[Use of mycophenolate mofetil in patients with a transplanted kidney and cyclosporin nephrotoxicity]. / Primena mikofenolat mofetila kod bolesnika sa presadjenim bubregom i ciklosporinskom nefrotoksicnoscu.

Cyclosporine (CsA) nephrotoxicity is an important problem in renal transplant recipients, which can influence long-term graft survival. The safety of conversion from CsA to azathioprine (AZA) remains controversial and can result in higher incidence of acute rejection. Mycophenolate mofetil (MMF) is a new immunosuppressive agent superior to AZA in the prevention of acute rejection. Five patients with cyclosporine nephrotoxicity were converted from CsA/AZA/prednisolon to MMF/prednisolon protocol. All patients had low immunological risk and 4 out of 5 patients received antithymocyte globulin before conversion as the induction therapy or as the treatment for acute rejection. Mean follow-up after conversion was 16.8 months (range 4-32 months). No patient experienced acute rejection during follow-up period. The mean serum creatinine concentration decreased from 219 +/- 44.18 (range 168-280) to 122.6 +/- 48.02 mumol/l (range 72-187 mumol/l) (p = 0.002). Arterial hypertension improved after CsA withdrawal in 20% of patients. We have concluded that, in selected patients with cyclosporine nephrotoxicity, CsA withdrawal with concomitant use of MMF is safe and effective in the improvement of graft function and arterial hypertension.

[Indications and results of fasciotomy in vascular injuries of the lower extremities]. / Indikacije i rezultati fasciotomija kod vaskularnih povreda donjih ekstremiteta.

Aim of this study was to re-evaluate the indications for fasciotomy in war vascular injuries of the lower extremities. Retrospective and partially prospective analysis of 31 patients with surgical revascularisation performed during 1999 was done. Fasciotomy has been used as a prophylactic measure against development of Compartment Syndrome (CSy) in three out of ten patients within the first group where ischemia time was less than six hours before the time of repair. The second group, where ischemia time was longer than six hours before the time of repair, prophylactic fasciotomy (measured compartmental pressure lower than 30 mmHg) was performed in 8 patients. In 13 patients with already developed CSy fasciotomy was performed as the delayed treatment (measured compartmental pressure higher than 30 mmHg). Neither one of patients from the first group developed CSy. All patients who developed CSy had necrosis of neuromuscular tissues at the time of surgery. Musculectomy was required in five and limb amputation in six patients. The conclusion of this study is that when the ischemia time is less than six hours before the time of repair fasciotomy is not necessary. When the period from injury to the revascularisation is longer than six hours the prophylactic fasciotomy is recommended.

Emergency surgery of acute traumatic arteriovenous fistulas.

The purpose of this report was to analyze the clinical presentation, diagnosis, surgical and non-surgical treatment and the outcome of patients with acute AVFs seen during the last 8years. During 1991-98 we treated 47 patients with traumatic AVFs. Among these patients 11 were classified as 'acute' AVF. All the patients were male and they ranged in age from 17 to 64yr (mean 25yr). The time from injury to admission to our two institutions varied from 4h to 17days. Emergency surgery was performed in unstable patients and in those with an expanding haematoma base on clinical assessment alone. The acute surgery group consisted of stable patients that were operated after angiography examination. A ??? murmur and thrill were present in seven patients, and peripheral pulses were absent in four patients. The main blood vessels were reconstructed using various techniques in eight patients and minor blood vessel were ligated in three patients. Two lower limb amputations had to be performed, both after reconstruction of popliteal AVFs. In the remaining nine patients reconstruction of the axial vessels was successful and no signs of ischemia developed in patients after ligation of minor vessels. No neurological deficit developed in two patients whose AVFs were vaporised in the neck. The average hospital stay was 8. 6days. Emergency surgery is safe in unstable patients with traumatic AVFs. A thrill and murmur are characteristic signs even in the acute setting, but the examiner must be persistent in looking for them whenever there is a suspicion of a blood vessel injury. Angiography is a reliable diagnostic tool in stable patients, but whether it is essential when there is an expanding pulsating hematoma remains debatable.

[Analysis of a 4-year follow-up of the results of kidney transplantation from living related donors]. / Analiza cetvorogodiznjeg pracenja rezultata transplantacije bubrega od zivog srodnog davaoca.

The aim was to present a four-year experience in living related kidney transplantation. A total of 43 patients (9 females and 34 males) were enrolled in this study. The standard triple immunosuppressive therapy (steroids, azathioprine and cyclosporine) was administered in 19 (44.1%) patients, and in 20 (46.5%) mycophenolate mophetil in daily dose of 2 g instead of azathioprine. In 5 (14.2%) patients with high immunological risk and delayed graft function was administered antithymocite globulin in duration of 7-14 days, prophylactically. In 3 (6.97%) patients graft loss was caused by vascular complications and in 1 (2.32%) by infection as the complication. During the first post-transplantation year acute rejection was noticed in 8 (34.7%) patients and in 3 (37.5%) it was steroid resistant. The graft loss was never caused by acute rejection. Six-months graft survival was noticed in 91.1% patients and one-year graft survival in 88.4% patients. One-year patient survival was 100%. Short term results in living related kidney transplantation are excellent and nowadays, due to improvement in immunosuppressive therapy, the success in this type of kidney transplantation is mainly limited by surgical and infective complications.

[Management of war injuries of blood vessels in prolonged ischemia]. / Zbrinjavanje ratne povrede krvnih sudova kod produzene ishemije.

We present a successful management of a gunshot wound of major blood vessels of the leg, in condition of prolonged ischemia. The patient has been sent to our hospital for the complete vascular management of the complete interruption of the major blood vessels of the left leg that were primarily ligated and marked. Because of the difficulties in evacuation, the patient arrived 20 hours after the wounding. There was no indication for the arteriography. The interruptions of the continuity of the superficial femoral artery in length of approximately 10 cm and of deep femoral vein in length of 8 cm were managed by interposition of autovenous grafts taken from the large subcutaneous vein of the other leg. Standard fasciotomy and partial exclusion of muscles of the left lower leg with relaxing fasciotomy of the left upper leg muscles were performed in the operative procedure. A successful rehabilitation has been completed and five years after the wounding, completely correct vascular and functional condition of the wounded leg was observed.

[Lesions of the peripheral nerves associated with pseudoaneurysms of the major arteries caused by gunshot wounds]. / Lezije perifernih nerava uzrokovane postsklopetarnim pseudoaneurizmama magistralnih arterija.

Ten wounded persons, operated on for gunshot-induced peripheral nerve lesion in which pseudoaneurysm of the main artery was found intraoperatively, were presented. Preoperative clinical course, intraoperative neurovascular topography and pathoanatomy, operative procedures and postoperative results were analyzed. The correlation was established between preoperative neurologic deficit and intraoperative findings on arteries and nerves. It was concluded that such patients have to be operated on as soon as possible, but not later than five days from the beginning of neurologic aggravation, to prevent the development of irreversible neural damage.

Treatment of wounded in the combat zone.

Authors presented their own experiences in treating 735 wounded in high-intensity combat zones in the territories of former Yugoslavia during 1991 to 1992. The mobile field hospital with surgical crews was situated 5 to 10 km from the front line, and its basic task had been continuous triage, immediate resuscitation with vital surgical aid, as well as organization of adequate primary and secondary air evacuation. At the field hospital level, fresh wounds were explored according to principles of war surgery, and major surgical interventions were performed in 3.3% of the wounded. Patients with massive hematothorax were treated with autotransfusion. Mortality at this primary level, field hospital was 0.75% with primary immediate resuscitation and 1.9% with immediate evacuation. We concluded that immediate resuscitation with delayed transport had advantages, compared with fast evacuation of only the wounded.

[Incidence and localization of deep venous thrombosis and disorders of pulmonary perfusion in patients after surgery in colorectal carcinoma]. / Ucestalost i lokacija tromboze dubinskih vena i poremecaja plucne perfuzije kod bolesnika operisanih od kolorektalnog karcinoma.

In 50 patients aged 60 +/- 4 operated for colorectal carcinoma simultaneous combined radionuclide phlebography (RNP) and pulmonary perfusion scintigraphy (PPS) using 99Tcm labeled macroaggregates of the human serum albumin (MAHSA) were performed within 20 postoperative days aiming to detect deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE). The aim of the study was to determine the incidence and segmental DVT localization as well as incidence, localization and clinical characteristics of developed pulmonary perfusion disorders. Deep vein thrombosis was detected in 33 (66%) patients with rather uniform distribution in vein segments. According to their scintigraphic characteristics the findings suggested recent thrombosis in almost all cases (only two of them had signs of chronic thrombosis). Of patients with detected DVT 17 (52%) had pulmonary perfusion disorders of which 10 (59%) were unilateral (7 right and 3 left) and 7 (42%) bilateral. Characteristics and extent of perfusion defects suggested very probable PTE in 11 (65%) patients and less probable in 6 (35%). It has been concluded that patients operated for colorectal carcinoma were highly exposed to DVT and PTE development which necessitates all measures contributing to their prevention.