Acute carotid stent thrombosis after carotid artery stenting

BACKGROUND

Carotid artery stenting (CAS) is a reasonable alternative to carotid endarterectomy (CEA), especially in patients at high risk for surgery. Carotid artery thrombosis of the treated segment is a rare, early but potentially devastating complication of this endovascular procedure. The aim of this article is to identify and critically review cases of acute stent thrombosis reported in the literature.

MATERIALS AND METHODS

Previous trials that compared CEA with CAS were rather heterogeneous and not large enough to allow reliable conclusions. Furthermore, because there is limited follow-up information to date, the long-term effect of CAS remains unclear. Acute carotid thrombosis after angioplasty and stenting is a very rare but potentially fatal complication, and there are very few reports in the literature. This article reviews twelve cases of acute carotid thrombosis published in the English literature from eight different Vascular and Radiology Departments around the world.

RESULTS

The different ways of immediate treatment of this rare complication of acute carotid thrombosis after CAS are, open surgical procedure with thrombus removal and thromboendarterectomy with or without removing of the stent, selective local or facilitated thrombolysis with the rescue use of GPIs (glycoprotein IIb/IIIa receptor inhibitors), recanalization by instent percutaneous transluminal angioplasty with distal protection and additional stent placement on the stented portion of the internal carotid artery (ICA) in conjunction with the intravenous administration of recombinant tissue plasminogen activator (rtPA: 1300,000 IU).

CONCLUSION

Carotid artery stenting has to be performed under specific pro- and post procedure protocol from experienced endovascular specialists. The treatment of acute carotid thrombosis after CAS must be urgent and immediate in order to regain restoration of blood flow and avoid major neurological adverse events.

Dermatofibrosarcoma: a rare form of soft tissue. Management and review of the literature

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor of cutaneous origin of intermediate grade malignant potential. The incidence of DFSP is 0.1% of all cancers and 1% of all soft tissue sarcomas. We present the case of a 65years old female with a palpable, painful mass on the right thigh. A surgical excision of the lesion was done and the histopathology, as well as the immunohistochemical analysis with CD-34, confirmed the diagnosis of DFSP. Two years later, the patient is free of disease and no local recurrences or metastases have been found. Wide radical excision is the preferred surgical method for therapy of DFSP without distant metastasis. Furthermore, DFSP resists to conventional chemotherapy and radiation therapy, while, in cases of metastasis, therapy depends on cytogenesis and molecular biology of the tumor, so new therapeutic strategies are under research.

Gastrointestinal carcinoid tumors: diagnosis and treatment

Carcinoid tumors are malignancies originating from neuroendocrine cells, most commonly encountered in the gastrointestinal tract, in a rate of 64%, with the majority affecting the ileum. Certain genetic syndromes sometimes include carcinoid tumors in their phenotype. These malignancies may be rather asymptomatic, although occasionally they behave aggressively. They are typically diagnosed due to the effects of a locally advanced disease, or when producing symptoms because of hormone secretion (carcinoid syndrome). A better understanding of their molecular biology and behavior is demanded so that these tumors to be diagnosed precociously and managed effectively.

High concentrations of reactive oxygen species in the BAL fluid are correlated with lung injury in rabbits after hemorrhagic shock and resuscitation

Increased levels of cytokines or reactive oxygen species (ROS) in the bronchoalveolar lavage (BAL) fluid are associated with acute lung injury after ischemia/reperfusion. We investigated the correlation of these markers with the degree of lung injury in a rabbit model of hemorrhagic shock. Rabbits, maintained by mechanical ventilation, were left untreated (control) or subjected to hemorrhagic shock by withdrawing blood (n = 12 for each group). Shock animals were re-infused their shed blood for resuscitation. At the end of the experiment, BAL fluid was recovered, in which parameters of oxidative stress and cytokines were measured. Macrophages and malondialdehyde levels were increased (p = 0.043 and p = 0.003, respectively), and total antioxidant capacity (TAC) was decreased in the shock animals compared with control (p = 0.009). Production of ROS was significantly enhanced in shock animals compared with controls (p < 0.001). BAL fluid levels of tumor necrosis factor-alpha, interleukin (IL)-1beta and IL-6 were higher in shock rabbits by more than twofold (p < 0.001 for each). Shock animals also showed higher histopathological scores that represent severe tissue damage than controls (p = 0.022). Numbers of macrophages and levels of ROS and TAC were correlated with the degree of lung injury (p = 0.006, p = 0.02, and p = 0.04, respectively), but not cytokines. Therefore, resuscitation from hemorrhagic shock results in acute lung injury, with enhanced pulmonary oxidative and inflammatory responses. In conclusion, ROS in the BAL fluid are good markers that predict lung injury following hemorrhagic shock and resuscitation.

Insulinoma: a rare neuroendocrine pancreatic tumor

Insulinomas are functional endocrine tumors originating from the pancreatic b-cells. In 1902 Nicholls described the first adenoma of pancreatic islets, while the first insulinoma was described in 1927 in Mayo Clinic, which was dissected two years later in 1929 in Toronto. The first enucleation of insulinoma took place in a St. Jouis hospital in 1931, and after four years, in 1935, Whipple described the classic diagnostic triad: symptoms of fasting hypoglycemia or fatigue, blood glucose levels under 50 mg/dl and disappearance of symptoms after glucose administration.

Primary adenocarcinoma of the appendix: an update

Adenocarcinoid arising in the vermiform appendix is a rarity. The diagnosis of appendiceal adenocarcinoma has never been made preoperatively and is frequently an incidental finding at the time of operation for unrelated conditions. Because of the rarity of the disease, its natural history is poorly understood. Benefits from adjuvant radiation, chemotherapy, or a combination have not been reported. Most studies emphasize survival outcome based on surgical technique. There are few data and, consequently, much debate on the appropriate management of these lesions. The aim of this article is to review this entity and to assess and report new data, through a study of the literature.

The management of patients with retained foreign bodies in the rectum: from surgeon with respect

BACKGROUND

The introduction of foreign bodies into the rectum is not an uncommon medical problem. The phenomenon has increased in the homosexual population. In a 25-year period we have encountered 34 patients with retained rectal foreign bodies.

MATERIAL AND METHODS

We have performed five laparotomies due to perforation and a laparotomy in order to retrieve a large wooden object.

RESULTS

We have observed only one complication in a woman who developed a retrovaginal fistula.

CONCLUSIONS

In order to obtain successful extraction of the foreign body the surgeon, apart from the well-known techniques, must exercise a high degree of ingenuity. Finally, it should be emphasized that the appropriate respect should be shown to all patients who seek treatment for this problem.

Anthelminthic treatment: an adjuvant therapeutic strategy against Echinococcus granulosus

The main goal of the paper is to clarify anthelminthic treatment as an alternative hydatic cyst therapy, its indications and contraindications. Chemotherapy constitutes a non-invasive treatment and is less limited by the patient's status than surgery or PAIR. Many investigators have employed benzoimidazole carbonates for the management of human hydatid disease. Both, albendazole and mebendazole have, a favourable effect in patients suffering from multiorgan and multicystic disease, in inoperable primary liver or lung echinococcosis, and they can also prevent secondary echinococcosis. Chemotherapy is contraindicated for large cysts that are at risk to rupture and for inactive or calcified cysts. The main adverse events are related to changes in liver enzyme levels. The best efficacy is observed with liver, lung, and peritoneal cysts. Certain various factors influence the therapeutic results of medical treatment. The vast majority of the recurring cysts show good susceptibility to re-treatment.

Hydatid disease of the urinary tract: an update

Hydatid disease constitutes an endemic zoonosis caused by different species of the cestode Echinococcus. The main organs affected are the liver and the lungs. Echinococcosis of the urinary tract is an extremely rare medical condition, met in 2-4% of cases. This pathologic entity has to be included in the differential diagnosis of occupying lesions of the urinary tract at any age, especially among patients in endemic areas. Meticulous laboratory and imaging control when taking into consideration the suspicion for the disease, can guarantee an accurate diagnosis and successful outcome.

Mammary candidiasis. A breast infection difficult to handle

Mammary candidiasis is a disease with significant impact on breast feeding. Early diagnosis and treatment is essential for successful long-term breastfeeding. It constitutes however a significantly rare breast inflammatory entity. A case of a young woman with breast candidiasis properly diagnosed and treated in our clinic is reported.

Complications of clavicle fracture and acromioclavicular joint rupture. What the general surgeon should know

Fractures of the clavicle and acute dislocations of the acromioclavicular joint are common seen in the emergency room. Displaced or comminuted clavicle fractures and acromioclavicular joint ruptures (types III-VI) are associated with complications, such as subclavian vessels injury, hemopneumothorax, scapula-thoracic dissociation or brachial plexus paresis. Herein we discuss the usually complications seen after these injuries and underline whatever a trauma surgeon should know in order to avoid fatal situations.

Superficial parotidectomy under local anaesthesia

The modern tendency of surgery is to perform a constantly rising number of operations under local anaesthesia. Superficial parotidectomy under local anaesthesia has not been widely attempted. However only few reports show that this kind of procedure could be feasible. If this is the case, standard assessment of benign parotid tumors will change radically.

Evaluation and surgical management of the gallstone ileus. A single center experience

Gallstone ileus representing 1-4% of all bowel obstructions cholelithiasis. Impaction of a gallstone in the human of the bowel is a surgical emergency. Relief of the obstruction is the treatment of choice, but controversy exists regarding the repair of the fistula and cholecystectomy. Our experience in the management of gallstone ileus is presented in the following article.

Spontaneous bilateral subcapital hip fracture due to multiple myeloma: an 18-month follow-up

We present a rare case of bilateral subcapital hip fracture as a first sign of multiple myeloma in a young man. Right femoral neck fracture was treated by three Asnis screws and the left one by hemiarthroplasty. In order to avoid implant failure, we used zoledronic acid, a bisphosphonate compound, instead of methacrylate cement. After an 18-month follow-up, there was no evidence of avascular necrosis, no implant failure and no periprothetic fracture.

Lower extremity infections by vibrio vulnificus

BACKGROUND

Vibrio vulnificus is a Gram-negative pathogen which is found in seawater and shellfish during warm months and can cause local infections in healthy individuals or septicemia in patients with chronic liver disease.

MATERIALS-METHODS

Clinical and laboratory records of four complicated cases are presented, with a 4.2 mean year follow-up.

RESULTS

Three patients underwent urgent leg amputation because of of irreversible necrotic changes with septic complications and failure of incisional drainage to control the infection. Another one patient underwent only excision of necrotic soft tissue but he developed calcaneus osteomyelitis after three years of the initial fish bone injury.

DISCUSSION

Clinicians must maintain a high index of suspicion, especially in regions endemic for vibrio necrotising fasciitis and antibiotic prophylaxis must be given to swimmers before or during bathing.

Adrenal rupture after blunt abdominal trauma

The case of a patient, victim of a car accident, with rupture of the left adrenal gland associated with splenic rupture and liver laceration is reported. Injury of the adrenal glands is most frequently caused by blunt abdominal trauma and is usually associated with injuries of other abdominal organs. Careful exploration of the upper retroperitoneal space where adrenals are located is considered necessary during laparotomy for severe blunt abdominal trauma. If adrenal lesion has been overlooked continuous hemorrhage may occur, which could be lethal if not promptly treated.

Echinococcal cyst of the subcutaneous tissue: a rare case report

Hydatid disease is an endemic zoonosis caused by the cestode Echinococcus granulosus. The most common affected organs are the liver and the lungs. Echinococcal cyst located in the subcutaneous tissue constitutes an extremely rare manifestation of the hydatid disease. Here we present a case report with a cystic mass in the subcutaneous tissue of the left gluteal area, diagnosed as being a hydatid cyst.

Abdominal compartment syndrome: effects on organ function

Abdominal compartment syndrome (ACS) constitutes a critical clinical situation presenting a remarkable incidence being the causal factor of variable abdominal and extra-abdominal pathology, thus a rising issue of interest in intensive medical care over the past decade. Moreover, ACS as a condition potentially leading to Multiple Organ Failure (MOF), its better understanding could provide more effective management resulting to limitation of MOF incidence and mortality.

Fournier's gangrene: exists and it is still lethal

BACKGROUND

Fournier's gangrene is an aggressive form of necrotizing fascitis of the perineal, perianal or genital regions, caused by a polymicrobial infection that includes virulent organisms.

PATIENTS AND METHODS

Eleven cases of Fournier's gangrene were treated in our department during the last 20 years. Portals of entry were ischiorectal abscess, perirectal abscesses, scrotal abscess and trauma in the perianal area. The documents were analyzed according to clinical and epidemiologic patterns.

RESULTS

We dispensed systemic chemotherapy with broad-spectrum antibiotics, and performed surgical debridement for all patients. In addition, one patient was treated by local use of 100% oxygen, with excellent results in wound healing. All patients made a full recovery, except one who died of sepsis.

CONCLUSION

These cases are presented with some notes underlying the reasons for the persisting incidence and mortality of this disease.

Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review

The treatment of patients with calcific tendonitis is typically conservative, including physical therapy, iontophoresis, deep friction, local or systemic application of noninflammatory drugs, needle irrigation-aspiration of calcium deposit, and subacromial bursal steroid injection. If the pain becomes chronic or intermittent after several months of conservative treatment, arthroscopic and open procedures are available to curette the calcium deposit, and additional subacromial decompression can be performed if necessary. As an alternative, minimally invasive extracorporeal shock wave therapy (ESWT) has been postulated to be an effective treatment option for treating calcific tendinitis of the shoulder, before surgery. Herein we discuss the indications, mechanism of therapeutic effect, efficacy of treatment, and complications after ESWT application.

Changes of Bone Turnover Markers after Marathon Running over 245 km

We evaluated bone turn over markers, cortisol and parathyroid hormone (PTH) levels in male athletes after 245 km of marathon running. Sixteen athletes were studied five days before, immediately after, and 1, 3, and 5 days after the run. We used T-test and Pearson correlation for statistical analysis. Osteocalcin levels were significantly decreased from 4.6 microg/lit to 3.8 microg/lit (p < 0.05). Activity of b-ALP was significantly decreased from 66 U/lit to 61.5 U/lit (p < 0.05). PICP levels were also significantly decreased from 168 microg/lit to 153 microg/lit (p < 0.05). Hydroxyproline levels decreased after the run from 70 mmol/min to 65 mmol/min (p < 0.05). ICTP levels increased after the run but without being statistically significant, from 6.62 microg/lit to 7.0 microg/lit. Urine calcium decreased significantly by 68 %, immediately after the run. Cortisol increased from 212 ng/ml to 455 ng/ml, and PTH levels increased from 12 pg/lit to 16 pg/lit immediately after the race (p < 0.05). Cortisol levels were significantly negatively correlated with osteocalcin (r = - 0.61, p < 0.05) and b-ALP (r = - 0.98, p < 0.05). PTH levels were significantly negatively correlated only with serum osteocalcin (r = - 0.8, p < 0.05). These findings suggest a transient suppression in osteoblast function during the marathon run probably due to cortisol and PTH levels elevation.

Spigelian hernia. A rare case of bilateral hernia and presentation of our experience

Spigelian hernia is a relatively rare defect of the abdominal wall. Due to its unspecific and variable clinical presentation, presents a difficult diagnostic challenge. We present a rare case of bilateral Spigelian hernia that was diagnosed and successfully treated with open surgery and hernioplasty. Also we present our experience in management of the disease. In our department the last fifteen years, 12 cases of Spigelian hernia have been treated surgically, using direct reconstruction with excellent results.

Intrahepatic bile duct rupture of hydatid cyst: a severe complication for the patient

In most cases of echinococcal disease the liver is the mainly affected organ. The clinical manifestations are defined by the size and the localization of the hydatid cyst. The appearance of complications, such as purulence and rupture of the cyst, aggravate the patients' clinical condition. Intrabiliary rupture, although rare, carries severe health risks; timely diagnosis and appropriate management of this entity are vital for the patient's survival.

The four-year functional result after a displaced subcapital hip fracture treated with three different surgical options

According to the literature, hip function after hip fracture is affected by the type of surgery. Our aim was to determine the correlation between surgical treatment of hip fracture and postoperative function in the elderly. Inclusion criteria were displaced hip fracture and age over 70 years. One hundred and twenty-nine participants were randomly divided into three groups according to the type of the surgical operation they underwent (hemi-arthroplasty [Merete, Berlin, Germany], total arthroplasty [Plus; De Puy, Warsaw, IN, USA] and internal fixation [Richards plate screw; Smith & Nephew, Memphis, TN, USA]). The function of the patients was estimated using the following parameters: the Barthel Index and Harris Hip Score, the range of passive hip motion, the gait speed of individuals, after 1 and 4 years of follow-up. The Barthel Index scores after 4 years of follow-up were 85.3, 82.6, 80.1 after total arthroplasty, hemi-arthroplasty and internal fixation respectively. Similarly, the Harris Hip Scores after 4 years of follow-up were 83.7, 79.5 and 73.6. The range of passive hip motion in the three groups of patients did not differ significantly (p>0.05). Also, patients of the total arthroplasty and hemi-arthroplasty groups walked faster than the patients of the internal fixation group 4 years after discharge (p<0.05). In conclusion, we believe that total hip arthroplasty is the treatment of choice for displaced subcapital hip fractures in patients over 70 years old.

Hydatid disease of the parotid gland: a rare case report

A 40-year-old female suffering from hydatid disease located in the parotid gland is presented. Although Greece remains an endemic area for echinococcosis, this presentation of the disease is rare. Total excision of the cyst with partial parotidectomy was performed. The patient refused to receive general anesthesia and the operation was carried out under local anesthesia. Perioperative adjuvant medical therapy with albendazole was administered. In a two-year follow-up no recurrence has occurred.

The coexistence of carcinoma of the rectum and of ischiorectal abscess: what is the optimal therapeutic approach?

This article deals with the dilemma of the surgeon to choose the optimal surgical procedure in case of coexistence of ischiorectal abscess and a rectal carcinoma. The case of a patient suffering from ischiorectal abscess in association with rectal carcinoma is reported.

Choledochoduodenal anastomosis: a technical tip to ensure the impermeability of the anastomosis

In 1891 O. Sprengel described a successful side-to-side choledochoduodenostomy and since then this has been a method frequently used in dealing with the problem of constriction of the lower third-portion of the bile duct, due to malignant or benign causes. Taking in consideration that the first choledochoduodenostomy was performed by H. Riedel in 1888 and the patient died 9 hours after surgery due to leakage of the anastomosis (disclosed in autopsy), it is evident to conclude that hermetic anastomosis is the main factor for fast and uncomplicated recovery of the patient. In order to ensure intraoperatively a hermetic "bile-proof" anastomosis, we have applied a technical tip, which has been proved to be efficient.

Solitary hydatid cyst in the pelvis: A case report

Hydatid disease mainly affects the liver and the lungs. Pelvic involvement have been rarely reported in the literature. Herein we present a rare case of isolated hydatid cyst of pelvis attached to the urinary bladder.

Complications of thyroid surgery

Thyroid surgery has a history of significant changes in the technique and the incidence of complications. Since then continuous developments in surgical techniques and better understanding of thyroid anatomy and pathology have increased the safety of thyroid surgery and reduced the incidence of complications. Nowadays, the rate of postoperative mortality is extremely low. Nevertheless, the incidence of postoperative complications varies in literature from 7.4% to 53% of the operations performed. The most common and potentially life-threatening complications in thyroid gland surgery are vocal cord palsy and hypocalcemia. Herein we discuss the common complications in thyroid gland surgery and their proper management.

Hydatid disease of the seminal vesicle: A rare presentation of hydatid cyst

Seminal vesicle belongs to the unusual sites of the hydatid cyst presentation. Even though the patient had a history of surgically treated hydatid disease of the liver, however, solitary echinococcal cyst of the seminal vesicle is a rare condition. Surgical removal of the cyst intact is the treatment of choice.

Diagnostic and therapeutic aspects in medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a rare and particularly aggressive type of thyroid cancer with several distinctive features that distinguish its management from other thyroid cancers. Since MTC was first recognised as a distinct tumour in 1959, it became clear that MTC is more difficult to cure than differentiated thyroid cancer and has higher rates of recurrence and mortality, but it is usually a slow growing tumor compared with other malignancies. In addition, unlike differentiated thyroid cancer, there is no known effective systemic therapy for MTC.

Portal and systemic endotoxemia in abdominal operations: the significance of acute abdomen

Little evidence is available for the implication of bacterial translocation in cases of acute abdomen. Intraoperative endotoxemia in both portal and systemic circulation was studied in 20 surgical patients with acute abdomen and in 36 controls undergoing elective abdominal surgery. Blood was sampled simultaneously from a mesenteric vein immediately after opening the peritoneum and from a peripheral vein. Endotoxin was measured by a colorimetric Limulus amebocyte lysate assay and malondialdehyde (MDA) was measured by the thiobarbiturate assay and passage through a high-performance liquid chromatography (HPLC) system as a marker of the oxidative status. LPS concentrations (mean +/- SE) in portal vein blood from patients with acute abdomen was 5.69 +/- 1.58 and from patients with chronic diseases 1.05 +/- 0.07 EU/ml (P < 0.0001). Respective values for the systemic circulation were 4.98 +/- 1.47 and 1.36 +/- 0.31 EU/ml (P < 0.0001). Concentrations of MDA (mean +/- SE) in portal vein blood from patients with acute abdomen was 11.16 +/- 4.00 and from patients with chronic diseases was 10.56 +/- 2.39 mum (P NS). Positive correlations were observed between endotoxin and MDA in both portal and systemic circulation. These results indicate increased levels of endotoxin in acute abdominal conditions pointing to the gut as the site of origin of the bacterial products.