Surgical treatment of peripheral aneurysms in patients with Behcet's disease.

INTRODUCTION: Our aim was to report our experience with 23 patients presenting with 32 peripheral aneurysms secondary to Behcet's disease (BD) and their outcome after vascular surgery. METHODS: The study was retrospective in nature. Except for those presenting with aneurysm rupture, patients underwent surgery after treatment of acute inflammatory lesions. All aneurysms appeared to be pseudo-aneurysms. Graft interposition with polytetrafluoroethylene or saphenous vein was most commonly employed. Postoperatively, all patients were put on immunosuppressive and antiplatelet therapy. Follow-up was done every 6-12 months, complications recorded and managed appropriately. RESULTS: All the patients were males. The mean age at diagnosis of a peripheral aneurysm was 41.0 ± 9 years. There were 17 (53%) femoral, 8 (25%) popliteal, two carotid, two external iliac, two brachial and one internal iliac aneurysms. Fourteen (61%) patients had a single peripheral aneurysm while nine had two. Surgery was performed for all initially presenting 23 aneurysms. Six patients with multiple peripheral aneurysms had surgery for their second asymptomatic aneurysm. The mean follow-up period was 84 ± 62 months. Of 29 aneurysms operated on, 7 (24%) anastomotic pseudo-aneurysms and 11 (38%) graft occlusions developed. Five (22%) patients underwent major lower extremity amputations. Six (26%) mortalities were recorded. CONCLUSION: Surgery for peripheral aneurysms in BD is warranted in many instances. Results of operation can be improved by prolonged monitoring. However, despite all efforts, peripheral aneurysm involvement in BD worsens the prognosis.

Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy.

BACKGROUND: Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. The safety of direct disposable shielded trocar insertion for the creation of pneumoperitoneum was assessed by comparing with Veress needle insertion during laparoscopic cholecystectomy (LC). METHODS: One thousand five hundred patients undergoing LC with pneumoperitoneum were included in this study. In 470 patients the Veress needle insertion technique was used, and in 1,030 patients direct trocar insertion technique was used. Patients having indications for open trocar insertion were excluded from the study. RESULTS: Complication rate was significantly higher in the Veress needle group (14% versus 0.9%; P <0.01), and the two major complications, gastric perforation and iliac artery laceration, were also encountered in this group. CONCLUSIONS: Our results suggest that with a lower complication rate, direct insertion of the disposable trocar is a safe alternative to Veress needle insertion technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost/instrumentation and rapid creation of pneumoperitoneum.

The fate of intraperitoneally retained gallstones with different morphologic and microbiologic characteristics: an experimental study.

Management of intraperitoneally retained gallstones after laparoscopic cholecystectomy (LC) is controversial, as their natural course is not known. This study was undertaken to assess the probable effects of stone morphology and clinically obvious infection on the outcome of retained gallstones in a mouse model. Forty albino mice were divided into four groups. Group I served as the control group (simple laparotomy, n = 10). Groups II, III, and IV (n = 10 in each group) were study groups. "Intact-sterile-cholesterol" (group II), "crushed-sterile-cholesterol" (group III), and "intact" (n = 5) [group IVa] and "crushed" (n = 5) [group IVb] "infected-cholesterol" gallstones aseptically retrieved from three different human patients were implanted to the peritoneal cavity of the animals. Group IV animals were implanted with stones retrieved from an acutely inflamed gallbladder with proven infection. Animals were sacrificed 6 and 12 weeks after the operations. Cultures and tissue samples were obtained. No animal was lost, no microscopic or macroscopic abnormality was observed in groups I and II, and cultures remained negative. In group III, adhesions surrounding the fragmented stones were evident at the 12th week, and no mortality was encountered. The histopathology revealed a fibroblastic reaction, and cultures remained negative in group III. In group IV, three animals from group IVb and one animal from group IVa died because of intra-abdominal sepsis before their sacrifice. All remaining mice showed severe adhesions with localized abscesses at the 12th week. In conclusion, intraperitoneally retained cholesterol gallstones remain inert and do not cause serious peritoneal reaction unless they are crushed into fragments or are from an acutely inflamed gallbladder. It is for this group of patients that laparotomy for total stone clearance is probably not justifiable. Better stone retrieval techniques or even laparotomy may be worthwhile considering in patients with crushed and particularly infected retained stones.

Simultaneous manifestation of an aortocaval and aortoduodenal fistula.

An unusual case of traumatic aortocaval and aortoduodenal fistula is presented in which the two conditions occurred simultaneously. A 19-year-old man was admitted with acute upper gastrointestinal bleeding and a pulsatile abdominal mass. An aortography revelead an aortocaval fistula and at the operation an aortocaval and aortoduodenal fistula was found. An aortocaval fistula can be discovered when a patient presents with an abdominal bruit or cardiomegaly with or without heart failure. The diagnosis of an aortoenteric fistula is difficult because of the subtleties in manifestation. The presence of an abdominal pulsatile mass and acute gastrointestinal bleeding should indicate that an aortoenteric fistula is possible.

Thromboxane synthase inhibitor, UK 38485, prevents renal injury in the rabbit isolated perfused kidney exposed to cold ischemia.

Recent studies have indicated that, the administration of thromboxane A2 (TxA2) inhibitors improved renal functions in experimental renal allograft transplantation. Thus TxA2, a vasoconstrictor metabolite of arachidonic acid, may play a role in renal function and blood flow during hypothermic storage. The aim of the present study was to evaluate the cytoprotective effect of TxA2 synthase inhibitor, UK 38485, on altered renal function due to cold ischemia for 24 and 72 h. Experiments were performed in isolated perfused kidney from adult rabbits. Kidneys were perfused with Euro-Collins (EC) containing UK 38485 and incubated with the same solution in a beaker exposed to cold ischemia for 24 and 72 h. The same procedure was applied to the control kidneys in EC solution alone. Vascular responses and urinary output to noradrenaline, angiotensin II, endothelin-1, acetylcholine, and sympathetic stimulation were assessed as the functional activity of kidney. The addition of UK 38485 to EC solution increased the preservation time of kidney and protects the vascular endothelial regulatory functions and urine excretion when compared to EC alone. The results of the present study can be taken as an evidence of the cytoprotective effect of the UK 38485 and might be useful for kidney preservation.

The endothelium-derived relaxing factor-mediated acetylcholine response of the arterial perfusion pressure after cold storage of the isolated rabbit kidney.

The vasodilatation induced by acetylcholine (ACh) in a rabbit isolated perfused kidney was abolished when the tissue was exposed to cold ischemia for 72 h in Euro-Collins (EC) solution. This vasodilatation is due to the release of endothelium-derived relaxing factor (EDRF) from renal vasculature as evidenced by the attenuation following methylene blue pretreatment. When kidneys were preserved in EC solution containing UK 38485, a thromboxane synthase inhibitor, or nicardipine, a calcium channel blocker, ACh-induced vasodilatation persisted after 72 h of cold ischemia. These results were taken as evidence of tissue protective activity of UK 38485 and nicardipine and have promising implications for cadaveric kidney transplantation.

Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog.

Somatostatin and its long-acting analog octreotide (SMS 201-995) inhibit several gastrointestinal functions. Their effects have been studied in the treatment of small numbers of external pancreatic, intestinal and biliary fistulas. We treated 8 biliary, 4 pancreatic and 5 intestinal cutaneous fistulas with octreotide. Mean decreases in fistula output before octreotide treatment were not significant (p > 0.01 for each group). On the 1st day of octreotide treatment, mean fistula output decreased from 412 +/- 60.4 to 234 +/- 57.7 ml in the biliary, from 457.5 +/- 57.5 to 217.5 +/- 11.8 ml in the pancreatic and from 564 +/- 49.2 to 217.5 +/- 11.8 ml in the enterocutaneous fistula groups (p < 0.01 for each). No serious side effects were recorded. We conclude that octreotide is an important adjunct in the conservative treatment of external biliary, pancreatic and intestinal fistulas, by decreasing their output.