Should embolectomy be performed in late acute lower extremity arterial occlusions?

BACKGROUND: We analyzed the embolectomy results and complications of patients who were operated on after a diagnosis of late acute arterial occlusion of lower extremities. METHODS: A total of 122 patients operated on in our clinic between 2004 and 2009 for late acute arterial occlusion were included in the study. Late arterial occlusion was defined as occlusion occuring 72 hours after initial manifestation of the patient complaints related to the affected lower extremity. RESULTS: Average age of the 122 patients (71 male, 51 female) was 54.2 +/- 16.8 years. In this cohort, 64.75% of patients had cardiac pathologies, while 28.68% had extracardiac causes; 1.64% patients had cathetherization, 0.81% patient had malignancy, and 2.46% patients had a history of trauma. In 1.64% of the cases, no reason for thromboembolysis could be found. Thirty-one patients (25.40%) had additional surgical operations, 14 (11.47%) had fasciotomy, and 9 (7.37%) had amputation. Re-embolectomy was performed on 37 patients (30.32%) who had ongoing ischemia after an operation. Additional surgical operations were performed on 31 patients (25.40%) with ongoing ischemia. In 14 of these cases (11.47%), patients were treated with fasciotomy due to development of compartment syndrome. Amputation was performed on a total of 9 patients. Early in the postoperative phase, mortality was observed in 11 patients (9.01%). CONCLUSION: We believe that late embolectomies of acute late leg ischemia increases blood flow in the extremity and reduces the number of amputations required.

Arterial thrombosis and thalidomide.

Arterial emboli are largely a reflection of cardiac disease. Thalidomide is an antiangiogenic drug used in cancer therapy. Venous thrombosis incidence increased during treatment with thalidomide. We reported arterial thrombosis in two cases with multiple myeloma implemented in thalidomide treatment. Standard emergency intervention was applied. In the postoperative period, enoxiparine was given to all the patients. Warfarin treatment was started in the level of INR 2-2,5. ASA with a dose of 100 mg/day was added to the treatment. In conclusion, this side effect of the use of thalidomide should be taken into consideration while doing examinations with respect to the etiology in arterial thromboembolism and because of this vascular complication that threatens life; we suggest stopping the thalidomide treatment.

Isolated thoracic duct injury in penetrating neck trauma: a case report.

A 39-year-old man was admitted with a stab wound to left lower neck. Chest X-ray revealed a left hydropneumothorax. Thoracentesis was performed and analysis of the fluid revealed chyle. Patient was treated conservatively by closed chest drainage and total parenteral nutrition. On the basis of this clinical report and review of the literature, it is concluded that thoracic duct injury should be kept in mind in penetrating neck trauma and conservative treatment should be the first line therapy.

Huge popliteal arterial aneurysms in Behçet's syndrome: is ligation an alternative treatment?

Behçet's syndrome is a multisystemic disease characterized by relapsing uveitis, oral and genital ulcerations, and vascular system involvement. The vascular involvement is seen as venous occlusion, arterial occlusion, and aneurysm formation in this disease, and the surgical treatment of a Behçet's aneurysm has technical difficulties. In this report, we suggest that the huge popliteal artery aneurysm in Behçet's syndrome can be treated by ligation of the popliteal artery. A 58-year-old male patient was admitted to our clinic because of an infrapopliteal great mass at the left leg. Color Doppler ultrasonography and arteriography revealed a 71 x 54 mm aneurysmal dilatation at the distal popliteal artery. Surgery did not reveal any suitable arterial formation for bypass to the distal area of the popliteal artery and tibial arteries. For this reason, we applied ligation of aneurysmal dilatation at the distal popliteal artery. The patient tolerated the operation well and had no signs of ischemia during the postoperative period. In conclusion, especially in aneurysm of arteries such as the popliteal artery, which has critical importance for maintaining distal perfusion, ligation may be a treatment method if there are no other alternatives.

Non-capitonnage method for surgical treatment of lung hydatid cysts.

Capitonnage is usually advocated for obliteration of the residual cavity after removal of a hydatid cyst. To assess a non-capitonnage method, results in 33 patients were compared with those of 80 patients who had capitonnage. The non-capitonnage patients had a shorter mean hospital stay and earlier radiologic improvement but higher morbidity than the capitonnage patients. Extended air leak caused significant morbidity in each group. Bronchoscopic intervention was needed for atelectasis in 1 patient. There was no mortality in either group. In the follow-up period, no late complication or recurrence was observed in non-capitonnage patients. Among the capitonnage patients, 2 had bronchiectasis, and suture material expectoration occurred in one. The non-capitonnage method may be a good alternative to the capitonnage procedure for lung hydatid cyst. Better management of bronchial openings should improve the results of the non-capitonnage method.

Spontaneous pneumothorax in children in the South-east of Turkey.

BACKGROUND: The purpose of the present study was to investigate the etiological factors, symptomatology, management and outcome of spontaneous pneumothorax in children aged <15 years. METHODS: The authors' reviewed the records of 44 children with spontaneous pneumothorax between January 1990 and February 2002. RESULTS: The median age was 4.6 years (range 2 months-14 years), and 51% were male. Breathlessness and coughing were the most common symptoms. All pneumothoraces were initially managed by closed tube drainage. Thirty-seven (84%) of the children responded well and were cured of pneumothorax with closed tube thoracostomy alone. Seven children (16%) underwent thoracotomy. The median hospital stay was 12.9 days. There were two deaths from respiratory failure. Six- to 96-month follow-up information was available for 32 patients, and only one recurrence was found. CONCLUSIONS: Lung infections were the most frequently observed underlying pathology in the patients studied. Closed tube thoracostomy alone was sufficient for the majority of patients.

Primary giant hydatid cyst of the diaphragm.

We report a case of an hydatid cyst of diaphragma in a 34-year-old female who was admitted to our clinic for right basithoracic pain. Magnetic resonance imaging (MRI) reported a giant hydatid cyst including multiple vesicles at the right lower thoracic cavity. Surgical exploration revealed an independent giant diaphragmatic hydatid cyst. We performed cystotomy and more than 200 daughter vesicles were removed from the cyst. The rest of the giant cyst cavity was excised.

Open fixation in flail chest: review of 64 patients.

The strategy for treatment of flail chest remains controversial. Various alternatives were assessed by reviewing the records of 64 patients treated from 1991 through 2000. Patients were classified according to therapeutic approach: group 1 was 27 patients who underwent open fixation of the fractured ribs, group 2 was 19 patients managed by intermittent positive-pressure ventilation, and group 3 was 18 patients managed mainly by synchronized intermittent mandatory ventilation. Two patients initially treated by ventilation underwent successful open fixation. In group 1, ventilatory support was required in 21 (77.8%) patients postoperatively, the mean duration of ventilation was 3.1 days, mean hospital stay was 18.3 days, morbidity was 11.1% (3/27), and mortality was 11.1%. In groups 2 and 3, the mean time for stabilization of paradoxical chest wall movement was 6.6 days, and mean duration of ventilation was 7.2 days. Mortality was 27.0% (10/37) in patients treated nonsurgically; 21.0% (4/19) in group 2, and 33.3% (6/18) in group 3. In groups 2 and 3, pain control required epidural analgesia in 13 (35.1%) cases, intercostal nerve blockade in 16 (43.2%), and narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). Open fixation is a successful treatment modality for traumatic flail chest.

Thoracic firearm injuries in children: management and analysis of prognostic factors.

OBJECTIVE: Thoracic firearm injuries (TFI) have become increasingly prevalent in children. Our purpose is to assess the injury pattern, Injury Severity Score (ISS), length of hospital stay (LOS), management and outcome of children with TFI with respect to the type of injury and to evaluate the value of ISS for predicting injury severity and the eventual need for thoracotomy, as well as the rate of morbidity and mortality. METHODS: Between January 1987 and June 2002, 110 children (88 boys and 22 girls) 25. SGW and EW groups had a significantly higher ISS. The mean LOS was 10.84+/-4.7 days (range 4-42). The value of LOS was significantly higher in children with SGW and EW. CONCLUSION: The majority of TFI in children can be treated successfully by tube thoracostomy if there are no gross pulmonary lacerations and airway injuries. SGW and EW were commonly associated with higher ISS and LOS. The ISS was found to be an independent predictor of the need for thoracotomy, as well as for rates of morbidity and mortality.

The effect of aprotinin on ischemia-reperfusion injury in an in situ normothermic ischemic lung model.

OBJECTIVES: In the context of the physiopathology of damage due to ischemic preservation and reperfusion injury following preservation, we aimed to demonstrate the positive effects of the addition of aprotinin, a serine protease inhibitor, to low potassium dextran (LPD), used as a single-flush solution in normothermic ischemic animal models, on lung protection and the prevention of reperfusion injury. METHODS: In the study, 21 New Zealand white rabbits were used as experimental subjects. The subjects were ventilated with the assistance of a manual mechanical ventilator at 30 breaths/min and 10 ml/kg tidal volume. Lung protection solution was supplied to the pulmonary artery via a catheter. After applying the solution, ischemia was carried out for 120 min. At the end of this period, reperfusion was carried out for 90 min. The subjects were divided into three groups of seven subjects each. In the control group, pulmonary perfusion solution was not employed, whereas in the second group LPD was employed, and in the third group LPD and aprotinin (LPD+A) were perfused. Blood gas analysis, bronchoalveolar lavage (BAL) fluid examination, tissue malondialdehyde (MDA) level analysis and morphological examinations were performed. RESULTS: The LPD+A group showed the significantly highest levels of oxygenation at the 15th and 60th minutes of reperfusion (297+/-76.7 and 327+/-97.4 mmHg) in comparison to the LPD (157+/-20.6 and 170+/-53.6 mmHg) and control (64+/-8.4 and 59+/-7.2 mmHg) groups (P<0.001). The LPD+A group showed the significantly lowest levels of alveolar-arterial oxygen difference at the 60th minute of reperfusion (389+/-15 mmHg) in comparison to the LPD (478+/-19 mmHg) and control (542+/-23) groups (P<0.001). The BAL fluid neutrophil percentage was significantly lower in the LPD+A group (22+/-2.4%) compared to the LPD (31+/-6.1%) and control (38+/-2.4%) groups. MDA levels were significantly lower in the LPD+A group (119.8+/-5.3 nmol MDA/g) when compared to the LPD (145.06+/-9.5 nmol MDA/g) and control (147.3+/-3.9 nmol MDA/g) groups (P<0.05). Morphological examinations revealed pathological lesions and alveolar hemorrhaging in all samples, with the LPD+A group having statistically more significant levels than the LPD and control groups (P<0.005). The LPD+A group had a significantly lower percentage of pathological lesions and alveolar hemorrhage grade values than the LPD and control groups (P<0.005). CONCLUSIONS: It was observed that the addition of aprotinin to LPD solution as a pulmonary flush solution in an in situ normothermic ischemic lung model prevents reperfusion injury by means of various mechanisms and also protects the morphological, functional and biochemical integrity of the lung. In our view, therefore, the addition of aprotinin to lung protection solution will provide positive results in lung transplantation protocols.