Biomedical subjects
Publications and source records attributed to D Böckler.
Leiomyosarcomas of the inferior vena cava are rare and the clinical symptoms unspecific. We report a case of leiomyosarcoma of the inferior vena cava in an 82-year-old woman presenting with weight loss and abdominal pain. Following elaborate preoperative examinations, surgical resection was performed and the inferior vena cava was reconstructed. Clinical signs, diagnosis, therapy, and prognosis are discussed.
BACKGROUND: We studied haemodynamic and metabolic variables, and cerebral function after cardiac arrest induced by high dose of adenosine in patients undergoing thoracic aorta endovascular repair. METHODS: Arterial blood pressure, blood gas values and EEG were recorded continuously in 15 patients undergoing anaesthesia (isoflurane) for endovascular thoracic aorta repair. Cardiac arrest was induced by different doses of adenosine (Adrekar, Sanofi-Synthelabo, Berlin, Germany; 0.4-1.8 mg kg(-1) body weight). Serum concentrations of neurone-specific enolase (NSE) were determined before and after stent graft implantation. Neurological function was assessed before and after surgery. RESULTS: After adenosine, the heart beat stopped immediately for 18-58 s in close relation to the adenosine dose. EEG power was significantly reduced to -57%, but reached normal values within 5 min after cardiac arrest. In particular, the fast alpha- and beta-EEG-frequencies sensitively reflected patients' EEG activity during the procedure. No intraoperative increases in NSE concentrations, and no neurological dysfunctions after surgery, were observed. CONCLUSION: After adenosine-induced cardiac arrest, changes in haemodynamic variables and EEG power spectra reversed completely within 1 and 5 min, respectively, without persistent brain dysfunction after stent graft implantation.
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Isolated iliac aneurysms (IIA) are uncommon lesions that require surgical repair to prevent rupture. The aim of this article is to give an update on the current surgical management of IIA. This report also evaluates the application of endovascular repair in IIA, based on a recent Pubmed search and on our own experience in the interventional field: Open reconstruction achieves good longterm results and still represents the golden standard in surgical treatment of IIA. Transluminally placed endovascular stent grafts can be successfully used to exclude isolated iliac aneurysms in selected high risk patients with suitable anatomy. A classification based on aneurysm morphology is useful for patient selection. The value of endovascular therapy has yet to be determined.
The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.
The prevalence of vascular disease among the elderly population is high (approximately 20%). The morbidity and mortality of many vascular operations show no differences between the fit elderly and younger patients. A major problem is that the elderly are often not diagnosed and treated early enough to prevent emergency operations, which carry a much higher mortality. Many new surgical techniques, especially endovascular interventions, have made vascular surgery less invasive. These advances have increased the potential of life saving and prolonging vascular surgery that can be offered to all patients regardless of age. Risk-benefit analysis, especially in elderly patients, is a cornerstone of proper patient selection. The main goal of vascular surgery in the elderly is preservation of quality of life and independence. Surgery of a ruptured aneurysm is a life saving exception. Indications for treatment in the elderly remains an individual decision making process. Advanced age should not be considered as a limitation or contraindication for carotid, aneurysm and bypass surgery. Age is not a disease, it is just a chapter of life.
The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.
OBJECTIVES: To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. METHODS: Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. RESULTS: Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. CONCLUSIONS: Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.
In this report, we describe successful treatment of a patient with hemoptysis by false lumen embolization of a type B aortic dissection.
Aortic intraluminal mass lesions of the thoracic aorta are rare disorders with a wide range of differential diagnoses. Generalized hypercoagulation or vascular endothelial disorders have been proposed as the main etiological factor. The risk of catheter-related thrombus development or embolization after interventional procedures is as high as 17%. Malignancies of the aorta are somewhat rare. In some cases, the specific source of the thrombus could not be determined. Mainly, intraluminal tumors of the thoracic aorta become evident through peripheral embolization. Modern diagnostic tools are able to identify the structure and location of intravascular formations. Therapy options are influenced, due to the heterogenic entity, by the individual risk to the patient and the pathology of the thrombus.
Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.
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BACKGROUND: Prostaglandins have been shown to protect against a variety of liver insults, including ischemia-reperfusion injury. Decreased graft injury and improved survival have been demonstrated in animal studies of liver transplantation after donor pretreatment with prostaglandin before organ retrieval. This potential clinical application has not been examined in human subjects. PATIENTS AND METHODS: One hundred and six liver donors were randomly assigned to receive either prostaglandin I2 (epoprostenol, 500 microg intravenous bolus) immediately before cold perfusion or no drug as control. Donor and recipient characteristics were recorded, and liver function tests were monitored after transplant to assess the effect of epoprostenol on graft injury. RESULTS: Donor pretreatment with epoprostenol significantly improved the rapidity and homogeneity of graft reperfusion. Epoprostenol pretreatment also significantly reduced peak values of transaminases after transplantation: serum glutamic-pyruvic transaminase, control (851+/-121 international units [IU]/L) and epoprostenol (463+/-78 IU/L); serum glutamic-oxalaacetic transaminase, control (870+/-127 IU/L) and epoprostenol (463+/-78 IU/L); serum glutamate dehydrogenase, control (458+/-95 IU/L) and epoprostenol (170+/-30 IU/L); P<0.01 for all, by t test. Serum levels of bilirubin and alkaline phospatase were not significantly altered by donor pretreatment with epoprostenol. CONCLUSIONS: Reduction of ischemia-reperfusion injury by administration of epoprostenol before graft retrieval may have important applications in liver transplantation. Further studies are required to establish the mechanism of this effect and to define its precise role in clinical practice.
BACKGROUND: Recurrent hepatitis B infection after liver transplantation is associated with poor graft and patient survival. Famciclovir is a nucleoside with virostatic action in hepatitis B infection. We report the case of a 51-year-old patient who developed recurrent delta-positive hepatitis B infection after liver transplantation. After famciclovir treatment, he became seronegative for hepatitis B early and hepatitis B surface antigens and developed protective anti-hepatitis B surface antibody titers. METHODS: After recurrent hepatitis B was confirmed, treatment with famciclovir was initiated. RESULTS: Eighteen days after starting famciclovir, the patient became seronegative for hepatitis B early antigen and delta antigen, and hepatitis B virus DNA was no longer detectable in serum. Three months later, the patient became hepatitis B surface antigen negative and remains well 16 months later with increasing anti-hepatitis B surface levels. CONCLUSIONS: Antiviral treatment with famciclovir may be useful in treatment of delta-positive hepatitis B infection following liver transplantation. Further evaluation of famciclovir in treatment and prevention of hepatitis B in these patients is warranted.
The safety and effectiveness of nonoperative management of selected adults have been confirmed in those patients who meet selection criterias of isolated splenic injury and hemodynamic stability. The CT scan is a very precise and the most specific diagnostic procedure in splenic trauma. Nonoperative treatment is successful in 80% of adults in such selected group of patients.
Endoscopic subfascial sectioning (ESDP) is an effective method for the interruption of incompetent perforating veins. From March 1993 to April 1994 27 patients underwent ESDP in 35 legs. ESDP was performed in combination with Babcock's operation in 31 cases. Most patients demonstrated chronic venous insufficiency stage II or III (n = 25). A venous ulcer was found in 9 patients. Intraoperative complications were not seen. Postoperative complications were delayed wound healing (n = 1) and subfascial hematoma (n = 1). At follow-up examination after a mean interval of 8 months persistent insufficient perforating veins were seen in 3 of 88 Cockett veins (4%). A local dysesthesia of the saphenous nerve was found in 6 legs. Prior active venous ulcers had healed in 8 of 9 cases.
BACKGROUND: Widespread adoption of minimal access techniques forced a generation of abdominal surgeons to re-learn many standard abdominal procedures. This threatened to reduce the pool of suitable "training" operations for surgical residents. METHODS: Operator grade, duration of operation, acute/elective operation, conversion rate, complications, and postoperative stay were recorded prospectively on all laparoscopic cholecystectomies (LC) since 1992. This data was evaluated to determine how the introduction of LC affected residents' training. RESULTS: The percentage of LCs performed by residents increased progressively to reach 58%. Operating time was longer for trainee surgeons, particularly for acute cases (145+/-50 minutes vs 111+/-54 minutes, p<0.05); however, conversion rate, incidence of complications, and postoperative stay were no different. CONCLUSIONS: LC can be performed by surgical trainees with similar complication rates and outcomes as those of qualified surgeons. Once institutional experience has accumulated, this procedure can be integrated into residency training.