Results after surgical treatment of abdominal aortic aneurysm

During the period 1983-1993 altogether 403 patients were operated on for abdominal aortic aneurysm. The median age was 69.5 years. 246 were operated on electively whereas 58 had symptoms without rupture and 99 had ruptured aneurysm. The 30 day mortality in the three groups was 4.1, 12.0 and 28.3% respectively. The mortality in hospital was 4.5, 12.0 and 31.3% in the three groups respectively. Coronary artery disease dominated as cause of death in the group as a whole, whereas irreversible shock and complications secondary to haemorrhage were common in the group with ruptured aneurysm. There were no graft infections in this series, and only one superficial infection which healed without complications. Investigation and treatment of coronary artery disease might perhaps decrease the mortality rate in the elective group. These results form a basis against which the results of endovascular treatment should be compared.     

Reproductive performance in women with bicornuate uterus

The medical records of 21 patients with bicornuate uterus were analyzed. Thirteen patients did not undergo corrective surgery, whereas eight underwent metroplasty. The pregnancies in patients who did not undergo surgery, and the outcome evaluated. The outcome of pregnancies after corrective surgery was also analyzed. The cumulative pregnancy rates at 12 and 24 months were 67% and 95% in patients without surgical correction and 63% and 88% in patients after surgical correction. The probability of giving birth to a live-born infant with no corrective surgery was 30%, 58% and 79% for the first, second and third pregnancy respectively; the probability of giving birth to a live-born infant after corrective surgery was 71% for the first and 86% for the second pregnancy. Fertility is not impaired in patients with bicornuate uterus, but gestational capacity is. A prognostic estimate of the likelihood of giving birth to a live-born infant can be formulated according to the number of pregnancies and/or surgical correction.     

Efficacy of preoperative medical treatment in facilitating hysteroscopic endometrial resection, myomectomy and metroplasty: literature review

The evidence of the efficacy of preoperative medical treatment with danazol, gonadotrophin releasing-hormone agonists (GnRHa) or progestins in facilitating surgery and improving the long-term results of myomectomy, hysteroscopic metroplasty and endometrial resection has been reviewed. Sixteen randomized and non-randomized controlled clinical trials, published in the English literature between 1990 and 1996, were identified. In all studies comparing GnRHa or danazol versus no treatment, fluid absorption during surgery was less in subjects who underwent medical treatment independently of the drug used and the type of intervention, the reduction ranging from 142 to 572 ml. A reduction in operating time (between 2 and 25 min) was observed in both the danazol and GnRHa-treated groups in comparison with untreated controls, regardless of the type of operation (endometrial resection, myomectomy or metroplasty). With regard to long-term results, amenorrhoea tended to be more frequent in patients who received GnRHa: the pooled odds ratio (OR) of amenorrhoea for GnRHa-treated women compared with untreated controls was 2.0 [95% confidence interval (CI), 1.1-3.8]. In studies comparing GnRHa with danazol, no marked differences were observed in mean operating time, but the OR of amenorrhoea at 6-12 months after surgery was 1.9 (95% CI 1.0-3.3).     

Doppler velocimetry of the uterine arteries after hysteroscopic rollerball endometrial ablation

The aim of this study was to document the Doppler indices [pulsatility index (PI) and resistance index (RI)] of the uterine arteries in 30 patients who underwent hysteroscopic rollerball endometrial ablation for dysfunctional uterine bleeding by transvaginal pulsed Doppler sonography, and to reveal whether treatment failures (persistent menometrorrhagia) can be predicted by the blood flow characteristics of the uterine arteries in advance. On the basis of the outcome of patients at the end of the first postoperative year, the Doppler indices of the uterine arteries were meaningful 1 year after the operation when PI (1.32 +/- 0.11; mean +/- SD) and RI (0.71 +/- 0.04) in six menometrorrhagic patients were statistically different from PI (2.19 +/- 0.28; 1.95 +/- 0.36 and 1.82 +/- 0.37) and RI (0.87 +/- 0.06; 0.82 +/- 0.06 and 0.81 +/- 0.04) in normally menstruating, amenorrhoeic and hypomenorrhoeic patients respectively (P < 0.05). On the other hand, the patients who would be menometrorrhagic one year after the operation had a thicker endometrium in the first post-operative month. These findings suggest that the angiogenetic role of the persistent endometrial islands after endometrial ablation needs at some time to be reflected as changes in the Doppler parameters of the uterine arteries.     

Is estrogen necessary after hysteroscopic incision of the uterine septum?

STUDY OBJECTIVE: To evaluate the influence of estrogen after hysteroscopic incision of the uterine septum. DESIGN: Prospective, randomized, blinded study. SETTING: A national referral university hospital. PATIENTS: Fifty women in whom hysterosalpingography (HSG) showed a fundal defect and had septate uterus confirmed by laparoscopy. INTERVENTIONS: Preoperative HSG, hysteroscopic incision of the septum, and postoperative HSG. Four patients were omitted from the analysis because the angle of the uterus could not be corrected, as shown by postoperative HSG. Group 1 (23 women) received conjugated estrogen and progesterone postoperatively and group 2 (23 women) received no hormone. MEASUREMENTS AND MAIN RESULTS: The ratios of the length of the septum to the length of the uterus in the HSGs obtained preoperatively (a/b) and postoperatively (a'/b') were calculated and subtracted from each other (a/b - a'/b'). The means of the subtractions in the two groups were compared. The t test was used for statistical comparison. The results showed no statistically significant difference. CONCLUSION: Estrogen has no apparent role after hysteroscopic incision of the septum.     

Histocompatibility antigen studies in women with recurrent miscarriages and Müllerian uterine anomalies

The objective of the present study was to examine the effects of a long-acting angiotensin converting enzyme inhibitor, imidapril ((4S)-1-methyl-3-?(2S)-2-[N-(1S)-1-ethoxycarbonyl-3-phenylpropyl) amino] propionyl?-2-oxoimidazolidine-4-carboxylic acid hydrochloride), for 7 days on the cerebral blood flow autoregulatory response to hypotension in hypertensive rats. We measured the cerebral blood flow at rest and during hemorrhagic hypotension, using laser-Doppler flowmetry. At the same time, the absolute baseline cerebral blood flow values in the parietal cortex were quantified with the hydrogen clearance method. After administration of imidapril at a dose of 5 mg/kg/day for 7 days, the resting value of mean arterial blood pressure was significantly decreased by 25 mm Hg (P < 0.001), cerebral vascular resistance was lowered by 14.4% (P < 0.05) and the lower limit of cerebral blood flow autoregulation was shifted to a lower level, 106+/-11 mm Hg (mean +/- S.D.), from 137+/-8 mm Hg in the control group (P < 0.001), while resting cerebral blood flow remained unchanged. The present results demonstrated that imidapril preserves cerebral blood flow and significantly shifts the lower limit of cerebral autoregulation towards lower blood pressure levels.     

Results of surgical treatment of ruptured abdominal aortic aneurysms

This paper analyzes results of 5-year surgical treatment of patients with ruptured abdominal aorta aneurysms (1991.-1995.) at the Clinic for Vascular and Transplantation Surgery of the Institute of Surgery in Novi Sad. 105 patients with abdominal aorta aneurysm underwent surgery, whereas in 31 patients there was a suspicion of rupture and it was confirmed by US and CT examination. One of basic factors to decrease mortality in these patients is early diagnosis and surgery before hemorrhagic shock occurs. Results in hemodynamic stabile patients with blood pressure over 100 mmHg and regular diuresis are much better with mortality of 20%. In order to estimate the correlation of hemodynamic state and outcome of the operation, patients were divided into three groups--hemodynamic stable with blood pressure over 100 mmHg and regular diuresis at admission: hemodynamic unstable patients with signs of mild or moderate shock and blood pressure under 100 mmHg and without initial diuresis which was regulated at the beginning of therapy and hemodynamic unstable patients in severe shock and unmeasurable blood pressure. The highest survival rate (10% mortality) and the least complications occurred in the first group of patients. The total mortality of patients after surgery was 48.48%. Timely diagnosis, suspicion of rupture and adequate first and with urgent transfer to a competent surgical institution are key factors in treatment of this disease and its outcome.     

The surgical treatment of aneurysms of the abdominal aorta

The sputum specimens from 1363 patients at the age of 16 to 65 years with nonspecific pulmonary diseases and the pleural exudate specimens from 325 patients were tested for fungi in 1989-1994. The etiological significance of Candida was stated at a concentration of > 10(5) GFU per 1 ml of the sputum. The identification was performed by the routine methods. An increase in the rate of the fungi isolation was studied in the time course of the observation: 15.3 +/- 1.9 per cent in 1989 and 31.6 +/- 3.4 per cent in 1994. The fungi were more frequently isolated from the patients with lung abscesses (38.0 +/- 4.1 per cent of the cases). In the patients with pyothorax the fungi were isolated from the pleural exudate specimens only in 6.8 +/- 1.4 per cent of the cases. The groups of risk of the susceptibility to Candida were revealed. They included patients at the age of 21 to 30 years and above 60. Out of 484 Candida isolates 80.7 per cent belonged to C. albicans, 4.2 per cent to C. tropicalis, 2.1 per cent to C. kefyr and 1.8 per cent to C. krusei. The isolates of C. parapsilosis, C. guillermoudii, C. utilis and C. brumptii were rate. The isolates were highly susceptible to nystatin (91,8 per cent) and lowly susceptible to levorin (35.4 per cent), amphoglucamine (24.7 per cent) and ketokonazol (16.8 per cent).     

Meta-analysis of prophylactic or empirical antifungal treatment versus placebo or no treatment in patients with cancer complicated by neutropenia

OBJECTIVE: To determine whether antifungal agents given prophylactically or empirically decrease morbidity and mortality in patients with cancer complicated by neutropenia. DESIGN: Meta-analysis of randomised trials of amphotericin B, various lipid soluble formulations of amphotericin B (for example, AmBisome), fluconazole, ketoconazole, miconazole, or itraconazole compared with placebo or no treatment. SETTING: Trials conducted anywhere in the world. SUBJECTS: Patients with cancer complicated by neutropenia. MAIN OUTCOME MEASURES: Mortality, invasive fungal infection (defined as positive blood culture, oesophageal candidiasis, or lung or deep tissue infection), and colonisation. RESULTS: 24 trials with 2758 randomised patients were reviewed; the total number of deaths was 434. Prophylactic or empirical treatment with antifungals as a group bad no effect on mortality (odds ratio 0.92; 95% confidence interval 0.74 to 1.14). Amphotericin B decreased mortality significantly (0.58; 0.37 to 0.93) but the studies were small and the difference in number of deaths was only 15. Antifungal treatment decreased the incidence of invasive fungal infection (0.47; 0.35 to 0.64) and fungal colonisation (0.45; 0.30 to 0.69). For every 73 patients treated (95% confidence interval to 48 to 158) one case of fungal invasion was prevented in surviving patients. CONCLUSIONS: There seems to be no survival benefit of antifungal agents given prophylactically or empirically to patients with cancer complicated by neutropenia. These agents should be restricted to patients with proved infection and those in randomised trials. A large, definitive placebo controlled trial of amphotericin B is needed.     

The basis of surgical treatment for extensive postoperative abdominal hernia

The hernioplasty method was elaborated by the authors. The method stipulates the prosthesis of polyurethane placement in the duplicature from the hernial sac and parietal peritoneum and is sewn under the hernial defect edge, which are then sewn contactly. With the application of method elaborated 36 patients were operated on, suffering from large abdominal hernia. In 2 patients the lymphorhagia was observed in postoperative period during 9 days, in 1 the wound have suppurated and the prosthesis was removed. The late follow-up results were observed from 3 months till 3 years, the hernia recurrence was not revealed.     

The surgical treatment of hiatal hernias combined with diseases of the abdominal cavity organs

An experience with treatment of 210 patients with hiatal hernias is summarized, 162 (77.1%) of them having a concomitant pathology of the abdominal cavity. Most frequently the hiatal hernias were associated with gastroduodenal ulcers (48.6%), chronic cholecystitis (18.1%), ventral hernias (5.7%). A new method of correction of hiatal hernias is described which prevents the development of complications resulting from an extreme narrowing of the hiatus. Good long-term results were obtained in 55.9% of the patients, satisfactory--in 34.3% unsatisfactory in 9.8% of the patients, results of the isolated correction of the hiatus being worse that those obtained after the combined operations. A conclusion is made that well-grounded simultaneous operations for hiatal hernias are followed by perfect medico-social and economic effects.     

Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage

OBJECTIVE: Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension. METHODS: Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined. RESULTS: The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12. CONCLUSION: EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.     

The outlook for the surgical treatment of refractive anomalies in flight personnel

The authors discuss one of the important problems in aviation ophthalmology--correction and treatment of refraction anomaly in flying personnel. They disclose the methods of professional medical rehabilitation provided by the modern science development and analyze the surgical methods of refraction anomaly treatment with their pros and cons. Furthermore, the authors evaluate the prospects of keratotomy and excimer laser keratectomy's application for professional rehabilitation of flying personnel. In their opinion, the results of the study prove, that the problem of refraction anomaly's surgical treatment needs further research and development.     

Localized dissection of the abdominal aorta. Diagnosis and surgical treatment

Abdominal aortic dissection is a rare pathology. As far as we are concerned, only 59 cases have been reported in the English literature. In the last two years, two cases were treated at our Institution. Both were males, over 70 years of age. They were evaluated with ultrasonography, angiography (1 case) and Magnetic Resonance Imaging which showed localised dissection of the abdominal aorta with aneurysmal dilatation. They underwent surgical treatment with good results. At 1 and 2 years from operation both patients are alive and well. A postoperative ultrasonography didn't show any residual dissection.     

Results of radical surgical procedures after radiation for treatment of invasive carcinoma of the uterine cervix in a private practice

An analysis is made of the results of treatment of 96 women with carcinoma of the cervix, Stages IB and II, in a private practice. All 96 women were treated preoperatively with uterine intracavitary radium, followed 6 weeks later by Wertheim hysterectomy with pelvic lymphadenectomy. If malignant tumor was present in the lateral pelvic lymph nodes, external radiation was given postoperatively. The over-all survival rates were: Stage IB, 88% and 84% at 5 and 10 years; Stage II, 72% and 62% at 5 and 10 years. Regardless of the clinical stage, the highest survival rates were found in those patients who had no malignancy in the lateral pelvic lymph nodes and no residual cervical carcinoma. The lowest survival rates were found in those patients who had both residual cervical carcinoma and lymph node metastases.     

Severe surgical infection with no information in terms of bacteria

The incidence of bacteria caused postoperative infections was performed at the timing when bacteria or fungi is not yet detected. This period is important for management of postoperative infections. MRSA, E. faecalis, P. aeruginosa and fungi were detected with high frequency irrespective of the surgical area. After the operation of esophageal cancer, the most frequent infection was postoperative pneumonia, and the isolated bacteria was P. aeruginosa frequently. In the cases of gastric cancer, hepato-biliary-pancreas cancer and colorectal cancer, intraabdominal sepsis was the highest incidence, and the isolated bacteria was E. faecalis. In terms of intravenous catheter infection, fungus was common. Thus, it may suggest that we can identify the bacteria caused, and the management for postoperative infections was performed appropriately by using the antibiotics which have the sensitive against the expected pathogen.     

Endoscopic management of uterine perforation with the ENDO-UNIVERSAL surgical stapler

The management of an uterine perforation occurring during a D & C, in which a bleeding could not be stopped by coagulation per laparoscopiam is described. The closing of the bleeding injury in the uterus wall was performed by ENDO-UNIVERSAL-clip-instrument. The wound was closed and the bleeding stopped. The possibility to manage an uterine perforation with this simple method is reported and discussed.     

Pregnancies following treatment by GnRH-a (Decapeptyl) and myomectomy in infertile women with uterine leiomyomata

PURPOSE: Uterine leiomyomata alone are an infrequent cause of infertility. We presumed that--since the smaller the uterine size at the time of myomectomy, the greater the chances of subsequent conception--diminishing the preoperative tumor size in infertile patients with large leiomyomata prior to myomectomy should be beneficial. PROCEDURE: Decapeptyl (D-Trp6-LHRH) depot 3.2 mg was administered for a period of 3-6 months to 23 infertile women. No causes of infertility were found in these patients except for uterine leiomyomata. In 10 of the 23 patients conservative myomectomy was added to Decapeptyl treatment. FINDINGS: Following Decapeptyl treatment an average decrease in uterine volume of 57% (range: 22%-86%) was observed in all patients. In ten of the 23 patients conservative myomectomy was added to Decapeptyl treatment resulting in a further 16% decrease in uterine volume. Uterine regrowth following Decapeptyl and myomectomy was found to be significantly lower (P < 0.01) when compared with cases treated with Decapeptyl alone. Five of the ten patients treated by Decapeptyl and myomectomy achieved successful pregnancies and delivered. Among the women treated with Decapeptyl without myomectomy, only one patient conceived. CONCLUSIONS: From these findings it may be concluded that combined GnRH and myomectomy is the treatment of choice for infertile women with large uterine leiomyomata.