cases of contralateral nephrectomy resulting from metachronous WT or subsequent renal trauma.