Long-term results with the modified Sugiura procedure for the management of variceal bleeding: standing the test of time in the treatment of bleeding esophageal varices.

BACKGROUND: The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices. METHODS: Ninety patients with cirrhosis and portal hypertension were managed in our department for variceal esophageal bleeding between January 1985 and December 1992. The modified Sugiura procedure was performed in 46 patients on an emergency (25 patients) or semi-elective (21 patients) basis. Liver cirrhosis stage according to Child classification was A in 4 patients, B in 16 patients, and C in 26 patients. RESULTS: Acute bleeding was controlled in all patients. Postoperative mortality was 23.9% (11 of 46 patients). The mortality rate was 34.6% in Child class C patients (9 of 26 patients), and 12.5% in Child class B patients (2 of 16 patients). Twenty-four patients had long-term follow-up extending from 14 months to 22 years (mean 83.1 months). Ten of 24 patients (41.6%) did not develop rebleeding for 5-22 years (mean 10.3 years). Overall 5-year survival in these 24 patients was 62.5%. CONCLUSIONS: The modified Sugiura procedure remains an effective rescue therapy for patients with bleeding esophageal varices when alternative treatments fail or are not indicated. Moreover, it can be a life-saving procedure in patients with anatomy unsuitable for shunt surgery or for patients treated in nonspecialized centers where surgical expertise for a shunt operation is not available.

Analgesic efficacy of an ibuprofen-releasing foam dressing compared with local best practice for painful exuding wounds.

OBJECTIVE: To examine if wound aetiology has an effect on the pain-relieving properties of an ibuprofen-releasing foam dressing, which was previously shown to reduce pain in wounds of various aetiologies, compared with local best practice (LBP). METHOD: This was a secondary analysis of data from a multicentre, randomised, parallel group trial of patients with painful exuding wounds of various aetiologies. Wound aetiology was determined at enrolment. Of 853 patients enrolled into the trial, 688 belonged to a wound aetiology subgroup that included >25 patients and were included in the analysis reported here. Patients were randomised to a dressing containing 112.5mg of ibuprofen (ibuprofen foam) or to LBP for 5 days. Patients recorded pain relief and pain intensity daily. The main endpoint was the proportion of patients who, from day 1 to day 5, reported a summed pain relief score >50% of the total maximum pain relief score (TOTPARD5>50%) and the corresponding number needed to treat (NNT) for each wound aetiology subgroup. Further analyses included the proportion of patients who, on a daily basis, reported pain relief >50% of the maximum daily pain relief, the proportion of patients who, on day 5, experienced a reduction in pain intensity of >50% of the maximum score (PIDD5>50%), and if PIDD5>50% was related to baseline pain intensity. RESULTS: Patients were categorised by the following five wound types: arterial, venous, and mixed arterial-venous leg ulcers, vasculitis and traumatic ulcers. The ibuprofen foam dressing was associated with significantly greater pain relief than LBP in all different wound aetiology subgroups, whether chronic or traumatic (acute). Overall, TOTPARD5>50% was 55% in the ibuprofen foam group and 24% in the LBP group (p<0.0001; NNT, 3.2). The pain intensity evaluations revealed similar results in favour of ibuprofen foam compared with LBP. No correlation was observed between PIDD5>50 and initial pain intensity. CONCLUSION: In this study, the ibuprofen foam dressing was shown to consistently relieve wound pain in exuding wounds of various aetiologies, irrespective of basal pain intensity. The data suggest that local pain relief by an ibuprofen foam dressing is possible in the most common, painful, exuding, chronic and acute/traumatic wounds and so is a safer alternative to systemic pain treatment.

Infected Venous Leg Ulcers: Management With Silver-releasing Foam Dressing .

The aim of this work was to study the safety and effectiveness of silver foam dressing (Contreet® Ag, Coloplast, Humlebaek, Denmark) in promoting the healing of infected venous ulcers over 9 weeks of treatment. Forty-two patients with infected venous ulcers were included and randomized into two groups. Group A had 21 patients (12 women and 9 men, mean age 61.2 years) who were treated with the silver foam for 9 weeks. Group B also had 21 patients (14 women and 7 men, mean age 58.7 years) who were treated with a nonadhesive foam (Biatain®, Coloplast, Humlebaek, Denmark) for 9 weeks. In both groups, ulcer size and depth, intensity of pain, wound exudation, bacterial load, side effects of both materials, and ulcer healing were documented and compared. There was no significant difference at the initial assessment in both groups regarding ulcer size, ulcer depth, grade of exudation, pain intensity, or bacterial load. However, group A ulcers had a significantly greater healing (P = 0.02) compared to group B. Pain intensity was significantly less in group A patients at several time points. After 9 weeks of treatment, the silver foam dressing was found to be a safe material that promotes rapid healing of venous ulcers and relieves pain. .

Abdominal aortic aneurysm with ectopic renal artery origins: a case report.

The coexistense of an abdominal aortic aneurysm with ectopic main renal vasculature complicates aortic surgery and mandates a focused imaging evaluation and a carefully planned operation to minimize renal ischemia. We present the case of a 75-year-old man with an abdominal aortic aneurysm and a right kidney with two ectopic main renal arteries, one originating from the aneurysmal distal aorta and the other from the right common iliac artery; the patient underwent a surgical repair and followed an uneventful course with no deterioration of renal function. The preoperative and intraoperative details are reported, along with a review of the literature.

Therapeutic tactics and late results in predominant truncal congenital malformation.

BACKGROUND: Congenital vascular malformations are rare vascular lesions of unknown etiology, non-degenerative or of inflammatory nature, which begin during embryological development; they are characterized by anomalies of the vascular system, apparently due to hemodynamic and metabolic disturbances. METHODS: Our diagnostic and therapeutic management in addition to the late results in 60, mainly truncal cases, out of 265 congenital vascular malformations, are analyzed in the present study. In a 20-year period 25,000 vascular examinations were carried out, among which 265 (1.06%) congenital vascular malformations (CVMs) were discovered, that is 77% (205/265) extra-truncal venous angiomata and 22.7% (60/265) truncal diffuse or localized types. The distribution of the above types was: 22 (36.6%) arteriovenous, 30 (50%) venous and 8 (13.4%) lymphatic. RESULTS: Surgery was carried out in 48.3% (29/60) of the truncal types of which 37.9% of the cases, on average, recurred 8 years later. Of the 22 arteriovenous malformations 20 patients were operated on (90%), of whom 35% (7/20) had a recurrence; of the 30 venous defects 30% (9/30) were operated on and 44.5% (4/9) of these had a recurrence. The recurrence rate rose to 50% (5/10) in cases of operative therapy of arteriovenous defects and to 20% (2/10) with combined surgical and non surgical methods. The recurrence incidence of venous defects with surgical treatment and sclerotherapy was 54.1% (6/11). CONCLUSIONS: Timely diagnosis, microsurgical techniques and highly specialized surgical and interventional experience are expected to improve these results significantly.

Monograft reconstruction of all the major aortic arch trunks.

Male aged 56 years, a smoker of 60 cigarettes daily, with multifocal disease, presented with vertigo, headaches, syncopal crises and intermittent claudication in both lower extremities. Angiography revealed pre-occlusive stenosis at the origin of the innominate artery, a significant degree of stenosis at the origin of the left common carotid and occlusion of the left subclavicular artery with steal syndrome as well as injury to the aortoiliac system. Revascularisation of all the branches of the aortic arch concomitantly was achieved with the technically simple monograft method using only one Dacron double velour 8 mm prosthesis, restoring circulation to both the cerebral and upper extremities without postoperative complications. Eight years later the subjective clinical findings have remained unchanged. Angiography revealed good function of the graft and subjectively the patient remains in satisfactory condition.