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At least 1,513 records · Page 84Linked to original sources
PubMed1997

[Carotid endarterectomy by eversion and reimplantation. Techniques and results].

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

Carotid Artery, Internal↗
PubMedDate not supplied

[Current indications for reimplantation of the upper extremity].

In the last decades there has been a great development in microsurgery that has enabled successful replantation of totally severed parts. Nowadays, the important issue is to decide which segments should be replanted, in order to achieve a good functional result. In this paper we study the indications and contraindications of replantation, based in our experience and we present a review of the recent literature. We consider the following aspects: general condition and age of the patient, mechanism of lesion, amputation level, ischemic time and also economic aspects. We conclude that replantation should be attempted in thumb and multiple digits amputations, in amputations at the palm, wrist and forearm, in single digit amputations distal to the flexor superficialis insertion and in any case in children.

Adult↗
PubMed1998

[Revascularization and reimplantation of the upper extremity. 15-year-experience with 114 cases].

Progress in micro or macro replantation has resulted in higher survival rates of formerly amputated parts. More amputated digits or limbs survive because the time of ischemia can be exceeded by using cold storage or perfusion. Homo or heterodigital vessel transposition, expanded indications for vein graft interposition, as well as heterotopic transplantation allow for extremity preservation even in crush injuries, and in disastrous multiple amputations combined with contusion or avulsion. Secondary reconstruction with regard to bone defects, tendon repair, and eventual nerve grafting have to be aspired, finally leading to an improvement of functional results in daily and leisure activities as well as in early professional readaptation. A total of 114 microvascular extremity replantations/revascularizations with a survival rate of 77.2% were followed for an average of 15 years.

Accidents, Occupational↗
PubMed1996

The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms.

PURPOSE: We developed a monitoring system to detect spinal cord ischemia during aortic cross-clamping (AXC). This system was used to prospectively determine in which patients ischemia occurs, in which patients reimplantation of intercostal arteries is unnecessary or mandatory, and when reperfusion of intercostal arteries (ICAs) is urgent. METHODS: Two hundred sixty patients underwent thoracoabdominal aortic aneurysm (TAA) repair with simple AXC. In 167 patients, two electrocatheters were placed before the onset of anaesthesia at level L1/L2 (stimulation) and level T5/T6 (recording) within the epidural space. During surgery, spinal cord function was monitored by recording spinal somatosensory evoked potentials (sSSEP). According to the extent of aortic replacement, most patients were expected to have a high risk of paraplegia. RESULTS: In group A (59 patients), sSSEP remained normal throughout surgery, and in 54 of these patients ICAs were not reattached outside the proximal aortic anastomosis. In the other five patients ICAs were reimplanted separately because of possible anatomic relation to spinal cord blood supply. No patient in group A had postoperative neurologic deficit. In group B (54 patients) sSSEP remained normal until 15 minutes after AXC but were impaired thereafter. Nineteen patients had early reimplantation of ICAs. Of the 19, three had paraparesis and two had paraplegia. Neurologic deficit developed in the patients without early reimplantation of ICAs. In four patients separate reimplantation of ICAs was performed late in the procedure because of incomplete sSSEP recovery. Subsequently, the sSSEP returned to normal and only one of the four patients had mild paraparesis. The total rate of neurologic deficits in this group was 13% (paraplegia, 3.5%; paraparesis, 9.5%). All 54 patients in group C showed rapid loss of sSSEP within 15 minutes of AXC. In 28 patients ICAs were reimplanted only within the proximal anastomosis. Twenty-one of these patients showed prompt signal recovery after blood-flow release into the reimplanted ICAs, and none had neurologic deficit. Seven patients had no or very late and incomplete sSSEP recovery. Of the seven, three had paraplegia and four had paraparesis. In 26 patients ICAs were reimplanted separately to the proximal anastomosis. This was done early during the procedure in 17 patients, of whom 13 had full recovery of sSSEP and normal neurologic status. Four patients had incomplete or no recurrence of sSSEP, followed by paraplegia in one and paraparesis in three. In nine patients ICAs were reimplanted after the aortic replacement had been completed because of sSSEP recovery was not satisfactory. In all patients in this subgroup sSSEP returned to normal. Six patients had a normal neurologic status and three had mild paraparesis. The total neurologic complication rate in group C was 26% (paraplegia, 7.5%; paraparesis, 18.5%). CONCLUSION: The risk of ischemic spinal cord injury during replacement for TAA can be assessed continuously by monitoring the sSSEP directly from the spinal cord. Patients without sSSEP changes during aortic reconstruction do not require ICA reattachment and will not have neurologic deficit. Patients who lose sSSEP after AXC are at risk for paraplegia. Patients with impairment or loss of sSSEP >15 minutes after AXC have some collateral vessels, and must have ICAs reimplanted only if sSSEP do not return within normal recovery time after blood-flow release into the proximal anastomosis. Loss of sSSEP within 15 minutes of AXC shows poor collateralization and mandates early restoration of spinal cord blood supply. If the surgeon can achieve the return of sSSEP to normal by subsequent separate reimplantation of ICAS, paraplegia will not occur and paraparesis will be rare and mild. Spinal cord monitoring is a valuable guide to detect whether the spinal cord is at risk and to take measures against par

Anastomosis, Surgical↗
PubMed2001

Vesicoureteral reflux after ureteroneocystostomy: indications for postoperative voiding cystography.

PURPOSE: The aim of this study was to determine the risk factors for vesicoureteral reflux following ureteral reimplantation to identify a population that can be safely excluded from postoperative voiding cystography. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 273 patients who underwent ureteroneocystostomy for vesicoureteral reflux between 1990 and 1998 and recorded the postoperative renal ultrasonography and voiding cystography results. RESULTS: There were 273 patients (534 ureters) who underwent ureteral reimplantation. We recorded the grade of preoperative hydronephrosis and vesicoureteral reflux and noted several preoperative and intraoperative variables, such as dysfunctional voiding, breakthrough infections, renal scarring, bladder trabeculations, type of reimplant, and postoperative urinary tract infections. With a mean follow-up of 20.6 months, persistent postoperative vesicoureteral reflux was noted in 11 patients (4%). Persistent postoperative reflux was noted in 11 patients (4%) or 12 renal units (2.2%). Reflux resolution rates for 534 renal units and 273 patients after routine follow-up voiding cystourethrogram (VCUG) was 97.8% (renal units) and 96% (patients), respectively. Contralateral vesicoureteral reflux developed in 4 (5.1%) of the 78 patients who underwent unilateral reimplantation. Two patients (0.7%) had postoperative ureteral obstruction. The risk factors for persistent postoperative reflux were identified as preoperative and postoperative hydronephrosis, renal scarring, and tapered reimplantations. The type of reimplant did not correlate with outcome. CONCLUSIONS: Vesicoureteral reflux after ureteral reimplantation is uncommon (4%). Because of the high success rate of ureteral reimplants and the benign course of those patients with persistent low-grade postoperative reflux, it is safe and efficient to eliminate postoperative VCUG in most patients who had a simple ureteral reimplantation for reflux. However, in some higher-risk patients, such as those with preoperative hydronephrosis, renal scarring, and ureteral tapering, postoperative voiding cystography may be indicated to assure resolution of vesicoureteral reflux.

Cystostomy↗
PubMed1995

Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model.

To date, laparoscopic urological surgery has largely been limited to diagnostic or ablative procedures. Herein we report our experience with laparoscopic reconstructive surgery to perform an extravesical ureteral reimplantation. Seven anesthetized pigs with iatrogenic ureteral reflux underwent a laparoscopic extravesical ureteral reimplantation. The newly created ureteral tunnel varied from 2 to 4 cm. In 3 pigs, the tunnel was created with tacking staples, while in the other 4 pigs, the tunnel was created with intracorporeal suturing techniques using a 3-zero polyglyconate running suture. The procedure required an average of 132 minutes. There was one anesthetic death. There were no urinary tract infections. At 3 to 8 weeks after reimplantation, the cystograms were repeated on 5 pigs. One of 2 stapled reimplant pigs still had reflux; 1 of 3 sewn reimplant pigs had reflux. At 6 months following the reimplantation, only 1 pig had residual grade I reflux and this was a sutured reimplantation. None of the stapled reimplantations exhibited any residual reflux on the surgical side; however, in 1 animal a submucosal staple was noted at the time of harvest.

Animals↗
PubMed1997

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves.

PURPOSE: There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. MATERIALS AND METHODS: We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. RESULTS: Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. CONCLUSIONS: Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Adolescent↗
PubMed1994

Mechanical, but not infective, pacemaker erosion may be successfully managed by re-implantation of pacemakers.

OBJECTIVE: When a pacemaker box causes erosion it is usually removed and a new pacemaker implanted at a contralateral site. In this study when there was no evidence of systemic infection an attempt was made to clean and reimplant the same pacemaker in the same site. RESULTS: Over 10 years 62 patients had pacemaker reimplantation. In 18 patients the procedure was repeated a second time. Reimplantation was successful after at least six months follow up in 38 patients (61%): in nine two attempts had been made. Mean hospital stay for all patients was 21.3 days; for patients in whom the procedure was successful it was 12.5 days and for those in whom it was unsuccessful it was 35.4 days. 31 (82%) of the 38 patients in whom reimplantation was successful had no bacterial growth from wound swabs from 17/24 (71%) patients in whom reimplantation was unsuccessful (p < 0.001). Bacteria were grown from swabs from 7/8 patients with a protruding wire compared with 9/23 patients with a protruding pacemaker (p = 0.05). Thin patients and those who were older were more likely to have successful reimplantation: neither association reached statistical significance. A clinical impression of infection was not helpful. If re-implantation had been attempted only in the patients with negative wound swabs or intact skin the success rate would have been 74% at a cost of 5010 pounds per patient compared with a cost of 6509 pounds per patient for explantation and a reimplantation of a new contralateral pacemaker. CONCLUSION: These data support the hypothesis that pacemaker erosion is caused by primary infection or by a non-infective process (probably mechanical pressure). Pacemaker erosion that is not caused by infection can be successfully managed by ipsilateral reimplantation and this approach saves money.

Adult↗