Infrarenal abdominal aorta approach through median minilaparotomy.

Classically, infrarenal aortic exposure is achieved by xyphopubic or xypho-infraumbilical laparotomy, in transperitoneal approach, or through a left abdominal incision, in retroperitoneal approach. The transperitoneal approach is associated with longer intestinal activity resumption time and incisional hernias on long term, due to intestinal extracavitary mobilization and long incision. These disadvantages disappear in laparoscopic approach, but this method is extremely laborious, requires an extended period for dissection, and elicits increased difficulty in performing the anastomosis on the aorta. The purpose of the study is to evaluate the infrarenal abdominal aorta approach through median minilaparotomy, a method that combines the excellent exposure of xypho-pubic incision with the low morbidity of laparoscopic approach. Between 07.01.2010 - 07.01.2011, we performed 37 revascularization surgeries in 36 patients with aorto-iliac occlusive disease (one patient required reintervention due to graft thrombosis), approaching the infrarenal aorta through median minilaparotomy. The sex distribution was 35 men and one woman. The average age was 61.1 years. There have been 25 aorto-bifemoral bypasses, 11 aorto-unifemoral bypasses, and one aorto-biiliac bypass. The mean aorta clamping time was 15 minutes. Average operating time was 150 minutes. We used 26 bifurcated Dacron prostheses and 11 linear ePTFEprostheses. The average intestinal activity resumption time was 32 hours. All patients included in the study were mobilized 24 hours after surgery. The average length of hospitalization was 7.7 days. 5 patients experienced complications during hospitalization and 3 patients suffered long term complications. Infrarenal abdominal aorta approach through median minilaparotomy is a viable alternative to conventional surgical techniques used in aortoiliac occlusive disease.

[Accessory renal allotransplantation with internal or external urinary drainage. An experimental model in pig]. / Allotransplantarea renala accesorie cu drenaj urinar intern sau extern. Model experimental la porc.

This study describes an experimental model of accessory renal allotransplantation in the big laboratory animal (pig). A total of 24 common-breed pigs were used. All allografts were transplanted in an accessory manner and revascularized at the level of the infrarenal abdominal aorta and inferior vena cava. The urinary drainage was performed either through a nexternal uretheroneostomy at the ipsilateral lumbar region (Group A--n=8) or by internal uretheroneocystostomy (Group B--n=8). All transplants were monitored for 8 days postoperatively using translumbar ultrasound-guided biopsies at 1, 4, 7 days. A total of 16 transplants were performed. 1 ectopic donor kidney was found and transplanted in the same fashion. Mean operative time was 125 minutes, immediate postoperative survival was 100% and at 72 hours, 87.5%. The onset of acute rejection was at day 4, by massive lymphocyte infiltration and was directly correlated with the abrupt decrease of the allograft diuresis in Group A, at day 3. At day 7, the rejection was complete. Both methods of urinary drainage are functional and can be employed. This experimental model is a useful tool for training of the transplant surgeons or for transplantation research. The surgical technique for accessory renal allotransplantation in pig is easy to learn and offers the possibility for allograft monitoring until complete rejection without influencing the receptor health condition.

[Experimental model of pancreas transplantation with portal or systemic drainage in laboratory rats]. / Model experimental de transplant pancreatic cu drenaj portal sau sistemic la sobolanul de laborator.

The aim of this study was to develop an experimental model of pancreas transplantation in rats as a standardized tool for research in transplant immunobiology. Brown Norway (donors) and Lewis (receptors) rats, males, with an average weight of 220 grams, were used. The diabetes was induced in recipients using streptozocin. The pancreas was harvested with a duodenal stump, a segment of aorta containing the celiac and superior mesenteric artery and the portal vein and transplanted as follows: Group A (n=8) - systemic venous drainage; Group B (n=8) - portal venous drainage. The exocrine drainage of the pancreatic graft was established by para-topic reintegration of the graft duodenal stump in the recipient. Postoperative follow-up consisted of daily measurement of glycemia and macroscopic evaluation of the proximal duodenal stump mounted as a cutaneous stoma. Overall postoperative survival at 8 days was 87,5% for Group A and 75% for Group B. Glycemia levels started to regain normal values in both groups, at 2 days postoperatively. Rejection started at 9 and 10 days postoperatively for Group A and B respectively, being expressed by the gradual re-appraisal of hyperglycemia that followed necrosis of the proximal duodenal stump. The experimental model described is functional and has the advantage of being used either with portal or systemic drainage of the pancreatic graft. The results obtained show no significant difference between the time-points of normal postoperative glycemia when either systemic or portal venous drainage were used.

[Complex microsurgical reconstruction of diabetic foot]. / Reconstructie complexa microchirurgicala a piciorului diabetic.

Microsurgical techniques increased the operability of patients with critical limb ischemia to more than 95%. However, the percentage of ischemic limb salvage remains limited, especially in diabetic patients with associated tissue gangrene and neuropathy. The study presents a 67 years old female patient with type II diabetes mellitus and critical limb ischemia, complicated with progressive gangrene of the pre-calcaneal region and thus representing a classical indication for thigh amputation. A sequential femur-popliteal-tibial anterior by-pass was performed, followed by soft tissue reconstruction using a latissimus-dorsi musculo-cutaneous free flap. Two years postoperatively, the patient developed clinical signs of symmetrical peripheral distal neuropathy, managed by bilateral posterior tibial nerve decompression. The patient follow-up was of 3 years. Through the entire period, distal pulse (ram of posterior tibial artery) remained present with a good integration of the flap and with absent clinical and paraclinical signs of neuropathy. The patient regained full ambulation. Morphologically and functionally the affected limb is entirely salvaged. Using microsurgical techniques, a more complex and complete approach of the diabetic patient with ischemic-neuropathic syndrome can be considered. This includes revascularization, soft tissue reconstruction and nerve decompression. In selected patients with indication of major amputation these methods offer a salvage option, with excellent long-term results.