[Ischemic colitis and mesenteric ischemia after abdominal aortic reconstruction]. / Ischämische Colitis und mesenteriale Ischämie nach abdominaler rekonstruktiver Aortenchirurgie.

Ischemic colitis is quite a rare condition, which can be subdivided into two categories, a so-called occlusive form as a complication of various vascular diseases, and a non-occlusive form caused by exogenous administration of drugs, or i.e. higher cocentrations of various endotoxines or cytokines. Besides the most serious cases with transmural ischemia, needing operation and resection, over 50% of all cases suffer from non-transmural or mucosal ischemia which can be treated conservatively. These cases usually show a rather favourable outcome. A part of these patients will suffer from bowel stenosis or strictures later on and may need secondary resections. Ischemic colitis following aorto-iliac reconstructive surgery is a rare but well known complication. Although it should be suspected much more frequently, only 1 to 2% of the patients will present a condition of clinical importance. The complication is more frequent in patients who undergo surgery as an emergency, especially reconstruction for aneurysmal disease, and it is less frequent in patients who undergo aorto-iliac reconstruction for occlusive disease; probably because the latter have already developed collateral vessels in the visceral area. A preoperative evaluation of this specific risk is rarely possible by angiography. Intraoperative strong pulsating backflow from the inferior mesenteric artery is considered as a quite reliable prognostic factor for a sufficient mesenteric circulation. Measurement of inferior mesenteric stump pressure, fluoresceine instillation and doppler ultrasound have been proposed as more reliable predictive elements. Wherever mesenteric circulation seems to be doubtful, inferior mesenteric replantation is advisable. In the postoperative course, a thorough clinical surveillance and probably systematic sigmoidoscopy especially on patients with prolonged intubation in strongly advisable in order to detect ischemic lesions in an early stage. Early operations on transmural lesions will help to improve this otherwise very serious and life threatening complication.

[Insertion of permanent perfusion systems for chemotherapy. A ray of hope for the patients]. / Les implantations de systèmes de perfusion permanents pour la chimiothérapie. Une lueur d'espoir pour les patients.

The number of patients undergoing chemotherapy for tumor disease has considerably increased in the last years. One of the problems of these long-term treatment modalities is the destruction of the peripheral venous system due to the repeated venous punctures for the therapy itself as well as for the laboratory analyses. This has been the motive for the research on permanent perfusion systems which would work at long term in a reliable way. Nowadays, several industrial products are available, devices for the standard implantation intravenously but also devices for intraarterial and intraperitoneal use. In our hands, the access through the subclavian vein with the end of the catheter in the superior caval vein has proven to be a safe and easy method. The port is placed in the triangle between the coracoid process and the clavicula. The large experience made by the centers in Basle and Berne as well as our own experiences in Bienne have clearly demonstrated the benefit of these systems for the patient. Nevertheless, some complications have to be mentioned such as the wellknown complications of the puncture of the subclavian vein. The risk of complete occlusion of the catheter must be expected at the rate of 0.5%. Hematomas immediately after the punction of the port have also been described. We would like to outline that complications of these permanent infusion systems are rare, especially in comparison with the complication rate of the normal percutaneous central venous sets. We therefore strongly advocate the implantation of these devices in the first instance before the beginning of any treatment in order to save the peripheral venous system of these patients.

[Blunt thoracic trauma with bronchial rupture]. / Stumpfes Thoraxtrauma mit Bronchusruptur.

Diagnosis of bronchial rupture after blunt chest trauma may be difficult and this is demonstrated on behalf of four patients treated in our institution. Bronchoscopy is mandatory for exclusion or confirmation of a bronchial rupture. In addition spiral CT scan was found to be helpful for diagnosis and localisation of bronchial injury. Early diagnosis allows prompt surgical therapy that will avoid irreversible loss of pulmonary parenchyma.

[Pelvic fracture with shock-inducing retroperitoneal bleeding and concomitant lower extremity ischemia syndrome: discussion of management exemplified by a case report]. / Beckenfraktur mit schockierender arterieller retroperitonealer Blutung und gleichzeitigem Extremitäten-Ischämiesyndrom: Diskussion des Managements anhand eines Fallbeispieles.

BACKGROUND: Initial treatment of severe pelvic fracture consists of appropriate resuscitation and early pelvic reposition and stabilization. Concomitant retroperitoneal arterial bleeding in a hemodynamically unstable patient in combination with lower extremity ischemia make early management decisions very difficult and the mortality rate of this entity of injuries is extremely high. CASE REPORT: We report on a successful treatment of a 36 year old skier, referred in hemorrhagic shock, who had sustained a severely displaced both column fracture of the right acetabulum, an unstable pelvic ring injury on the left and a retroperitoneal bladder rupture. He developed complete ischemia of the right lower extremity. Angiography revealed an obliteration without extravasation of the external iliac artery and allowed treatment of a right superior gluteal artery disruption by embolization. The right lower extremity ischemia was revascularized with a subcutaneous femoro-femoral bypass graft. Delayed internal fixation of the right acetabulum and exploration of the iliac vasculature was done through an ilio-inguinal approach. Simultaneously, the cross-over bypass could be removed. After 18 months, the patient recovered without any ischemic symptoms, but continues with a mixed sciatic nerve lesion. DISCUSSION AND CONCLUSIONS: The combination of severe retroperitoneal arterial bleeding and total ischemia of the lower extremity requires immediate surgical therapy. Direct exploration of the retroperitoneum, however, can be fatal and should be avoided if the iliac vessels are angiographically intact or if a hemorrhage is controllable by an embolization procedure. Extraanatomic temporary revascularization of the lower extremity should be envisaged when a lower leg ischemia due to obliteration or compression of major intrapelvic vessels cannot be directly and immediately treated.

Video-assisted thoracoscopic treatment of pleural empyema. A new therapeutic approach.

Pleural empyema is a disease which is not always recognized. Despite consecutive treatment and antibiotics its mortality rate is still high, especially in older patients with concomitant disease or in the case of delayed treatment. We report our experience with early video-assisted thoracoscopic surgery of pleural empyema in 13 patients, where chest tube drainage had failed. The clinical symptoms of empyema did not exceed 14 days, bacteriologic cultures were positive in 62%. In all patients the fever disappeared within 1 to 5 days (mean 3.5) post-operatively and they remained in hospital for an average of 11.5 days after video-assisted thoracoscopic surgery. Pulmonary function tests 6 months later revealed normal values without a substantial loss of lung volumes. No relapse of empyema occurred.

[Therapy of pulmonary arteriovenous aneurysm]. / Zur Therapie des pulmonalen arterio-venösen Aneurysmas.

Connections of branches of the pulmonary artery to branches of the pulmonary vein resulting in aneurysmatic dilatation are defined as pulmonary arterio-venous aneurysm (pava). The spontaneous course shows a morbidity of 26% and a mortality of 11% within a six-year observation period following diagnosis. If there is an arterial branch with small diameter (< 15 mm) we recommend the embolisation with the catheter; this procedure is less stressing for the patient and does not involve the loss of pulmonary tissue. If the arterial branch has a big diameter, if a complex pava or a pulmonary abscess is present a conventional surgical resection should be envisaged.

[Catheter embolization of the solitary pulmonary arteriovenous aneurysm]. / Katheterembolisation des solitären pulmonal arteriovenösen Aneurysmas (PAVA).

Catheter embolization with coils was performed as a method of treatment in 3 patients with solitary pulmonary arteriovenous aneurysms (PAVA). This led to permanent occlusion of the PAVA in all cases. There were no complications following embolization. Bearing in mind that other workers also achieved good results by this method, embolization of a solitary PAVA by coils should be preferred to balloon embolization. Surgical treatment should only be carried out for a malformation which is not accessible to embolization or as part of a more complex procedure.

Influence of failed arterial reconstruction on the outcome of major limb amputation.

BACKGROUND: Unsuccessful vascular repair may further preexisting limb ischemia and thus increase the risk of revascularization procedures. METHODS: The results of 94 primary major amputations (group A) have been analyzed and compared with 112 secondary ablations (group B) carried out after failed revascularization efforts. All patients suffered from chronic critical ischemia (grades III and IV) of the lower extremities. In group A the severity of ischemic symptoms was more pronounced (trophic changes in 80% vs 66% in group B), and a preponderance for older age, diabetes mellitus, and incidence of cardiac failure and cerebrovascular insufficiency was evident. RESULTS: In patients undergoing secondary amputation the final transection level was adversely affected by preceding unsuccessful reconstructive attempts. In spite of the better risk profile, 30% of patients in group B were subjected to above-knee amputation compared with 13% of patients in group A. The aggravated limb ischemia caused by graft failure is reflected by the decrease of the mean ankle systolic pressure index from 0.27 to 0.13 (before and after failed revascularization attempts). Although more amputations at the below-knee level were performed initially in group A, primary wound healing was obtained among these subjects in 68% of patients (compared with only 39% for patients in group B). CONCLUSIONS: In a substantial number of cases preexisting limb ischemia may be promoted by failed attempts at vascular reconstruction, thus leading to severe wound healing complications and a higher level of amputation.

[Long-term results after infrainguinal arterial reconstruction in patients with type 2 diabetes mellitus and without diabetes mellitus]. / Langzeitergebnisse nach infrainguinaler Arterienrekonstruktion bei Typ-II-Diabetikern und Nicht-Diabetikern.

The influence of type II diabetes on the success rate of arterial bypass operations in the leg was assessed in a prospective study, since 1984, of long-term results of infrainguinal arterial reconstruction in 67 type II diabetics (41 men and 26 women; mean age 71.2 [47-90] years) and compared with 133 nondiabetics (90 men and 43 women; mean age 71.5 [45-91] years). All had a bypass for chronic critical ischaemia of the legs. Graft patency, leg preservation and survival rate were calculated and compared by the actuarial method. Coronary heart diseases and cerebral ischaemia were a little more common in the diabetic group, but the incidence of heart failure was the same (20%). A venous bypass was used in 73% of diabetics, polytetrafluoroethylene grafts in 27% (nondiabetics: 79% and 21%). Bypass occlusions occurred in 9 diabetics and in 24 nondiabetics (not significant). During the observation period of 5 years 37 diabetics (55%) and 39 nondiabetics (29%) died (P less than 0.001). These data indicate that the results of infrainguinal arterial bypass operations are equally good in diabetics and nondiabetics. Amputation was avoided in 80% of legs at risk in both groups. Primary amputation is indicated only in exceptional circumstances.

[Peripheral arterial complications of various catheter angiography methods]. / Periphere Arterienkomplikationen katheterangiographischer Methoden.

Between 1980 and 1988 12,251 arterial punctures for cardiac catheterization (CC), percutaneous transluminal angioplasty (PTA), or pure diagnostic intraarterial angiography (IAA) have been performed in our clinics. 54 (0.44%), 39 (0.63%, CC), 12 (0.67%, PTA), 3 (0.07%, IAA) patients suffered from a complication at the site of the arterial puncture necessitating surgical correction. Adults developed false aneurysms or large hematomas whereas children tended to show thrombotic arterial occlusions. Generally the surgical procedures of these complications proved to be quite simple (over two thirds) but some, especially in children, turned out to be more difficult. 3 arterial spasms in children and 1 prolonged wound healing in the groin, all without long-term sequelae and 1 severe graft infection necessitating ligation of the common femoral artery with severe ischemic signs for several months were the only complications of our corrective surgical procedures. We therefore plead for these iatrogenic complications of arterial puncture for an early correction performed by a surgeon with at least some experience in vascular surgery.

Mediastinal infiltration of lung carcinoma (T4N0-1): the positive predictive value of computed tomography.

The value of computed tomography (CT) in predicting direct mediastinal infiltration of stage T4N0-1 lung carcinoma was evaluated prospectively in 11 patients with surgical and histological proof. Furthermore, its role in twelve non-operated patients was assessed retrospectively. The radiologic signs detected independently by two radiologists correlated in 90%. Mediastinal infiltration was verified in 7 of 11 patients (63%). Only in 3 out of the 12 patients treated non-surgically was CT the only criterium for inoperability. In all other patients additional findings, such as scintigraphy, radiologic or bioptic proof of distant metastases, supported inoperability. The limited specificity of CT (63%) demands aggressive staging procedures before any patient is excluded from surgery, the only potentially curative treatment.

[The postoperative myocardial infarct in the surgical therapy of pelvic and leg arterial occlusions].

A total of 4063 surgical interventions for arterial occlusions of the lower limbs have been reviewed in a retrospective study. As compared to patients without specific diagnosis of preexisting coronary heart disease, the incidence of postoperative myocardial infarction is 10 times greater in the presence of clinical and electrocardiographic evidence of previous infarction; for patients suffering from typical angina pectoris the risk is 5 times higher and for patients with suspected preoperative infarction the incidence of postoperative infarction is 3 times that in surgical patients without such a history. The mortality rate from myocardial infarction occurring postoperatively in patients with no previous history of coronary heart disease is 26% as compared to 100% for patients who had sustained preoperative infarction. The rate of recurrence is significantly greater when the time interval between previous myocardial infarction and operation is less than three months. Comparison between elective and emergency cases shows that in the group undergoing emergency surgery the incidence of post-operative infarction is twice that under elective surgery, whereas mortality from myocardial infarction is 3 times higher following acute interventions. The problem of critical establishment of surgical indication, the need for accurate prior investigations and the requirement of adequate preoperative treatment are discussed.