Comparing the efficacy of preoperative magnetic resonance cholangiopancreatography with intra-operative cholangiography in patients suspicious to biliary stones

This study was performed to compare the efficacy of preoperative magnetic resonance cholangiopancreatography [MRCP] and intra-operative cholangiography [IOC] methods in patients suspicious to gall stones. According to previous studies, it is recommended that common bile duct investigation should be done in order to rule out choledocholithiasis in all patients with symptomatic cholelithiasis. IOC is an invasive procedure with probable complications, it would seem that MRCP could replace the direct cholangiography. In a diagnostic clinical trial, Fifty-nine patients with symptomatic biliary stones or cholecystitis were recruited in this study. The included patients had normal size biliary ducts in sonography but high serum alkaline phosphatase level. Preoperative MRCP and IOC were performed for the patients and the obtained results were analyzed and compared. The positive predictive value for IOC was 88% and for MRCP was 43%. The diagnostic accuracy of IOC and MRCP were 98% and 85% respectively, suggesting that IOC is much more diagnostically accurate. There were no significant difference in specificity and sensitivity of these two methods. According to the results, we can conclude that MRCP may not obviate the need for IOC. The suggestion for routine use of MRCP instead of IOC and as a substitution of that procedure needs further investigations on more patients

Autologous bone marrow-derived stem cell therapy in patients with Buerger's disease

Patients suffering from Thrornboangiitis Obliterans [TAO] or Buerger's disease have endothelial cell dysfunction and the severity of the disease lies in the need for amputation in more than a quarter of all sufferers. The aim of present study was to determine whether granulocyte colony-stimulating factor mobilized autologous bone-marrow derived mononuclear cells transplantation improves endothelial dysfunction in these patients. Circulating mononuclear cells containing endothelial progenitor cells were obtained from patients following bone-marrow mobilization with granulocyte colony stimulating factor. Mononuclear cells and CD34+ cells were enumerated prior to intramuscular injection into the affected limbs. In this pilot study, autologous bone-marrow derived mononuclear cell therapy collected from peripheral blood following granulocytes colony stimulating factor [G-CSF] mobilization was effective, safe and resulted in sustained clinical results for patients with severe peripheral occlusive arterial diseases

Heart trauma

To report five cases of heart trauma, managed in a civil trauma surgery ward in one year and to carry out a review of literature .Three young male patients have been transferred to our center after direct stab wound to their upper chest at the left side. Another one was a sixty years old man who was trapped between two parts of an elevator door and the fifth case was an iatrogenic trauma during bone marrow biopsy in a fifty five years old patient. All of them underwent emergency left sided anterior thoracotomy because of the positive signs of cardiac tamponade and circulatory instability. The exploration revealed cardiac tamponade in all cases due to three perforations in right ventricle, one perforation in left ventricle at the apex and one perforation at the root of aorta. Echocardiography was performed in one case and revealed cardiac tamponade. In all cases repair of perforation in the beating heart was performed. Four patients survived. Heart trauma is an emergent and life threatening situation which needs immediate surgical intervention without any unnecessary workup. The outcome of surgery depends on several factors including trauma surgery team expertise

Intracardiac shunts and role of tissue Doppler Imaging in diagnosis and discrimination

We sought to assess right ventricular [RV] systolic and diastolic functions via tissue Doppler imaging [TDI] in order to discriminate right-to-left [bidirectional] from left-to-right intracardiac shunts. A tissue Doppler velocity study via Doppler echocardiography was performed in 20 patients with left-to-right shunt [without evidence of significant pulmonary hypertension] and 20 patients with right-to-left shunt or bidirectional shunt [with significant pulmonary hypertension] or Eisenmenger?s complex and 20 healthy subjects as the control group. RV myocardial performance index [MPI], S wave velocity, E wave velocity, isovolumic relaxation time [IVRT], and isovolumic contraction time [IVCT] from the lateral tricuspid annulus were measured using TDI. In the patients with left-to-right shunt, the tissue Doppler parameters showed higher S-wave, peak systolic[Sa]/early contraction[Ea], Sa/IVRT, and Sa/IVCT values; and in the patients with right-to-left or bidirectional shunt tissue, the Doppler parameters showed higher MPI and MPI/Sa value with a high specificity and sensitivity. We conclude that an evaluation of MPI, S wave, E wave, IVRT, and IVCT via tissue Doppler echocardiography is a useful index for the discrimination of right-to-left from left-to-right and bidirectional intracardiac shunts

alternative method for perioperative estimation of pulmonary artery systolic pressure by echocardiography

In the perioperative setting, pulmonary hypertension may be due to ischemic, left-sided valvular regurgitation and stenosis, residual shunt, pulmonary emboli or pericardial effusion. We purposed this study to determine whether tricuspid annular plane systolic excursion [TAPSE] and isovolumic relaxation time [IVRT] and S-wave velocity obtained by tissue Doppler imaging [TDI] could be used as an index of pulmonary systolic pressure in perioperative setting. Simultaneously, tricuspid annular plane systolic excursion and TDI by Echocardiography and right heart catheterization by Swan-Ganz catheter were performed in 55 patients [mean age 46 years,30 were male] with left -sided valvular disease [n=25], ischemic heart disease [n= 15] and adult-congenital heart disease [n= 10]. The TAPSE index S wave velocity from tricuspid annulus were measured by TDI. We also measured pulmonary artery systolic pressure [PASP] by right cardiac catheterization. In patients with moderate and severe pulmonary hypertension [PASP>45mmHg] the TAPSE value was [15.5 +/- 2.3mm]with sensivity of 90%and specifity of 80%. S wave velocity <11cm/s with sensivity of 90% and specifity of 86% and IVRT >79ms with sensivity of 93% and specifity of 95% [p<0.001]. Some factors such as underlying diseases [left-sided valvular disease, ischemic heart disease [IHD], congenital heart disease] had no effect on this correlation. We conclude that the evaluation of TAPSE index and IVRT and S-wave velocity by echocardiography provides a simple, rapid method for estimating of systolic pulmonary pressure in perioperative setting

Long segment, one-step thoracoabdominal aortic stent grafting

To report a case of painful and voluminous, Crawford type 1 thoracoabdominal aortic aneurysm, in a 87 years old man treated successfully with a long tube stent graft, using endovascular techniques, without any complication in the follow up. The proximal end was located just distal to the left subclavian artery, and the stent was placed to the region of the celiac axis