Antegrade revascularization for chronic mesenteric ischaemia.

OBJECTIVE: to evaluate the short- and long-term results, obtained after open revascularization for chronic mesenteric ischaemia as a reference in a field with growing interest for PTA and stenting. MATERIALS AND METHODS: we reviewed 14 patients with 15 antegrade revascularizations for chronic intestinal ischaemia, between 1996 and 2003: ten bypasses either to the celiac trunk or to the mesenteric artery and five bifurcated bypasses to both arteries were performed. There was one reimplantation for Wilki syndrome. Graft patency was monitored for a mean period of 24 months (range 1-84 months) by clinical examination and duplex scanning. MAIN RESULTS: one patient had recurrence of symptoms that disappeared after successful reoperation. There was one perioperative death All the other patients (84%) had a long-term symptom free survival. CONCLUSION: antegrade mesenterial revascularization through an upper abdominal approach is an excellent technique with good long-term results. It sets a high standard that will be difficult to obtain with mesenteric PTA and stenting. It remains the preferred method of revascularization in low-risk patients.

Endovascular repair of aortic rupture.

OBJECTIVES: To report a single centre experience with endovascular repair of ruptures of the descending thoracic and abdominal aorta. DESIGN: Retrospective non-randomised study in a university hospital. MATERIAL AND METHODS: Between February 1997 and October 2002, endovascular repair of the aorta was performed on 125 occasions. In 20 cases, this was done as an emergency (nine ruptured infrarenal aortic aneurysms and 11 descending thoracic aortic ruptures). All patients underwent spiral computed tomographic angiography to assess the feasibility of endovascular repair and the size of the endoprosthesis. RESULTS: Endovascular repair was successfully completed in all patients. Primary conversion to open repair was not necessary. Postoperative 30-day mortality was 5/20 (25%). There were major complications in 12/20 patients. No ruptures of the aneurysms occurred postoperatively. No primary endoleaks occurred, but in 4/20 (20%) secondary surgical interventions were required after a median follow-up of 12 months (range 1-42 months). CONCLUSION: Our early experience shows the feasibility of this technique with early results that compare favourably to those of emergency open repair. Further studies are required to assess the long-term efficacy.

Bronchial rupture after direct chest trauma in a child.

Tracheobronchial injuries are rare in trauma patients, and most often occur after motor vehicle accidents. Occasionally, other mechanisms cause airway disruption. The pliability of the chest wall in children greatly adds to the differences in injuries when compared with adult trauma patients. We present the case of a six-year old girl with an isolated right-sided bronchial rupture after direct trauma to the chest.

Recombinant humane thyrotropin (rhtSH) a new aid in the diagnosis and treatment of thyroid carcinoma with radio-iodine.

By example of two cases a newly available tool, the recombinant humane thyroid stimulating hormone (rhTSH) is discussed in its use as an adjunct in diagnosing and treating differentiated thyroid carcinoma with radio-iodine. This product is an easier and safe alternative to the necessary rise of TSH induced by thyroid hormone withdrawal and concurrent hypothyroidism. Although discrepancies in favour of the classical approach have been demonstrated in some patients, the clinical relevancy of these must be weighted against the advantage of avoiding undesirable symptoms and possible tumour growth by the use of rhTSH. The role of rhTSH in the follow-up diagnosis and radioiodine treatment of thyroid carcinoma will undoubtedly increase in importance.

A single center's clinical experience with quadruple immunosuppression including ATG or IL2 antibodies and mycophenolate mofetil in simultaneous pancreas-kidney transplants.

UNLABELLED: Acute rejection remains a major problem in simultaneous pancreas-kidney (SPK) transplant and occurs in 60-100% of the cases. With the introduction of mycophenolate mofetil (MMF) replacing azathioprine (AZA) as a basis immunosuppressant, reduced rates of rejection have been reported. This study investigates the frequency and clinical relevance of allograft rejection in SPK patients receiving antithymocyte globulin (ATG) or Basiliximab induction therapy and cyclosporine Neoral (CyA), MMF, steroid basis immunosuppression. Between December 1996 and October 1999, 21 consecutive patients (15 males, 6 females) received a SPK transplant at our institution with a mean +/- standard deviation (SD) age of 42 +/- 6 yr. Of these, 14 patients were treated with anti-thymocyte globulin (ATG) Fresenius (rabbit) 3-5 mg/kg for 6 +/- 2 d, cyclosporine Neoral (CyA) (trough levels 350-400 ng/mL), MMF 3 g/d and low dose steroid therapy. Seven SPK patients were treated with Basiliximab (Simulect, Novartis 20 mg on d 0 and d 4 post-transplant) instead of ATG. The patients had an average human leucocyte antigen (HLA) mismatch of 3.9/6 and a negative cross match. All patients remained on triple drug therapy. Three patients were switched to tacrolimus instead of Neoral for CyA intolerance. The mean +/- SD cold ischemia time (CIT) of the organs was 10.1 +/- 2.4 h for the pancreas and 10.5 +/- 2.6 h for the kidney. RESULTS: Biopsy-proven rejection occurred in the kidney of 1 ATG patient (8%), which responded to steroid bolus therapy. One of the patients (14%) with Basiliximab induction developed renal allograft rejection, which was resolved after a 6-d course of anti-CD3 mAb (OKT3) treatment. All patients (100%) were free from rejection in the pancreas, as measured by urine amylase levels and glycemic control without the need for exogenous insulin with a mean glycosylated hemoglobin (HBA1C) of 5.1 +/- 0.7%, and serum creatinine with a mean of 1.24 +/- 0.24 mg/dL in a mean follow-up period of 17 +/- 15 months (median 12, range 2 37). CONCLUSION: Triple drug immunosuppression including cyclosporine, MMF and low dose steroids with ATG or interleukin 2 (IL2) receptor antibodies induction therapy appears to be a very suitable immunosuppressive regimen for combined pancreas-kidney transplant (PKT) with a marked reduction in the incidence of rejection.

Cost-benefit analysis of endovascular versus open abdominal aortic aneurysm treatment.

OBJECTIVE: To compare the costs and benefits of open versus endovascular repair of abdominal aortic aneurysm (AAA). METHODS: A consecutive series of 29 elective patients (open treatment, N = 20 and endovascular treatment, N = 9) were compared retrospectively. RESULTS: Operating time was significantly shorter for endovascular treatment (mean 90 vs. 125 min, p = 0.026). No endovascular procedure was converted to open surgery; one early endoleak was seen which sealed spontaneously. Endovascular treatment resulted in a shorter ICU and hospital stay (0 days vs. 2 days, p. 0.001 and 5 days vs. 11 days, p = 0.01 respectively). Mean total cost did not differ 361,938 BEF (9,048 Euro) vs. 382,995 BEF (9,575 Euro), p = 0.46. Endovascular treatment generated significantly less hospitalization costs (73,162 BEF or 1,829 Euro vs. 18,2740 BEF or 4,568 Euro, p = 0.001) but required a more expensive implant (153,293 BEF or 3,832 Euro vs. 38,296 BEF or 957 Euro, p = 0.001). Mean total cost for the patient was significantly higher in the endovascular treatment group (66,309 BEF or 1,658 Euro vs. 24,969 BEF or 624 Euro, p = 0.003). CONCLUSION: Our experience confirms the feasibility and safety of endovascular AAA treatment. It is associated with a shorter ICU and hospital stay and less morbidity. Overall cost for society does not differ significantly as the benefit, of lower hospitalization costs is undone by the high cost of the endovascular graft.

Operative closure of patent ductus arteriosus in the neonatal intensive care unit.

Preterm infants undergoing surgical closure of patent ductus arteriosus are usually critically ill and are suffering from many concomitant diseases. The high risk of increased morbidity in transferring them from the neonatal intensive care unit (NICU) to a distant operating room is generally recognized. For this reason we report our experience in 33 premature infants with patent ductus arteriosus who have been operated in the NICU over a six-year period. There were no operative or immediate postoperative deaths and the 30 days hospital mortality was 6%. Based upon these findings we can confirm that operative closure of PDA can be performed safely in the NICU.

Recombinant human erythropoietin corrects anaemia during the first weeks after renal transplantation: a randomized prospective study.

BACKGROUND: Studies on the effect of recombinant human erythropoietin (rHuEpo) on haematopoiesis in patients with kidney transplants, have been limited to progressive chronic graft failure, late after transplantation. In the present prospective randomized study, the efficacy of rHuEpo in the correction of anaemia during the first weeks after renal transplantation (RTP) was evaluated. METHODS: Patients were allocated to either an Epo- (n = 14) or a non-Epo-treated group (n = 15). Epo (150 U/kg.week s.c.) was started at a haematocrit (Hct) < 30% and was increased at weekly intervals by 30 U/kg.week, as long as Hct remained < 25%. RESULTS: In the Epo group, Hct increased from a nadir of 22 +/- 4% 2 weeks after RTP to 30 +/- 4% at week 4 and to 36 +/- 4% at week 6 (P < 0.001 and P < 0.0001 respectively vs week 2). Corresponding values in the non-Epo group were 25 +/- 6%, 28 +/- 6% (P = NS) and 32 +/- 6% (P < 0.05 vs week 2) (overall evolution Epo vs non-Epo: P = 0.038 by variance analysis). The differences in Hct between the Epo and non Epo group were even more marked in patients without major complications (variance analysis P = 0.009). The Epo-treated patients required fewer post-surgical blood transfusions (0.005 vs 0.014/days follow-up, P < 0.05), in spite of greater post-surgical blood losses, especially at day 1 (P < 0.05) and the presence of more major complications (7 vs 4) and a higher number of ganciclovir-treated patients (4 vs 0; P < 0.05). The maximum Epo dose after RTP was > 2x higher than the one required before RTP (197.1 +/- 45.1 vs 85.0 +/- 76.0 U/kg.week; P < 0.05). CONCLUSIONS: It is concluded that rHuEpo during the first weeks after RTP is of benefit in the correction of the Hct in the early post-surgical period, in spite of relative Epo resistance.

Factors and complications affecting catheter and technique survival with permanent single-lumen dialysis catheters.

This long-term study on the outcome of permanent silicone single-lumen dialysis catheters consisted of 43 surgically inserted catheters in 33 patients. All catheters were attached to a pressure-pressure single-cannula dialysis system. Technique and catheter survival were 80 and 59% at 1 year, and 63 and 50% at the 3rd year respectively. These parameters were not different in older patients (> or = 70 years, n = 12). Factors corresponding to a less successful outcome were placement in the left jugular vein (3-month actuarial survival of 44%) and absence of distal side holes (1-year actuarial survival of 44%). Insertion in both subclavian veins was not different to the classical right jugular vein. Infectious complications (incidence of 0.72 per 1000 catheter days) often caused simultaneous catheter and technique failure (14 versus 15%), whereas inadequate flow (incidence of 2 per 1000 catheter days) caused catheter rather than technique failure (30 versus 12%). The incidence of both complications declined significantly with time after insertion during the follow-up period. The first 3 months after insertion were more predisposed to the occurrence of inadequate flow than catheter-related infections. The general performance of these permanent single-lumen catheter devices justifies their long-term application in haemodialysis, even as a first choice of vascular access, especially in the elderly. Insertion in the left jugular vein and use of catheters without side holes should be avoided, providing a better catheter survival.

[Renal autotransplantation]. / Renale autotransplantatie.

The progress of renal transplantation in the last 2 decades has made possible the development of autotransplantation and extracorporeal surgery of the kidney. By those techniques, it is possible to operate upon patients in which conservative conventional surgery is impossible. In this article the technique is described, and two typical cases are reported. The mean indications are renal vascular hypertension, malignant tumors of the kidney, traumatic lesions of the kidney and ureteral lesions. All these indications are described in detail.

Long-term results after carotid endarterectomy for carotid artery stenosis with contralateral occlusion.

Patients with one internal carotid artery occlusion and a contralateral stenosis run a significantly higher risk of stroke. We performed endarterectomy of the stenotic carotid in 44 such patients and followed them for mean 54 months (range 1-172 months). Early mortality was 2%. Life-table analysis shows that the incidence of a new stroke was 0.6% per year, the survival rate was 78% after three years, and 70% after five years. We conclude that carotid endarterectomy can be safely performed in patients with contralateral internal carotid artery occlusion and can significantly improve the long-term prognosis of these patients.

Simultaneous determination of pentoxifylline and three metabolites in biological fluids by liquid chromatography.

We describe a sensitive and specific liquid-chromatographic assay for pentoxifylline and three of its metabolites in human plasma and urine. Addition of hydrochloric acid to the sample before extraction, and incorporation of acetic acid in the chromatographic eluent, allow the simultaneous determination of the four compounds plus an internal standard in one chromatographic run. Unlike gas-chromatographic procedures, this method does not involve derivatization no similar analysis of serum or plasma samples has been described before now. The method has been applied successfully to routine analysis and to pharmacokinetic studies.

Peritoneal lavage after abdominal trauma: indications, technique, results.

This study represents our experience with 1461 patients who were seen in the Emergency Room of the University Hospital in Ghent with multiple traumatic lesions, between 1978 and 1982. In 43% of these polytraumata, we did an explorative peritoneal lavage in order to obtain a quick evaluation of intrabdominal haemorrhage. In 65% of the patients, the lavage was negative; 221 positive lavages (35%) underwent abdominal exploration; in 85% of these there were evident positive findings. The remaining 15% showed either no lesions, or minor lesions not involving risk of life. The overall accuracy-rate of the technique described above is at least 93%.

Single-dose prophylaxis with cefotetan in elective abdominal surgery. A controlled trial.

Single dose cefotetan was compared with either a combination of metronidazole and cefazolin given for 24 hours or 3 doses of cefuroxime as prophylaxis in elective abdominal surgery. Wound infections and infections at remote sites (UTI and RTI) were similar in all groups. In a third group prophylaxis of abdominal surgery using a single 2g dose of cefotetan was compared to 2 doses of the same drug, given 12 hours apart. There was no demonstrable advantage to giving 2 doses. The low incidence of post-operative infections seen in all groups indicates the efficacy of cefotetan in the surgical prophylaxis of elective abdominal surgery.

Pseudo-Kaposi's sarcoma as a complication of Cimino-Brescia arteriovenous fistulas in hemodialysis patients.

Pseudo-Kaposi's sarcoma is a skin lesion that is associated with chronic venous insufficiency and/or congenital arteriovenous fistulas. Theoretically, this lesion could also be expected in connection with hemodialysis vascular accesses. Nevertheless, this disease has been reported only once in conjunction with a Cimino-Brescia arteriovenous fistula, and no attention has been paid to the potential complications of this disease. In the present paper 3 cases are reported. In 1 patient pseudo-Kaposi's sarcoma was complicated by an infected open wound as a consequence of a trauma. In the 2 other patients, a skin biopsy was followed by local infection and retarded healing of the wound. Evaluation by fistulagraphy and/or Doppler revealed venous outflow stenosis in only 1 case. After reconstruction or ligation of the fistula, correction of the lesions was observed. It is concluded that pseudo-Kaposi's sarcoma can occur as a complication of Cimino-Brescia arteriovenous fistulas, necessitating early correction of the fistula. The performance of a skin biopsy might be associated with infection and delayed wound healing, so that this diagnostic procedure should only be performed in cases where the clinical diagnosis is not obvious.

Polydioxanone suture material in growing vascular anastomoses. Experimental study.

We studied the growth of vascular anastomoses after use of absorbable suture material in 21 piglets. In six piglets, end-to-end anastomosis of the infrarenal aorta was performed with 5-0 continuous polypropylene suture; stenosis developed in two of these animals. In 15 piglets, continuous polydioxanone sutures were used for the anastomoses, and no stenosis developed. On the contrary, 14 of these anastomoses showed some degree of dilation at the anastomotic site. Burst testing to 300 mm Hg caused no disruption. On histologic examination, only scar tissue at media and intima with good degree of differentiation was noted. Growth of a vascular anastomosis after use of absorbable polydioxanone suture material seems to be perfectly possible without stricture formation. Because the growing process takes years instead of months in human beings, with obviously less stress at the anastomotic site, it is likely that dilatation at the level of the suture line will not occur in clinical use.

LDH analysis of human thymocytes and thymocyte subsets.

The lactate dehydrogenase (LDH) isoenzyme pattern (expressed as the B:A subunit ratio) and two enzymes of the purine metabolism adenosine deaminase (ADA) and purine nucleoside phosphorylase (PNP) (expressed as the ADA/PNP ratio) were studied in human prenatal thymocytes, in subsets of human infant thymocytes, and in peripheral T lymphocytes. Prothymocytes were enriched by E rosette depletion, cortical thymocytes were enriched with a monoclonal antibody rosette technique using OKT6, and medullary thymocytes were enriched either with a monoclonal antibody rosette technique using OKT3 or with complement-mediated cytolysis using normal fresh rabbit serum. Peripheral T lymphocytes were isolated from normal adult peripheral blood by E rosette sedimentation. Prenatal thymocytes had the lowest B:A ratio. In the infant thymuses, prothymocytes had a lower B:A ratio (0.99 +/- 0.10) than the cortical thymocytes (1.04 +/- 0.08). The medullary thymocytes obtained either by OKT3 selection or normal rabbit serum cytotoxic treatment had higher B:A ratios (1.30 +/- 0.15 and 1.42 +/- 0.17, respectively). The highest B:A ratio is found in peripheral T lymphocytes (2.07 +/- 0.28) together with the lowest ADA/PNP ratio (0.50 +/- 0.07). The B:A ratios are paralleled by a progressive decrease in the ADA/PNP ratio. These findings indicate that during intrathymic T cell development, important changes occur not only in the activities of the enzymes of the purine metabolism but also in the distribution of the LDH isoenzymes.