Open repair of transverse cervical pseudoaneurysm

A 40-year-old woman was referred to the vascular surgery clinic complaining of right shoulder pain and swelling secondary to blunt trauma 4 months ago. Computed tomography angiography showed a partially thrombosed supraclavicular pseudoaneurysm adjacent to the subclavian artery measuring 4.5 × 4 × 3.1 cm. Open repair surgery with resection of the pseudoaneurysm was successfully performed without injury to the capsule. Patient was stable and discharged 2 days later with no complications.

Renal-inferior vena cava fistula complicating laparoscopic cholecystectomy causing heart failure repaired endovascularly, a case report and literature review

INTRODUCTION

Renal-caval Arterio-venous fistulas are rare entity which can be acquired, idiopathic or congenital. Laparoscopic cholecystectomy complicated by arteriovenous fistula formation is extremely rare and often go unnoticed. High output heart failure can occur as a consequence of such high flow fistulas. Repair can be done through open or endovascular approach with the latter being effective and less invasive. Repair can result in resolution of symptoms and improvement of heart function.

CASE PRESENTATION

We report a 43-year old female who developed an iatrogenic renal-caval fistula following laparoscopic cholecystectomy, that was complicated by intraoperative bleeding. She presented with worsening high output cardiac failure a year post-operative. Due to past history of Cor-triatriatum surgical repair -a congenital heart disease-, the diagnosis of renal arteriovenous fistula remained insidious. The fistula was diagnosed during cardiac catheterization in an attempt to diagnose her rapidly decompensating heart failure, and repaired successfully by endovascular repair.

DISCUSSION

To our knowledge, there are only a few reports in literature describing iatrogenic renal artery-caval fistulas in association with laparoscopic cholecystectomy. Such high flow fistulas can result in a significant, potentially life threatening physiologic impairment. The case was managed by endovascular approach resulting in return to baseline cardiac function and resolution of symptoms.

CONCLUSIONS

Renocaval arteriovenous fistulas are extremely rare to complicate laparoscopic cholecystectomy. It might go unnoticed, but may present with decompensated heart failure. It can be reversed by early recognition of symptoms, and diagnosis. High index of suspicion is a key, and endovascular modality is excellent treatment approach.

Intrahepatic CD4+ T-Cell Apoptosis is Related to METAVIR Score in Patients With Chronic Hepatitis C Virus

Hepatitis C virus (HCV) infection leads to liver injury, which is thought to be immune-mediated. Apoptosis of hepatic T cells could influence histological damage. We quantified peripheral and intrahepatic T-cell apoptosis in 28 patients with chronic hepatitis C by using cytofluorometric techniques. METAVIR score and HCV plasma viral load were determined. Six liver biopsies, obtained from controls without chronic hepatitis during hepatobiliary surgery, served as controls. In patients, liver T-cell apoptosis was upregulated compared to peripheral T cells: 35 versus 7% for CD4+ and 56 versus 13% for CD8+ T cells (P < 0.001). Liver T-cell apoptosis levels from patients were increased compared to controls for both CD4+ (P = 0.041) and CD8+ T cells (P = 0.007). Nine patients exhibiting METAVIR scores A and F < or = 1 showed higher intrahepatic CD4+ T-cell apoptosis compared to the 19 patients with a higher METAVIR score (P = 0.001) and both histological activity and fibrosis were related to apoptosis level. There was also an inverse relationship between the level of intrahepatic CD8+ T-cell apoptosis and serum transaminase activity (P = 0.023). Our study shows immune compartmentalization, suggesting that the study of peripheral blood lymphocytes may not be fully relevant to the pathophysiology of HCV hepatitis, and that the severity of liver injury is inversely correlated with intrahepatic CD4+ T-cell apoptosis.

[Vaginal evisceration. Report of a new case]

Vaginal evisceration is rare and most commonly found in postmenopausal women. We report the case of a postmenopausal woman due to ruptured enterocele. Surgical treatment was done through a midline laparotomy and consisted of bowel resection with primary anastomosis and vaginal vault suture repair. Risk factors for this rare clinical entity are discussed along with the different therapeutic options.

Small bowel volvulus resulting from a congenital band treated laparoscopically

In recent years, laparoscopy has dramatically changed the approach to the patient with acute abdominal pain. We report the case of a patient with small bowel volvulus caused by a congenital band binding the greater omentum to the mesentery, which was promptly diagnosed and treated using laparoscopy. Early intervention averted irreversible ischemic lesions of the intestine and the need for bowel resection. With the routine use of laparoscopy in the setting of acute abdominal pain, rare affections can be easily diagnosed and effectively treated.

Secondary thyroidectomy in patients with prior thyroid surgery for benign disease: a study of 203 cases

BACKGROUND

The goal of this study was to evaluate the complication rate of secondary thyroidectomy in patients with prior thyroid surgery for benign disease.

METHODS

Over an 8-year period, 203 thyroid reoperations were performed on 202 patients. All information relating to operative procedures, pathology, and complications was recorded prospectively.

RESULTS

There were 24 men and 178 women with a mean age of 52 years. Prior surgery was unilateral in 136 cases (67%) and bilateral in 67 cases (33%), and 14 patients (6.9%) had more than 1 previous thyroid operation. For euthyroid or pretoxic recurrent nodular goiter, 190 reoperations were performed and 13 reoperations were performed for recurrent thyrotoxicosis. Twenty-three cancers were found in a specimen (11.4%). Completion thyroidectomy was done in 143 patients. Postoperative complications occurred in 21 patients (10.4%): recurrent laryngeal nerve palsy (7 patients), hypocalcemia (8 patients), hematoma requiring surgical evacuation (5 patients), and wound infection (1 patient). Complications remained permanent in 4 patients (2%).

CONCLUSIONS

The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low enough to allow reoperation whenever it is necessary, provided precise operative rules are respected.

[Repeated thyroid surgery. Indications and results]

OBJECTIVES

To analyze the histology results and to assess operative risk of iterative operations for thyroid surgery.

PATIENTS AND METHODS

A total of 249 re-operations were performed in 248 patients over a 6.5 year period. Two groups of patients were defined according to the indications for re-operation. Group 1: 80 patients; pathology examination of the surgical specimen discovered thyroid cancer. Group 2: 169 patients; recurrent nodular goitre after an initially benign disease.

RESULTS

In group 1, 14 cancers were bilateral (17.5%) and 7 patients had cervical node metastases (8.8%). In group 2, 19 cancers were discovered (11.1%), including 5 cases with cervical node invasion (26.3%) and 4 with visceral metastases (21.1%). Twenty complications occurred in 20 patients (8%): compressive cervical hematomas (n = 3, 1.2%), recurrent nerve palsy (n = 7, 2.8%), hypoparathyroidism (n = 9, 3.6%; including 3 definitive cases, 1.2%) and mediastinitis (n = 1). These complications were significantly more frequent in patients re-operated for hyperthyroidism or those who had a past history of more than one cervicotomy.

CONCLUSION

The frequency of bilateral cancer justifies completing thyroidectomy after partial thyroidectomy. The rate of definitive complications after re-operations is greater than first line cervicotomy but is low enough to allow iterative surgery using rigorous procedure in selected patients.

Retroperitoneal laparoscopic nephrectomy in children: preliminary report of six cases

Laparoscopic nephrectomy is a new procedure that must be evaluated in adults and children. This technique allows a reduction in complications and sequelae. The majority of indications, such as renal dysplasia and destroyed kidneys due to obstructive or refluxing uropathy, are suitable for laparoscopic nephrectomy. Contraindications are Wilms' tumor and trauma, which represent only 20 percent of nephrectomies in our experience. As in open surgery, to perform nephroureterectomy for benign disease, a retroperitoneal approach seems more logical than transperitoneal approach, which is the usual approach for laparoscopic surgeons. We have attempted six retroperitoneal laparoscopic nephrectomies in children from 3 months to 14 years old. The patient is positioned in a lateral position after creation of a retropneumoperitoneum under visual control; three or four ports are needed and renal vessels are dissected then clipped, or coagulated if small. Destroyed kidneys are generally of small size, so they can be extracted via a 10- or 12-mm cannula site without morcellation. Operative time ranges from 35 to 210 mm (median 120 mm). We have had no complications or conversions. Retroperitoneal laparoscopic nephrectomy in children is a feasible and safe procedure in well-trained hands.