Conservative treatment of spontaneous dissection of the subclavian artery.

Dissection of the subclavian artery usually occurs as a result of trauma, endovascular interventions or connective tissue disorders. Only rarely has it been described occurring spontaneously. The treatment can be endovascular, open surgery, conservative or a combination of the above. There are no guidelines. The best approach is the one tailored to the lesion itself. This case presents a 73-year-old man with a tiresome and heavy feeling in the right arm. He was diagnosed having a spontaneous dissection of the right subclavian artery, accompanied by a complete occlusion more distally. Because of the relatively minor symptoms he was treated conservatively using anticoagulants. After 6 months of treatment there was complete revascularisation with good pulsations at the right wrist.

Conservative Treatment of Spontaneous Dissection of the Subclavian Artery.

Dissection of the subclavian artery usually occurs as a result of trauma, endovascular interventions or connective tissue disorders. Only rarely has it been described occurring spontaneously. The treatment can be endovascular, open surgery, conservative or a combination of the above. There are no guidelines. The best approach is the one tailored to the lesion itself. This case presents a 73-year-old man with a tiresome and heavy feeling in the right arm. He was diagnosed having a spontaneous dissection of the right subclavian artery, accompanied by a complete occlusion more distally. Because of the relatively minor symptoms he was treated conservatively using anticoagulants. After 6 months of treatment there was complete revascularisation with good pulsations at the right wrist.

Laparoscopic appendectomy combined with TEP for de Garengeot hernia: case report.

INTRODUCTION: A de Garengeot hernia is defined as a femoral hernia containing the vermiform appendix. De Garengeot hernia is a rare condition, reported to occur in only 0.8% of all femoral hernias. Acute appendicitis presenting within a femoral hernia is even rarer, occuring in 0.08-0.13% of all cases of acute appendicitis. CASE REPORT: We present the case of a 64-year-old woman with the diagnosis of incarcerated groin hernia. An urgent laparoscopy was performed showing the distal part of the appendix passing through a small right-sided femoral hernia. A laparoscopic appendectomy was performed, followed by TEP-procedure for femoral hernia repair. DISCUSSION: To our knowledge, this is the first report of this type of approach for a de Garengeot hernia.

Necrotizing fasciitis of the first ray caused by group A streptococcus.

Necrotizing fasciitis of the hand is a rare clinical entity, frequently with devastating functional consequences. A case of necrotizing fasciitis of the thumb and thenar eminence caused by Group A Streptococcus is reported and the management of this condition in the upper limb discussed.

Tailgut cysts: rare retrorectal tumours.

Two patients presented with tailgut cysts. The first patient complained of pain and pressure in the sacrococcygeal region. The second patient had developed a cystic mass superficial to the coccyx. Pelvic CT scans of both patients demonstrated a retrorectal mass. Both tumours were excised through a posterior para-sacrococcygeal approach with resection of the coccyx.

Caecostomy in the management of acute left colonic obstruction.

In the management of acute left colonic obstruction there is a tendency to perform immediate resection with anastomosis. We evaluated 27 consecutive patients (mean age 73.8 years) with acute left colonic obstruction and gross dilatation of the proximal colon treated by the "traditional" staged procedure. After caecostomy, no further resection was performed in two patients. In 25 patients, the obstructing tumour was resected after a median period of 14 days. In 17 (68%) patients the caecostomy was closed simultaneously. In 8 patients this was done at a third stage. Histologic examination revealed diverticular disease in 6 and adenocarcinoma in 19 patients. No deaths occurred after caecostomy nor was there major morbidity. After colonic resection, one in-hospital, nonprocedure related, death occurred (mortality rate 4%). In 21 patients with an anastomosis no dehiscence occurred. Other postoperative complications occurred in 5 patients (morbidity rate 20%). The median hospital stay for patients with a two-stage procedure was 32 days and with a three-stage procedure 39.5 days. The staged procedure in the management of acute colonic obstruction is still a safe and acceptable procedure in elderly patients with acute large bowel obstruction. To shorten the hospital stay the period between caecostomy and colonic resection should be reduced and it is best to close the caecostomy simultaneously.

Intramedullary fixation of forearm fractures in adults.

The authors present a retrospective study of acute fractures of the diaphysis of the radius or ulna, or both, in adults treated by intramedullary nailing. Seventy diaphyseal fractures in 38 patients (30 men and 8 women) were treated by intramedullary fixation. The mean age of the patients was 31.5 years. Union occurred in 66 fractures (94%). The average union-time was 73 days. Compared with the results published by other authors, using the same evaluation criteria, union-time with the intramedullary technique was shorter than with other techniques. Union-rates and functional results were similar to those in comparable studies. Closed nailing does have many advantages, including early union, low incidence of infection, small scars, less blood loss, and short operating time with minimal surgical trauma.

[Construction of a jejunal pouch using stapling technics in total gastrectomy]. / Constructie van een jejunal pouch met behulp van stapling technieken bij totale gastrectomie.

During the last four years we performed 16 total gastrectomies with construction of a jejunal pouch. The idea was that patients with a pouch should be able to eat larger meals. This was affirmed by the patients, also there were no complaints of regurgitation. Cachexia was not observed in the disease-free patients. Nevertheless the life expectancy stays poor. A description of the technique is given.

Multifinger photoplethysmography and digital blood pressure measurement in patients with Raynaud's phenomenon of the hand.

With the use of a multifinger photoplethysmography system, finger systolic blood pressures were measured before and after cooling in patients with Raynaud's disease. In 30 patients with arteriographically documented arterial obstructions, significantly low digital pressures were found in 91% of fingers with cold sensitivity. In this group of patients a mean decrease in finger pressure of 12.3% occurred during cooling. In a group of 32 patients with Raynaud's phenomenon from unknown causes (primary Raynaud's disease) normal finger pressures were found in 147 (97%) of 152 fingers with cold sensitivity. However, in patients with primary Raynaud's disease, significant lowering of finger pressures was observed after cooling, with an average maximal decrease of 59.2%. The multifinger photoplethysmography method promises to be a reliable instrument for objective measurement in patients with Raynaud's phenomenon.

[Determination of the value of spectrum analysis of the Doppler signal in the assessment of the carotid artery bifurcation]. / Waardebepaling van de spectraalanalyse van het Doppler signaal in de beoordeling van de bifurcatie van de arteria carotis.

A prospective trial was set up in 100 patients, who underwent arteriography of the cerebropetal and cerebral arteries, to determine the value of the direct examination of the Carotid arteries using a continuous wave bidirectionnal Doppler with spectrum frequency analysis. The results of this non-invasive direct technique are compared with the biplane arteriography and with the indirect noninvasive oculoplethysmography (OPG-Gee). The conclusions of this study are that the direct Doppler examination with spectrum frequency-analysis is a very good tool in detecting lesions in the Carotid arteries, and is superior to the indirect OPG-Gee examination, especially in stenoses of 30-69%.

Doppler ultrasound diagnosis of complications of polytetrafluoroethylene (PTFE) graft shunts.

Doppler spectral analysis of PIFE graft shunts for haemodialysis was carried out in 20 patients. All shunts were functioning satisfactorily. One patient had severe oedema of the forearm and hand. In four of the 20 patients, stenosis of the venous anastomosis was diagnosed by Doppler examination. Retrograde venous flow in the ulnar vein at the wrist was seen in the patient with severe oedema. All patients underwent angiography and the diagnosis of stenosis and retrograde flow was confirmed. Graft arteriography has proved useful in detecting shunt lesions, but may be hazardous at the access site and for the patient. Doppler investigation in noninvasive and can detect shunt complications early and with great accuracy.