Deep venous thrombosis in a patient with large uterine myomata. Case report.

A 42-year-old woman was admitted with a painful swelling of the left lower limb. Computed tomography revealed an inhomogenous uterine enlargement due to multiple myomata producing a thrombotic occlusion of the left iliac veins. Surgical treatment consisted of isolated hysterectomy. During the same operation, transfemoral thrombectomy and stent implantation in the iliac vein were performed. Hysto-logic examination revealed numerous leiomyomata as well as an endometriosis. The patient recovered well and is pain-free six months after surgery. The deep venous system is still patent at follow-up. Uterine myomata rarely cause acute iliac vein thrombosis due to direct compression. This case represents an example of successful therapy using an interdisciplinary approach.

MR venography in the detection of pelvic venous congestion.

PURPOSE: To investigate the feasibility of using magnetic resonance venography (MRV) to detect pelvic venous congestion (PVC). METHODS: A prospective study of 23 female patients with signs and symptoms of PVC, who underwent duplex sonography, MRV and phlebography (P). Examinations were interpreted in a blinded fashion. Visualization of venous anatomy, presence of venous incompetence and congestion grade were evaluated. Sensitivity and specificity of MRV using P as reference were calculated. RESULTS: MRV agreed with P in 96% (Cohen-K-value 0.646) and in 70% (K 0.555) of the cases respectively in the venous anatomy and congestion grade. Sensitivity and specificity of MRV were 88% and 67% for ovarian veins, 100% and 38% for hypogastric veins and 91% and 42% for the pelvic plexus. CONCLUSIONS: In this prospective study MRV showed high sensitivity in the evaluation of patients with suspected PVC. Routine use of this diagnostic method requires further studies in larger patient cohorts.

Acute iliofemoral deep venous thrombosis due to giant ovarian tumor: report of a hybrid treatment.

Ovarian tumors rarely cause acute iliofemoral thrombosis due to direct compression. This case represents an example of successful therapy using an interdisciplinary approach. A 37-year-old woman was admitted with a painful swelling of the left lower limb. Computed tomography revealed a giant abdominal mass originating from the left ovary producing a thrombotic occlusion of the left iliofemoral veins. Surgical treatment consisted of complete tumor removal, adnexectomy and appendectomy. During the same operation, transfemoral thrombectomy and stent implantation in the iliac vein were performed, followed by creation of an arteriovenous fistula in the left groin. Hystologic examination revealed a well-differentiated mucinous ovarian adenocarcinoma. The patient recovered well and is tumor-free 6 months after surgery. The deep venous system is still patent at follow-up. In this case, minimal surgical trauma and complete tumor as well as thrombus removal succeeded through a positive complementary interdisciplinary approach.

Is initial success of thrombolytic therapy with rt-PA in patients with lower limb ischemia durable? A long-term follow-up series.

BACKGROUND: Catheter-directed intraarterial thrombolytic therapy with rt-PA has been established as an alternative to surgery in selected patients with lower limb ischemia. The purpose of this study is to evaluate its long-term results and to try to identify patient variables influencing outcome. PATIENTS AND METHODS: The results of thrombolytic treatment for acute or subacute lower limb ischemia in 82 patients (51 male, 31 female) were retrospectively analysed. Clinical data (time of symptoms onset, clinical stage, type of affected vessel, anatomical localisation) as well as comorbidities were recorded. The success rate of thrombolysis as well as the incidence of adverse events was evaluated. Patients with initial success were followed up after a median of 52,5 months. RESULTS: Thrombolytic therapy was successful in 67 cases (82%). An additional endovascular or surgical procedure was necessary in 39 of these patients (48%). The overall bleeding rate was 18% and the mortality and major amputation rate was 1%. 42 patients with early clinical success were available for follow-up. 34 of them (81%) were free of ischemic symptoms and the overall limb salvage rate was 96%. We could not identify factors significantly influencing early or long-term results, although there was a trend towards better results in patients with acute ischemia and in patients with occluded native arteries. CONCLUSIONS: Intraarterial local thrombolytic therapy has a relatively high initial success rate in selected patients with lower limb ischemia, but is associated with a significant number of bleeding complications. Furthermore, additional procedures are required in almost half the patients. Initial success is durable at the long-term in the majority of cases. Better selection of patients and refinements of the thrombolytic therapy might help to further improve results and lower the bleeding complications.

Dacron patch infection after carotid angioplasty. A report of 6 cases.

OBJECTIVE: We describe our experience with Dacron patch infections after carotid endarterectomy (CEA). REPORT: From 633 patients undergoing carotid endarterectomy with Dacron patching, six re-presented with prosthetic infections. In 3 of the 6 cases a neck haematoma had necessitated surgical revision after the original carotid surgery. Five patients underwent interposition vein grafting and 1 vein patch angioplasty. Postoperatively, 2 patients developed a repeat infection including the 1 patient with patch angioplasty. All patients were free of infection and neurological symptoms after a maximum follow-up of 56.5 months. CONCLUSION: Following the development of haemorrhage or wound complications careful clinical surveillance should be carried out after carotid reconstruction.

[Pancreatic elastase-1 in the stool for the determination of exocrine pancreas function of postoperative patients with early enteral nutrition -- a pilot study]. / Pankreas-Elastase-1 im Stuhl zur Bestimmung der exokrinen Pankreasfunktion unter frühpostoperativer enteraler Ernährung -- Pilotstudie.

BACKGROUND AND OBJECTIVE: There are only incomplete data about exocrine pancreatic function after major gastrointestinal surgery. Early enteral nutrition with high-molecular diets is increasingly administered to these patients. A knowledge of exocrine secretion of the pancreas is crucial, because pancreatic enzymes are needed for the adsorption of the high-molecular diets. To determine the exocrine pancreatic secretion the fecal elastase-1 is a sensitive method for measuring exocrine pancreatic secretion. PATIENTS AND METHODS: In a prospective study fecal elastase-1 was measured in patients on enteral nutrition (n=12) early after major gastrointestinal operations. They were given a high molecular diet via an intraoperatively placed small-needle catheter jejunostomy, starting 12 hours after operation with a continuous infusion of 20 ml/h (1 kcal/ml),increased to 80 ml/h during the next few days. Samples from the first and second stools after beginning the enteral nutrition were taken for measuring the fecal elastase-1. RESULTS: All patients fed enterally had no relevant feeding-associated complications and no diarrhea. The elastase-1 concentrations were normal in both the first and the second stool samples in all patients (normal stool elastase is > 200 g/g). The average elastase concentration in the first stool sample was 361,4 mg/g (median: 317 mg/g) and 454 mg/g in the second (median: 466,6 mg/g). Thus no exocrine pancreatic insufficiency was detected in any of the patients. CONCLUSION: The results of elastase-1 in stool demonstrate that severe exocrine pancreas dysfunction is not generally present in patients on early enteral nutrition after major gastrointestinal surgery.

[Clinical and functional results after transfemoral thrombectomy for iliofemoral deep venous thrombosis: a 5-year-follow-up]. / Klinische und funktionelle Ergebnisse nach transfemoraler Thrombektomie bei tiefer Bein- und Beckenvenenthrombose: ein 5-Jahres-Follow-up.

PURPOSE: The optimal therapy of deep pelvic and leg venous thrombosis is still a matter of debate. The purpose of our study was to evaluate early and late results of iliofemoral thrombectomy with regard to the prevention of the development of a postthrombotic syndrome. METHODS: Between 1996 and 2000, 57 patients underwent transfemoral venous thrombectomy for acute iliofemoral thrombosis. 30 patients were reexamined after a mean of 60.4 months. At follow-up, the patency of the venous segments as well as the development of reflux was investigated by duplex-ultrasound. Furthermore, clinical signs and symptoms of chronic venous insufficiency as well as the subjective satisfaction of the patients with the operation were recorded. RESULTS: Postoperatively the veins of the lower leg were completely recanalized in 25 % of the cases, those of the thigh in 52.3 %. The patency rate at the level of the groin, the pelvis and the caval vein were 92.5, 86 and 100 %, respectively. At follow-up, the veins of the lower limb, the thigh and the pelvis were patent in 76.7 % each and in 73.3 % at groin-level. The caval vein was completely recanalized in all cases. Reflux occurred in 12 patients. 26.7 % of the patients showed no signs of a postthrombotic syndrome. 63.3 % had mild changes including dilated superficial veins and swelling tendency, and only in 10 % trophic skin changes were apparent. A healed or active ulceration did not occur in any case. Except one, all patients were satisfied with the results of the thrombectomy. CONCLUSIONS: Transfemoral thrombectomy for acute iliofemoral venous thrombosis offers good early and late results in terms of preserving venous function and reducing symptoms of venous insufficiency. In our patient population, the development of a severe postthrombotic syndrome could be reduced effectively.

Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study.

HYPOTHESIS: Perioperatively administered enteral immunonutrition will improve early postoperative morbidity and cost-effectiveness after gastrointestinal tract surgery. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Surgical departments in German university and teaching hospitals. PATIENTS: One hundred fifty-four patients with upper gastrointestinal tract malignant neoplasms who were eligible for analysis. INTERVENTION: Preoperatively, patients received 5 days of oral immunonutrition (an arginine-, RNA-, and omega3 fatty acid-supplemented diet) or an isoenergetic control diet (1 L/d). Early postoperative enteral feeding with immunonutrition or an isoenergetic, isonitrogenous control diet using a catheter jejunostomy was performed for 10 days. MAIN OUTCOME MEASURES: Postoperative infectious complications, their treatment costs, and cost-effectiveness of immunonutrition were analyzed. Plasma levels of the fatty acids eicosapentaenoic acid and docosahexaenoic acid were measured. RESULTS: In the immunonutrition group, significantly fewer infectious complication events occurred (14 vs 27; P = .05). The number of patients with complications was significantly lower in the supplemented diet group after postoperative day 3 (7 vs 16; P = .04). The treatment costs of complications in the supplemented diet group were suggestively lower than in the control diet group (DM 75172 vs DM 204273). Cost-effectiveness was DM 1503 in the experimental group vs DM 3587 in the control group, where DM denotes deutsche mark (German currency). CONCLUSION: The perioperative administration of an enteral immunonutrition significantly (P = .05) decreased the early occurrence of postoperative infections and reduced substantially the treatment costs of the complications after major upper gastrointestinal tract surgery.