[Fistula-in-ano treatment a modo Jonesko using brace].

References to fistula-in-ano date to antiquity. Hippocrates made reference to surgical therapy for fistulous disease. The English surgeon John Arderne described fistulotomy and seton use in 1376. Despite 2500 years of experience, fistula-in-ano remains a perplexing surgical disease. Over the last 30 years, many authors have presented new techniques and case series in an effort to minimize recurrence rates and incontinence complication. We offer a new technique for seton placement using a brace.

[Electrical stimulation for rapid assessment of extremity tissues vitality in critical ischemia]. / Stimulation électrique pour estimation rapide de la vitalité des tissus des extrémités en cas d'ischémie critique.

INTRODUCTION: In cases of trauma of the extremities, the development of critical tissue ischemia is a frequent complication, requiring surgical intervention with possible amputation. The exact duration of blood supply loss is often difficult to evaluate. Therefore, an easily applicable simple and rapid method for tissues vitality assessment would be of appreciable importance. It could also be used during surgery for delimitation of viable from non-viable tissue. METHOD: The well-known approach for nerve-muscle excitability assessment by electrical stimulation is adopted. Its simplest form is by visual observation of the tissue reaction to the respective excitation. A battery supplied electrical stimulator is built for this purpose, housed in two hand-held electrode holders. The stimuli parameters were selected for efficient excitation of denervated and partially denervated tissue structures. RESULTS: The stimulator was used in assessment of the condition of 23 patients: 16 with severe critical arterial ischemia from arterial occlusive disease and seven with vessel trauma and injuries. Eight extremities were tested immediately after amputation. CONCLUSION: The stimulator was shown to be very efficient for tissue vitality assessment in the diagnostic stage. The easiness of use makes it convenient for application in the ambulatory, during transportation, at the patient bedside, as well as during surgery. It can also be efficient in mass accidents, disasters, or in armed conflicts.

[Set for hermetization during transportation and draining of the pleural cavity]. / Set za transportna khermetizatsiia i drenirane na plevralnata kukhina.

In a situation of continuously growing road-and-traffic traumatism serious chest traumas with the presence of penetrating wounds are not a rare case. The correct transportation of the injured requires hermetization of the open pneumothorax with ensured draining of the pleural cavity in order to eliminate the possibility of the appearance of a valve pneumothorax. With the means, existing up to now, it is difficult to achieve hermetization during transportation and draining of the pleural cavity at the same time. The article presents the structure and the way of usage of the created by the authors so-called 'SET FOR HERMETIZATION DURING TRANSPORTATION AND DRAINING OF THE PLEURAL CAVITY'. The product is tested in an experiment on dogs. The SET is designed to render medical assistance in emergencies and to transport injured people with penetrating wounds in the chest wall and injuries in the lungs.

[Two methods of plastic reconstruction of extensive defects of the chest wall (experimental study)]. / Dva metoda za plastichna rekonstruktsiia na obshirni defekti na grudnata stena (eksperimentalno prouchvane).

The authors examine results from the experimental using two new methods for surgical reconstruction of broad defects of the chest wall. Our study was applied to 18 dogs separated in two series. In the first group of 8 dogs we used bone-muscle lambo for plastic reconstruction formed from the scapula and m.serratus anterior. This autotransplantation tissue was fixed for the neighbouring ribs limiting the defect of the chest wall. A good hermetisation of the pleural cavity and stabilisation of the chest wall was achieved. In the second group of 10 dogs the chest wall defects was closed with special antimicrobal chest prosthesis. It is built up by synthetic net and synthetic ribs. The antimicrobic qualities are being preserved for a continuous period of time. Histological the animals from the first group show the creation of a stabile fibrosis-bone-muscle laver which creates stability and hermetically of the chest cell. The synthetical ribs of the animals from the second group are tightly embraced by cellular tissue that passes through the openings of the ribs. The clinical observations of this methods are an object of another report of ours.

Thromboembolic complications in children with nephrotic syndrome in Bulgaria (1974-1996).

Over a period of 22 years, 447 children with nephrotic syndrome (NS) have been retrospectively studied for clinically apparent thromboembolic complications (TEC). The incidence of TEC is 2% (9/447); 16 clinically apparent TEC were registered in 9 children. The incidence of TEC was 1.5% among patients with steroid-sensitive NS and 3.8% among those with steroid-resistant NS. TEC were predominantly venous (81% venous vs. 19% arterial). The most commonly affected vessels were deep leg veins, followed by inferior vena cava (IVC). Rare locations of TEC were also observe--superior vena cava (SVC), mesenteric artery, IVC, and hepatic veins with the development of Budd-Chiari syndrome. Depending on the location of the TEC, imaging techniques used were: X-ray, computed tomography, and Doppler sonography. The major iatrogenic risk factor was furosemide, administered to 7 of the 9 children with TEC. In some patients additional predisposing factors were infections, dehydration, trauma, venepuncture, and immobilization. Treatment with heparin was followed by oral anticoagulation. Fibrinolytic therapy was effective in 3 of 4 patients. No new TEC occurred under oral anticoagulant prophylaxis. The outcome was a full recovery in 6 patients and a partial recovery in 1 patient. Two children died--1 with SVC thrombosis and the other with recurrent TEC affecting cerebral vessels. Although rare, TEC are among the most serious life-threatening complications in children with NS and require intensive care.

Transthoracic reconstructions of the innominate artery with atherosclerotic occlusions.

BACKGROUND: Literature reports concerning transthoracic reconstructive operations of the innominate artery (IA) are rare. METHODS: Six men and one woman aged from 48 to 64 years were operated on -- all of them had atherosclerotic IA lesions. Some of them had additional vascular disease such as coronary atherosclerotic lesions in one patient, another one had chronic arterial ischemia (CM) of the lower extremities and one patient underwent a stroke. All the patients had some neurological symptoms (headache, dizziness) and chronic arterial insufficiency of the right arm, five patients had clinically and arteriographically detected subclavian steal syndrome (SSS) with vertebrobasilar symptoms (ataxia and syncops). Peripheral arterial pressure (PAP) of both arms gave a difference from 30 to 80 mmHg. Aortoarteriography showed one stenosis and 6 thromboses of the IA, the left common carotid artery (LCCA) was affected in two cases. All operations were done through a longitudinal sternotomy continued by cervicotomy. In one patient an endarterectomy (EA) of IA was done. In six patients a bypass operation was performed. The ascending aorta was used for inflow. The distal anastomoses were with the distal part of the IA, in two patients, with the right subclavian artery (RSA) and the right common carotid artery (RCCA) in two patients and with RSA, RCCA and LCCA in two cases. RESULTS: There was no operative or postoperative mortality, the postoperative complications were pericarditis and pneumonia. The patients were observed for a period of 18 months to 10 years. The use of Doppler-control provided patency data of arterial grafts in all the patients. One patient died of a heart attack five years after surgery, another had an ischemic stroke of the left hemisphere four years after surgery. CONCLUSIONS: The authors consider that transthoracic IA reconstructions, although being traumatic, give good early and long-term results.

New method and device for assessment of functional capacity of upper extremity with chronic ischemia.

BACKGROUND: The aim of this study is to establish an objective diagnostic method, through which the functional capacity of the upper extremity with chronic ischemia could be best assessed. METHODS: For a 9-year period (1986-1994) 74 patients suffering Arterial Occlusive Disease (AOD) of the upper extremity with chronic ischemia were treated. Fifty five of them (74.3%) were males (an average age of 52.4 years) and 19 females (25.6%), (an average age of 42.5 years). Forty nine of them (66.2%) were in second stage according to the adapted Fontain's classification. An original method and device have been established for the investigation of the abilities of the upper extremity to make repeated movements till they get an intermittent claudication. The apparatus consists of tree modules: a mechanical device, an interface adapter and a microcomputer. RESULTS: During the flexion of the fingers the patient overcomes the resistance of springs which is 1.82 Nm. An Ischemic Fatigue Index (IFI) is calculated--it gives the quantitative value of the functional capacity of the limb. IFI in patients in second stage of Chronic Arterial Ischemia (CAI) is from 0.14 to 0.76 during the diagnostic test and from 0.18 to 1.0 after the operative or drug treatment or Percutaneous Transluminal Angioplasty (PTA). A retrospective analysis shows that in patients who were operated on, the preoperative IFI was less than 0.50. The measurement of Arm-Arm Blood Pressure Index (AABPI) before treatment and after it in some cases shows normal values in spite of the presence of subclavian artery stenoses. The angiographies that were done could not help for the evaluation of the functional capacity of the upper extremities. The presence of pulse in 9 patients (18.4%) does not exclude a presence of occlusion. CONCLUSIONS: IFI is a quantitative indicator for the upper extremity capacity. It shows whether the symptoms are severe enough to justify the surgery. The periodical measurement of IFI is a monitoring of the development of AOD.

[The use of continuous epidural analgesia in the combined treatment of chronic arterial obstruction in the lower extremities]. / Prilozhenie na produlzhitelnata epiduralna analgeziia v kompleksnoto lechenie na khronichnata arterialnata neprokhodimost na dolnite krainitsi.

Experience had with the application of continuous epidural analgesia (CEDA) in the complex treatment of 33 patients with advanced stage of chronic arterial obstruction in the lower extremities is presented. In fourteen of them (42.4 per cent) CEDA is effected using implantable catheterization system "Periplant", and in the remainder 19 (57.6 per cent)--through nonimplantable "Periflex++". The technique of application of the systems is described. The therapeutic effect is estimated on the basis of: 1) quantitative evaluation of pain perception by a 5-point rating system, 2) acral skin thermometry, and 3) Doppler ultrasound tonometry. Changes in the parameters listed are compared with their counterparts in a control group of 33 patients, and subjected to statistical processing. Proceeding from the obtained results the inference is reached that CEDA is very effective in terms of main relief, and improves perfusion of the ischemic limbs. The implantable catheterization systems contribute to the patient's comfort for rather prolonged period of time, and reduce infection hazards in the vicinity of the spinal cord.

[The surgical correction of an ostium secundum defect in the interatrial septum]. / Khirurgichna korektsiia na vtorichen defekt na mezhdupredsurdnata pregrada.

The operation of choice for correction of secundum type atrial septal defect is cardiopulmonary bypass. Combination of atrial septal defect with partial anomalous pulmonary venous drainage is considered absolute indication for bypass operation. The authors apply an original method for closure of the defect without resorting to bypass. For a period of seven years they have operated 240 patients from 3 to 54 years of age. Eighty four patients have been operated by the covered method of professor Zorin and in 23 correction of venous sinus defect was performed.

[Echinococcosis of the heart]. / Ekhinokok na surtseto.

From 1971 through 1987 six patients with echinococcus of the hear have been operated. In four of them the hydatid cyst was localized in the right portion of the heart and in two in the left ventricle. Left thoracotomy was used for the operation of the former four patients, whereas the hydatid cysts localized in the left ventricle were operated under bypass circulation. None of the operated patients died. The diagnosis was established by using computer tomography, which provided exact localization of the hydatid cyst and determined the operative approach. Echinococcosis of the heart is rare and creates diagnostic difficulties. This diagnosis is an absolute indication for operative intervention which under contemporary conditions should be performed by use of bypass circulation.

[Congenital anomalies of the coronary arteries]. / Vrodeni anomalii na koronarnite arterii.

Two patients with congenital anomalies of the coronary arteries were operated. One them had aneurysm of the Valsalva sinus and anomalous drainage of the right coronary into the right ventricle with 60 per cent arterio-venous shunt. The second had angiodysplastic-type anomaly of the left coronary artery. Both patients were operated on functioning heart, using II-shaped sutures through teflone appliances. However rare, congenital anomalies of the coronary arteries raise diagnostic difficulties. Exact diagnosis is feasible only after coronarography which determines also the type of operative intervention. The operation should preferably be made under bypass circulation.

[Suppurative complications following sternotomy]. / Gnoini uslozhneniia sled sternotomiia.

For a ten-year period when 366 median sternotomies have been performed, 206 of them in cardiac operations under bypass, there were 15 dehiscences of the sternum (4.09 per cent). The method of early revision with subsequent one-story suture and persistently washing aspiration drainage was applied for treatment of grave complication. In 90 per cent of the patients the causative agent of the infection was Pseudomonas aeruginosa and in the rest--Staph.aureus. Despite the early intervention, the adequate antibacterial therapy and local application of antiseptic agents, mortality was 46.6 per cent. The authors introduced also the so called nodulating sternotomy, which provides firmer fixation. This operation was performed in 135 patients. Rigid septics and antiseptics play crucial role for nonadmission of infection in operations under bypass.

[The indications for surgical methods in treating diseases of the coronary arteries]. / Pokazaniia za khirurgichni metodi na lechenie na zaboliavaniiata na koronarnite arterii.

Included in the study were 236 operations for ischemic heart disease (IHD) aorto-coronary shunt (ACS)--88 patients; ACS + aneurysmectomy--30; ACS + endarterectomy--12, aneurysmectomy--70; skin endocoronary balloon angioplasty--34, heart transplantation--2. The postoperative mortality was 6.5 per cent. Indications for ACS were specified on the basis of the patients state of well-being, the bicycle ergometry [correction of veloergometric] test, the coronarography and ventriculography, the end diastolic pressure and the ejection fraction. Decisive in selecting patients for operative treatment were the data of selective coronarography.

[The cellular immunity indices of patients with a rheumatic heart defect]. / Izsledvane na niakoi pokazateli ot kletuchniia imunitet pri bolni s revmatichen porok na surtseto.

In 29 patients with clinical diagnosis of rheumatic valvular disease the quantitative values of active rosettes and the specific sensitization to human heart myosin were examined. The specific sensitization to human heart myosin was examined by two methods concurrently: method of inhibiting leucocyte migration in agarose and method for direct specific lymphocytolysis with myosin. The results were compared with those of 44 clinically healthy controls. In the patients with rheumatic valvular disease (RVD) the values of the active rosettes are significantly lower (p less than 0.01) than in the healthy controls. With the method of direct specific lymphocytolysis with myosin statistically significant sensibilization of the lymphocytes to myosin was found in the patients with RVD (p less than 0.001). In 5 patients examined before and after operation it was established that 2-4 weeks after a successful correction of the hemodynamics the specific sensibilization of the lymphocytes to myosin was no more present.