Acute limb ischemia: delayed presentation and outcome

Acute limb ischemia still represents an important dangerous situation in vascular surgery. Delayed presentation of acute ischemia usually leads to catastrophic outcome. Late ischemia represented 20.4% of all cases of acute limb ischemia admitted to our hospital during one year period. We were aiming to evaluate such cases with acute prolonged limb ischemia identifying causes of delayed presentation and its imprint on patients limb and life. Forty-five patients [45 limbs] were included in this study. There were 25 females and 20 males with ages ranged between 20 and 85 years [mean; 58 years]. The lower limbs were affected in 91.1% of cases while the upper limbs were involved in 8.9%. Sixty percent of cases had embolic ischemia while 40% suffered from thrombotic ischemia. The average ischemic interval was 6.8 days. Methods of treatment included medical and/or surgical intervention. Doctors of other specialties were responsible for delayed presentation in 62.2% of cases because of wrong diagnosis or treatment. Patients themselves were blamed in 31.1% of cases due to ignorance or low socioeconomic level. Long distance from the nearest specialty hospital was the cause of delay in 6.7% cases. Overall, a good outcome was recorded in 11.1% patients. Major amputation was ultimately required in 71.1% patients. Death occurred in 4.5% patients. Treatment of acute prolonged limb ischemia is difficult and results in high morbidity. Proper management of acute limb ischemia requires educational programs for genior doctors, patients and community to realize its causes, manifestations, methods of diagnosis, and importance of time factor and its imprint on patient's limb and life

Enoxaparin versus heparin for the prophylaxis of post-operative deep vein thrombosis in general surgery

Patients undergoing surgery with a prolonged general anesthesia or a period of a limited postoperative mobility, or both, face a high risk of thromboembolism. Surgical procedure is considered as the third most common risk factor for thromb oembolism after old age and obesity. To asses the value of enoxaparin in the prophylaxis of venous thromboembolism and the possible complications in comparison to heparin in high risk patients undergoing general surgery. In the period between March 2003 and May 2005, 200 patients admitted for different surgical procedures were randomized into 2 equal groups: [1] Group A where unfractionated heparin was used as a prophylactic anticoagulant drug, and [2] Group B where enoxaparin was utilized. Patients were obese with one or more risk factors for deep vein thrombosis. Clinical and laboratory assessment in addition to venous duplex scanning of the lower limbs were performed. The ages of the patients ranged from 40 to 82 years with a mean of 61 years. A mean preoperative hospitalization period of 6.1 days and a mean operative duration of 95 minutes was recorded. Postoperative deep venous thrombosis [DVT] occurred in 10 [5%] patients, 8 of them were asymptomatic [4 in each group] and diagnosed by duplex ultrasound. The 2 remaining patients had symptomatic DVT, both were in group A. Bleeding complications occurred in 30% and 16% patients of group A and group B, respectively. Low molecular weight heparin [enoxaparin] is more effective and safer than unfractionated heparin, but with higher costs in the prophylaxis of postoperative deep venous thrombosis

Different surgical options in treatment of cancer cardia and lower third esophageal cancer

To study different techniques in resection of carcinoma of lower esophagus and cardia with regards to techniques, complications, morbidity, mortality, and survival. from Feb. 2005 to Aug. 2006, this study included 33 patients with operable carcinoma of the lower esophagus or cardia as evident by clinical and investigatory tools including endoscopy and biopsy, patients were classified into: Type I [cancer of distal esophagus,] included 10 cases, were treated by total esophagectomy in 5 cases, or distal subtotal esophagectomy in 5 cases. Type III [cancer of the subcardial area infitrating the esophagus gastric junction] included 8 cases, were treated by total gastrectomy in 4 cases, and proximal gastrectomy in 4 cases. Type 11 [cancer of the gastric cardia] included 15 cases, were treated by the 5 types of operation as guided by the extent of the tumor and the proximity to either stomach or esophagus. The extent of lymphadenectomy was dependent on tumor type, node size, and gross involvement, approach, and general condition of the patient. Curative resection [RU] was performed in 25 patients [75.8%], 7 cases of type I, 11 cases of type II, and 7 cases with type III tumors, while incomplete resection [RI+R2,] was done in 8 cases [24.2%,], 5 cases of transhiatal esophagectomy in type land II tumors, and 3 cases of proximal gastrectomy with less than D2 resection. Tumor free resection margins were achieved in 29 patients [88%,], node metastasis were found in 24 cases [72.2,], 6 cases of type I, 12 cases of type II, and 6 cases of type Ill tumors. Two cases with type I tumor had >50% positive mediastinal nodes, and 2 cases with type III tumor had >50% positive abdominal nodes. Significant complications occurred in 9 cases [27.3%], as anastamotic leak in 3 cases were managed conservatively, respirator]' complications in 2 cases [6.1%], and wound infection in 4 cases [12.1%]. Mean hospital stay was comparable with no statistically sigi4ficant difference [15.8, 15.2, and 14.8 days for type I, II, and III respectively,]. There was no significant difference in morbidity, mortality, and disease free survival [DFS,] between cases of subtotal or total esophagectomy [transhiatal or 3 field approach] with P values 0.1, 0.95, 0.91 respectively. Similarly there was no significant dfference between patients with type I and II who underwent proximal or total gastrectomy [P=0. 6]. There was a better survival for patients with stage I and II compared to stage III and IV [P=0. 00]], for well and moderately differentiated grade I and II tumors than poorly and undifferentiated tumors grade III and IV [P =0. 008], for negative nodes compared to those with positive nodes [P=0. 03], while involvement of more than 50% of abdominal lymph nodes had a reverse action on the survival [P =0. 001]. Type of the tumor had no influence on the survival [P=0.5], while the stage, node involvement, and operation were statistically significant. So efforts should be directed towards earlier diagnosis, better selection, and minimizing post operative complications, and R0 resection should be attempted

Role of MR chlangiopancreatography in biliary obstruction- A clinico-radiologic and opreative study

Thirty-five patients with obstructive jaundice suspected clinically [19 males and 16 females, their ages ranged from 5 to 81 years] were included in this study. All patients were subjected to complete medical history, full clinical examination, biochemical study [liver function tests and hepatitis markers], abdominal US and magnetic resonance cholangiopancreatography [MRCP]. Twenty-three patients were operated upon. ERCP was done in nine patients as well as percutaneous transhepatic cholangiography [PTC] and drainage transhepatic cholangiography [PTD] in two patients. One patient was diagnosed by ultrasound [US] and MRCP to have primary sclerosing cholangitis. MRCP images revealed extrahepatic biliary obstruction in 34 cases with good quality images. It demonstrated the levels of obstruction in all patients but diagnosed their causes in 33 only [16 were malignant, 11 calcular, one primary sclerosing cholangitis, 3 post-cholecystectomy stricture of CBD, one papillary stenosis and one chronic pancreatitis]. In two patients, there was a distal obstruction of undetermined origin by MRCP and one patient had calcular obstruction by ERCP [false -ve]

Common bile duct stones-endoscopic management experience in 107 cases

In this study, 107 patients with common bile duct stone[s] were selected for endoscopic management. The success rate of cannulation of the common bile duct was 97.1%. Endoscopic sphincterotomy was done in 104 patients, stone[s] extraction after endoscopic sphincterotomy was achieved in 73 patients using different endoscopic approaches, basket extraction in 38 cases, balloon extraction in 35 cases and mechanical manual lithotripsy, which was used successfully in 22 patients. The mechanical manual lithotripsy increased the ability to clear CBD stone[s] from 70.19% to 91.3% at the initial endoscopic session. The early complications of ERCP and its therapeutic applications were bleeding in three cases, pancreatitis in four cases and cholangitis in two cases. Late complications included cholecystitis in four cases and recurrent CBD stones in three cases. The overall success rate for CBD stone[s] clearance was 92.5%, while the overall morbidity after ERCP and its therapeutic applications was 16.3%. There was no recorded mortality