Emmanouil Pikoulis

Controlled resuscitation for uncontrolled hemorrhagic shock.

OBJECTIVE To test the hypothesis that controlled resuscitation can lead to improved survival in otherwise fatal uncontrolled hemorrhage. METHODS Uncontrolled hemorrhage was induced in 86 rats with a 25-gauge needle puncture to the infrarenal aorta. Resuscitation 5 minutes after injury was continued for 2 hours with lactated Ringers solution (LR), 7.3% hypertonic saline in 6% hetastarch (HH), or no fluid (NF). Fluids infused at 2 mL x kg(-1) x min(-1) were turned on or off to maintain a mean arterial pressure (MAP) of 40, 80, or 100 mm Hg in six groups: NF, LR 40, LR 80, LR 100, HH 40, and HH 80. Blood loss was measured before and after 1 hour of resuscitation. RESULTS Survival was improved with fluids. Preresuscitation blood loss was similar in all groups. NF rats did not survive 4 hours. After 72 hours, LR 80 rats (80%) and HH 40 rats (67%) showed improved survival over NF rats (0%) (p < 0.05). Rebleeding increased with MAP. Attempts to restore normal MAP (LR 100) led to increased blood loss and mortality. CONCLUSION Controlled resuscitation leads to increased survival compared with no fluids or standard resuscitation. Fluid type affects results. Controlled fluid use should be considered when surgical care is not readily available.

Arterial Reconstruction with Vascular Clips is Safe and Quicker Than Sutured Repair

BACKGROUND Non-penetrating, arcuate-legged vascular-closure staple clips made of titanium were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare vascular-closure staple clips to sutured anastomoses in common iliac arteries in a porcine model. METHODS In an experimental study, transected iliac arteries on both sides of 11 pigs were randomly assigned to end-to-end anastomosis performed with vascular-closure staple clips or interrupted 6-0 polypropylene sutures. Angiographic, macroscopic and microscopic results were assessed after 2 months. RESULTS There was no significant difference in the patency rate, tensile strength of the anastomoses, vessel diameter at the repair site, intimal thickness or wall thickness of the arteries after either method of closure. The mean (s.d.) clamp time was 19.8 (6.1) minutes for clip repair, and 36.0 (6.9) seconds for suture repair (P < 0.001). The times required for the reconstruction of the anastomoses were 17.4 (6.1) and 35.5 (7.1) minutes, respectively (P < 0.001). CONCLUSIONS Arterial anastomoses performed with vascular-closure staple clips are faster than sutured anastomoses, and result in comparable wound healing when assessed for patency, tensile strength, degree of narrowing and intimal reaction.

Arterial and venous repair with vascular clips: comparison with suture closure.

PURPOSE Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare the VCS clips with standard suture closure of arteriotomies and venotomies in common iliac vessels of pigs. METHODS In nine pigs, longitudinal 1 cm iliac arterial and venous incisions were repaired with VCS clips on one side and continuous 6-0 polypropylene suture on the other, and the macroscopic and microscopic results were assessed after 3 months. RESULTS The time required for vessel repair was significantly shorter with clips than with sutures both in arteries (51 +/- 9 vs 414 +/- 36 seconds) and in veins (100 +/- 32 vs 439 +/- 45 seconds). There was no significant difference in the inner diameter, intimal thickness, or intima-to-media height ratios of the arteries or veins after either method of closure. CONCLUSIONS Repair of 1 cm incisions in small-diameter arteries and veins with VCS clips results in wound healing as good as that achieved with standard suture closure, when assessed for patency, leakage, degree of narrowing, and intimal reaction. The time required for clip closure is considerably shorter than for suture closure.

Surgery for Renal Artery Aneurysms: A Combined Series of Two Large Centers

Objective: To review the clinical features and results of surgical treatment of renal artery aneurysms from two large centers. Patients and Methods: A retrospective analysis of 21 hypertensive patients with renal artery aneurysms operated in two centers during a 24-year period was performed. Results: The presenting symptom was subcostal or flank pain in 8 (38%) and hematuria in 5 (24%) cases. A ring-like calcification was seen on plain X-ray in 6 (29%) cases. All patients were evaluated with renal angiography showing a saccular aneurysm in 13 cases (62%), fusiform in 5 (24%) and dissecting in 3 (14%) cases. All saccular aneurysms were treated with resection followed by reconstruction with vein patch in 10 cases, and with and end-to-end anastomosis in 3 cases. All fusiform and dissecting aneurysms were managed with resection and reconstruction using aortorenal bypass. There was no hospital mortality or significant morbidity. During a follow-up ranging from 6 months to 23 years, there was definite cure of hypertension in 14 (67%) patients and improvement of blood pressure levels in 4 (19%) patients. Three patients continued to be hypertensive. Conclusion: Surgery for renal artery aneurysms can be accomplished with good results and should be considered for patients with aneurysms greater than 2 cm, for aneurysms causing renovascular hypertension, significant stenosis, flank pain, or hematuria, for dissecting, expanding and thrombotic aneurysms, and in women with a potential for pregnancy. However, all aneurysms cannot and should not be treated surgically.

Rapid Arterial Anastomosis with Titanium Clips

BACKGROUND The obvious advantages of rapid arterial anastomoses have prompted the continuing search for more rapid anastomotic techniques to complement the standard sutured anastomosis. Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses. The purpose of this study was to compare VCS clips with sutured arterial end-to-end anastomosis in larger vessels. METHODS In 6 pigs, transacted iliac arteries were reanastomosed with VCS clips on one side and continuous 6-0 polypropylene suture on the other. RESULTS The reconstruction time was 8.4+/-5.2 minutes for clip closure and 12.0+/-6.6 minutes for suture closure (P = 0.033). All vessels were patent half an hour after completing the anastomoses with no signs of early thrombosis. CONCLUSIONS Arterial end-to-end anastomosis can be performed more rapidly with VCS clips than continuous sutures, and are potentially useful in situations where the clamp time of the vessel is critical.

Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial

OBJECTIVE Postsclerotherapy pigmentation occurs in nearly 30% of patients. Hemosiderin, from degradation of the venous thrombus, is the possible cause. The hypothesis that early removal of the thrombus may eliminate or decrease the incidence of pigmentation has not been proved or documented. The objective of this study was to investigate the effects of early microthrombectomy on incidence of postsclerotherapy pigmentation. MATERIAL AND METHODS This multicenter, randomized, controlled study involved 101 patients with varicose veins (100 women, 1 man; mean age, 46 years [range, 25-68 years]). Patients were divided into two groups, with veins 1 mm or less in diameter (group 1, n = 50) or veins 3 mm or less in diameter (group 2, n = 51). Group 1 was treated with Sotradecol (STD) 0.25%, and group 2 with STD 0.50%. In each patient, an area of varicosities was selected and divided into halves. One half was randomized to microthrombectomy and the other half served as control. Microthrombectomy was performed 1 to 3 weeks after treatment in the randomized half. Standard photographs were obtained before and 16 weeks after treatment, and were evaluated by three independent reviewers who were blinded to treatment assignments. Each reviewer received an identical set of pretreatment and posttreatment 10 x 15-cm color photographs of the study area, and completed a scoring sheet. Average of the scores was used to evaluate primary (pigmentation) and secondary (overall clinical improvement) end points. The paired t test and chi-square test were used for statistical analysis. RESULTS In group 1, microthrombectomized areas had statistically significant less pigmentation (P =.0047) and better overall clinical improvement scores (P =.0002) compared with the control side. In group 2 there was no significant difference between the two areas, but patients reported significant relief of pain and inflammation associated with postsclerotherapy thrombophlebitis. CONCLUSION In veins 1 mm or smaller, microthrombectomy reduced pigmentation and improved overall clinical results. In veins 3 mm or smaller, statistical significance was not achieved, but thrombectomy resulted in faster resolution of the postsclerotherapy pain and inflammation. On the basis of these results, microthrombectomy after sclerotherapy is recommended.

Surgical Treatment of Carotid Body Tumours

OBJECTIVE To evaluate our results of the treatment of patients with carotid body tumours. DESIGN Retrospective study. SETTING University hospital, Greece. SUBJECTS 17 patients operated on for a carotid body tumour during the past 20 years. MAIN OUTCOME MEASURES Hospital mortality and morbidity, long-term outcome. RESULTS 3 patients had temporary cranial nerve lesions postoperatively, all of which resolved within three months. One patient developed a severe stroke and died seven days postoperatively. During follow-up that ranged from 7 months to 20 years, two patients died of unrelated causes. 5 patients were lost to follow up, and the remaining 10 were doing well with no signs of recurrence at the time of writing. CONCLUSION Excision of a carotid body tumour is recommended at the time of initial diagnosis in good-risk patients to avoid the difficulty of subsequent excision of an enlarging and highly vascular tumour with possible encasement of the carotid artery.

Benign Retroperitoneal Neural Sheath Tumors in Patients Without von Recklinghausen's Disease

Benign retroperitoneal neural sheath tumors in patients without von Recklinghausens disease are quite rare and usually presented as isolated case reports. There are two types of benign neural sheath neoplasms: schwannoma and neurofibroma. Confusion exists in the nomenclature of these tumors due to the disagreement upon their cell of origin. In a collective report from two institutions, three cases with benign retroperitoneal neural sheath tumors are presented, and the histological features, diagnostic and therapeutic options are discussed.

The TNBS-induced colitis animal model: An overview

Background Despite recent advances the pathogenesis of Crohns disease remains incompletely understood. A variety of animal models have been utilized in an effort to provide further insights and develop more therapeutic options. In order to simulate, to an extent, the pathogenesis and the clinical course of the disease, TNBS induced colitis is often used. Various approaches for inducing TNBS -colitis have been described in the literature. Methods/results In this review, we sought to present the animal model of TNBS induced colitis and outline the pathogenesis, pathophysiology, clinical course and pathological characteristics of the model. Furthermore, we describe the differences among those protocols regarding types of animals and colitis induction. Data sources The MEDLINE database was thoroughly searched using the keywords: TNBS, colitis, Crohns disease, animal model. Two investigators independently reviewed the abstracts and appropriate articles were included in this review. Additional articles were gathered and evaluated. Conclusion The aim of this study was to thoroughly present an updated review of the TNBS-induced colitis protocols that are implemented by researchers.

Trauma Management in Ancient Greece: Value of Surgical Principles through the Years

This article surveys in an interdisciplinary fashion the evolution of ancient Greek medicine and traumatology in particular. In sounding out the key methods and themes of Greek medicine, we cite a range of medical treatises and correlate them to the rich evidence of ancient Greek art (iconography), which often is explicit in its depiction of the management of disease and of trauma in particular. The article begins its survey from Homer, our first source of medical information, and highlights the pioneering work of Hippocrates and the secularized professional guild of the ”sons of Aesclepius.”