Pelvic congestion syndrome: a new approach to an unusual problem.

Pelvic congestion syndrome (PCS) is an uncommon and frequently overlooked cause of debilitating pelvic pain. The well-described clinical presentation is that of pain and fullness exacerbated by prolonged standing, coitus, and in the premenstrual period in multiparus women. Physical signs include vulvar varices that can communicate with the saphenous vein in the groin, causing thigh or buttock varices. The diagnosis is usually confirmed by ovarian vein venography demonstrating reflux to the ovaries and often into the thigh with erect positioning and valsalva. Standard surgical treatment is bilateral ovarian vein ligation and excision or ligation of as many collaterals as possible. The traditional approach is bilateral retroperitoneal incisions, with medial rotation of the viscera. We report the first patient managed transperitoneally using minimally invasive techniques. Our case suggests that this approach can easily and safely be performed by surgeons experienced in laparoscopic surgery with the advantages of improved cosmesis, less postoperative pain, and rapid convalescence typical of other minimally invasive procedures. Additionally, it provides the opportunity to perform diagnostic laparoscopy as well.

Prospective evaluation of magnetic resonance imaging in the management of acute diabetic foot infections.

Infectious complications of the foot are a major cause of morbidity and mortality in diabetic patients. This prospective study evaluated the ability of MRI to adequately direct the medical and surgical management of 41 diabetic patients with acute foot infections. Forty-seven MRI scans of the foot in question were performed and classified as consistent with osteomyelitis, abscess, cellulitis or diffuse soft tissue infection, or any combination of these. Twenty-seven scans were negative or showed ill-defined soft tissue infection, or superficial cellulitis. Nineteen of these infections were treated nonoperatively and 17 resolved without surgical intervention. MRI was unsuccessful in directing management in one patient in whom an abscess spontaneously drained but was not seen on an MRI scan 4 days earlier. Eight scans revealed focal osteomyelitis and all eight of these patients were successfully managed with one operation. MRI showed a focal abscess in 12 patients, and adequate drainage was achieved without excessive disruption of uninvolved tissue planes in 11 of these patients. The remaining patient required a major amputation from the outset. Based on clinical outcome during the acute hospitalization period, operative findings, and/or pathologic confirmation, the positive predictive value of MRI in defining infectious pathology in the foot was 100% in this series of 20 positive scans. The negative predictive value of MRI was 96%. On the basis of this experience, we conclude that MRI is a diagnostic modality particularly well suited to evaluate acute diabetic foot infections and reliably aids in the management of acute infection to avoid exploration and debridement of uninvolved tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of magnetic resonance imaging on the management of diabetic foot infections.

This combined retrospective/prospective study evaluated the value of magnetic resonance imaging (MRI) in 18 diabetic patients with apparent foot infections. The goal was to define the impact of MRI on directing the expedient and accurate surgical intervention so important in achieving optimal preservation of limb tissue and function. We found that MRI provides a rapid and reliable means of "viewing" the diabetic foot. Unsuspected or poorly localized abscess cavities can be pinpointed for thorough drainage with minimal exploration. An abscess can be differentiated from cellulitis or osteomyelitis. Moreover, persistent fever following drainage of a foot abscess can be reliably evaluated via MRI, obviating the need for empiric surgical reexploration. This exciting noninvasive imaging technique leads to the most accurate surgical drainage of foot abscesses and, at the same time, can prevent unnecessary surgical exploration of the tenuous diabetic foot.

Salvage of thrombosed forearm polytetrafluoroethylene vascular access grafts by reversal of flow direction and venous bypass grafting.

A technique is described for salvage of looped forearm polytetrafluoroethylene (PTFE) vascular access grafts that fail because of thrombosis due to cephalic vein outflow obstruction. It entails reversal of blood flow direction through the graft and construction of a new venous outflow in the medial upper arm. This procedure was performed in nine patients and, at the present time, has increased the graft life by an average of 6.2 months (range: 2 to 14 months) in eight. We conclude that this is a useful alternative to abandoning failed looped forearm PTFE grafts that have cephalic vein outflow obstruction.