Surgical treatment of carotid body tumors without embolization.

AIM: Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. METHODS: During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. RESULTS: Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. CONCLUSIONS: Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

Abdominal aortic aneurysm and hepatocellular carcinoma: a one-stage approach.

BACKGROUND: The operative management of abdominal aortic aneurysm (AAA) and co-existing intra-abdominal malignancy has been a long-standing controversy. It is unclear whether a single-stage or a two-stage approach is the more appropriate therapeutic option and also which lesion should be treated first. CASE OUTLINE: An 82-year-old man with a 4 x 5-cm mass in the left liver (segment IV), suspected to be a hepatocellular carcinoma (HCC), had a concomitant 6-cm infrarenal AAA. At the same operation he underwent a left hepatectomy followed by repair of the aneurysm. He was discharged on the 17th postoperative day. To the best of our knowledge, this is the third report in the world literature of a patient who underwent a successful simultaneous resection of an AAA and HCC and the first in which the liver resection was performed first. DISCUSSION: We recommend liver resection and AAA repair in a single-stage procedure, regardless of the time sequence of the procedures. This approach can be considered safe, and the theoretical risk of graft infection can be kept to a minimum.

Incidentalomas of the adrenal gland: diagnostic and therapeutic implications.

Incidentally discovered adrenal masses are common since the advent and application of sensitive noninvasive imaging methods. The significance of these so-called "incidentalomas" and the question of further evaluation or treatment remains elusive. This report describes a retrospective study of 86 patients with incidentaloma. Adrenalectomy was performed on 26 patients during initial admission. Histologically, two cortisol-producing adenomas, an adenoma with subclinical cortisol production, and two pheochromocytomas (all of the preceding detected during the preoperative hormonal evaluation), three cystic lesions, one myelolipoma, and one hematoma were found. One primary and two metastatic adrenal carcinomas were also found in this series. Sixty patients with a nonfunctioning incidentaloma smaller than 6 cm were observed in an average of 43 months with serial CT scans performed at 3, 9, and 18 months after the initial diagnosis. Enlargement of the mass was detected in two patients; both proved to be nonfunctioning adenomas. Based on these observations, it is concluded that the initial laboratory evaluation is mandatory in cases of incidentalomas, including parameters of adrenocortical and medullar function. Hormonally active incidentalomas and those suspected for malignancy should be treated surgically. Masses greater than 6 cm should also be removed. Smaller incidentalomas without endocrine activity or signs of malignancy should be followed by CT scan at 3, 9, and 18 months after the initial diagnosis.

Combined vascular reconstruction and adjunctive tissue transfer in the treatment of infected arterial prostheses and tissue defects.

One of the most serious complications in vascular surgery is infection of the vascular arterial prosthesis (VAP) which might lead to loss of limb or even death. Very often infected prostheses are combined with infectious infiltration of the adjacent tissues or even necrosis and their loss. This paper deals with the experience in the management of 5 patients suffering from infection of vascular arterial prostheses in various locations, for by-passing abdominal aorta and distal arteries with loss or necrosis of the skin and tissues adjacent to the graft. Removal of the infected graft was performed in all of the cases, together with wide debridement of the infested area and placement of a new graft, coursing far from the infected area for revascularization of the affected limb. The cleaned infected area was covered at a first or second stage by applying plastic procedures utilizing musculocutaneous tissue transfer. The results were quite satisfactory. We conclude that the management of infected vascular arterial prostheses, when these are combined with loss of adjacent tissues, is a challenge for the Vascular Surgeon. Their removal, extended cleaning and covering of the area by means of plastic procedures with tissue transfer, proved to be effective in the management of this problem.

The incidence of occult cancer in patients with deep venous thrombosis: a prospective study.

OBJECTIVE: This study was undertaken to assess a potential relationship between idiopathic deep venous thrombosis (DVT) and occult cancer. DESIGN: Prospective study with a 2-year follow-up. SETTING: The Angiology Unit of the First Department of Surgery, University of Athens, Greece, a tertiary referral centre. SUBJECTS: Two hundred and ninety-three patients with a first episode of venographically or Doppler-proved DVT were included in the study, of whom 264 were followed up for 2 years. INTERVENTIONS: After an initial extensive diagnostic workup, including routine blood counts and chemistries, erythrocyte sedimentation rate, CEA levels, chest X-ray and abdominopelvic CT scan, all patients were closely followed up and periodically examined. MAIN OUTCOME MEASURES: The incidence of cancer amongst patients with idiopathic and secondary DVT, and the validity of our screening programme. RESULTS: Cancer was diagnosed in 21 out of 84 patients with idiopathic DVT (25%) as compared with eight out of 202 patients with secondary DVT (4%). In 22 out of the 29 cases, cancer was detected during the initial admission, and the remaining seven cases were detected during follow-up. Cancer was diagnosed in 15 asymptomatic, healthy individuals, but only in seven of them was the diagnosis made by CT scan. CONCLUSION: Occult cancer is fairly common in patients with idiopathic DVT, but the routine use of extensive diagnostic studies for its detection remains to be validated by further prospective studies.

Acute type A dissecting aortic aneurysm requiring emergency arch replacement.

The intimal disruption is located or extends to the aortic arch in 10-20% of acute type A aortic dissections. Multiple tears are extremely rare. The reported mortality rate of emergency arch replacement varies from 25% to 40%, and therefore many surgeons elect to perform ascending aortic replacement only in these cases. However, with such an approach, the operative mortality rate of 10% is followed by a late mortality rate of up to 30% from residual aneurysm formation. Emergency arch replacement was carried out in five of 14 patients with an acute type A aortic dissection in whom the intimal tear either originated or extended into the arch, or in whom multiple tears existed. The ascending dissections were resected under moderate hypothermia, whereas the arch was explored under profound hypothermia, surface cooling and circulatory arrest. None of these five patients died; one developed slight hemiparesis, but no patient developed recurrent aneurysm in the follow-up period. These results appear to justify this aggressive approach, if it can be performed with an acceptable mortality rate < 25%, by avoiding the late deaths associated with more conservative surgical treatment.

Axillodistal bypass on critical limb ischaemia.

The axillodistal extra anatomic bypass is not an operation commonly performed and the only reason for performing it is to attempt limb salvage for a reasonable period of time or until death in patients with critical ischaemia. During the period 1983-1991 we performed 67 such bypasses where no other form of reconstructive arterial surgery was feasible. There were 27 axillopopliteal (15 below and 12 above the knee), five crossover, seven bilateral, 11 axillotibial and 17 jump (sequential bypasses). The first 34 procedures (1983-1987, early period) had a 5-year cumulative secondary graft patency of 20%, which increased to 33% for the 33 bypasses performed during the second period (1987-1991). The primary graft patency of the 67 bypasses was 13%. Our clinical results show that even in these patients with diffuse occlusive arterial lesions, limb salvage is possible in a reasonable number even when axillodistal bypass is used. Improvements in the technique, better selection of patients, the performance of jump grafts and the aggressive treatment of early and late graft occlusions have led to much better results being achieved.

Unresolved pulmonary embolism: the value of surgical management with extensive thrombo-endarterectomy.

In a small but definite number of patients with pulmonary embolism, either gradual resolution of the embolus does not occur or recurrent showers of emboli follow the acute onset, leading to a state of chronic pulmonary hypertension. Two new cases treated surgically without the use of cardiopulmonary bypass are described. The results were excellent in both cases with relief of the dyspnoea and an improvement in the PO2, a result that has been documented in the follow-up of 2-6 years. The only definite treatment of this chronic obstructive pulmonary hypertension is pulmonary thrombo-endarterectomy.

Pulmonary embolectomy (answered and unanswered questions).

Pulmonary embolectomy under total cardiopulmonary bypass was carried out in 16 patients with cardiogenic collapsus and hypotension not responding to vasopressors or cardiac arrest. Eleven patients (68.75%) survived and were followed up for years. Our observations are presented with special emphasis on the early and accurate diagnosis, the exact timing of the therapeutic methods, the use of the portable cardiopulmonary bypass-even in the ward, and the possibilities of decreasing the operative mortality rate in less than 30% (from 40% to 22% in our series). Despite the fact that in many countries, especially European, pulmonary artery embolectomy is no more carried out as a primary therapy for massive or submassive embolism since thrombolysis is today considered as the best therapy with a low mortality rate of 8-11%, we still believe that there is a number of patients who could benefit only from surgical intervention. Based on our own experience and that presented in the international literature, an attempt was made to discuss the existing problems, mainly diagnosis and treatment of this formidable condition, reevaluating pulmonary embolectomy.

Prophylactic fasciotomy of the legs following acute arterial occlusion procedures.

During the 3-year period, 1983-86, 194 procedures for acute arterial occlusion were performed in our Clinic. In 43 cases following revascularization procedures, decompression fasciotomy of the leg for a developed or impending compartment syndrome was performed. Of these, three fasciotomies were done as a prophylactic procedure, before the development of the syndrome. Adequate and early fasciotomy should be considered by the vascular surgeon in every case of embolectomy when the ischemic time is greater than 6 hours, when the patient is young without sufficient collateral circulation, the history of acute arterial occlusion is precipitous, the patient is hypotensive and the back-flow is inadequate intra-operatively, despite the passage of the Fogarty's catheter down to the malleolus. Skin closure after fasciotomy has to be done early, mainly with approximation of the skin edges, or to cover early the exposed viable muscles with a free split-thickness autogenous skin graft. This was done in our series between the 8th and 14th postoperative days. In the case of muscle necrosis of the anterior compartment, skin coverage of the cavity has to be done later, after 2-3 weeks, as in some of our patients.