George B. Kuzycz

Incarcerated Diaphragmatic Hernia With Intrathoracic Bowel Obstruction After Right Liver Donation

Liver transplantation has become an acceptable surgical procedure with the advancement of the technical and rejection considerations involved. Initially nonliving donors were used for transplantation procedures. However, with improved techniques, living donor procedures have become much more frequent. With this, complications involving the transplant organ donor may occur. We present 2 patients with intrathoracic bowel obstruction due to herniation of the small intestine and colon through a defect in the dome of the diaphragm with development of chest pain and gastrointestinal symptoms. Both patients were diagnosed by computerized tomography scan and had a right thoracotomy with lysis of the adhesions, reduction of the hernia, repair of the diaphragm, and mesh reinforcement of the diaphragm. Neither patient had a prior diaphragm defect. These patients, on review of the literature, represent the first 2 such reported cases and suggest the need to be aware of any potential diaphragm defects before closure of the abdomen after resection of the donor liver or if they develop appropriate symptomatology.

Endovascular Complications of Subclavian or Axillary Vein Cannulation

Venous access is regularly utilized for treatment and diagnosis of patients. The location of the vein and the organ that the vein serves dictates many of the procedures that might be performed with reference to that vein. Anatomically, the subclavian vein locations provide accessibility and convenience for multiple therapeutic purposes. These veins may be utilized for such procedures as central monitoring lines – both CVP and Swan-Ganz types – and for hemodialysis line access. They may also be utilized for placement of pacemaker leads or chemotherapeutic lines for port placement and chemotherapy access. Each of these procedures has its own unique characteristics and potential complication concerns.

Combination Endovascular Therapy and Open Surgery: Fogarty Tumor Embolectomy

The introduction of the balloon catheter for the removal and treatment of intravascular or intraluminal lesions in the 1960s by Dr. Thomas Fogarty initiated a widespread endovascular treatment concept for vascular or obstructive lesions. The passage of this narrow catheter through or beyond the obstructing lesion with expansion of the balloon and withdrawal of the catheter and the balloon enhanced the removal of multiple endovascular clots and emboli that, prior to that time, were unable to be or difficult to remove. The catheter technique of endovascular treatment thus initiated a new era of vascular access and therapy.

Infrarenal Abdominal Aortic Aneurysm: Aortoenteric Fistula

Aortic disease continues to be a problem for the medical community and may involve any part of the aorta from the aortic valve to the iliac vessels. The need for correction of these lesions depends on the type of lesion, the patient’s symptoms, and the risk or difficulty of repair. In the abdominal aorta, the most common lesions include aneurysmal formation (especially below the renal arteries) and total aortic occlusion due primarily to the atherosclerotic disease processes – the Leriche syndrome. These lesions occur primarily in the elderly and may present as both acute and chronic situations. The acute process usually involves acute expansion, leak, or rupture of a saccular aortic aneurysm (Fig. 31.1). The chronic problem usually is a slowly progressive expansion of an aneurysm or progressive stenosis and occlusion of the distal aorta. Both endovascular and open techniques may be used to correct the problem. However, either technique may be complicated by infection or fistula formation.

Internal Mammary Vein Cannulation during Port-o-Cath Insertion.

We read with great interest, the case report by Dr. Harish and Dr. Madhu regarding, “Inadvertent port: catheter placement in the azygous vein.”1 The authors aptly point out that this is an uncommon occurrence during central venous access. Its diagnosis is difficult with the fluoroscopy in the anterioposterior (AP) position. Indeed, even chest X-rays in the AP projection can be of little value. We have included a case of internal mammary vein cannulation during Port-o-Cath insertion in our textbook, Venous and Lymphatic Diseases.2 We have found that prompt diagnosis can be achieved with a venogram to confirm position. Furthermore, the lateral chest X-ray is often beneficial in delineating the course of the catheter. Once again, we appreciate the authors for sharing their case.

Re: "Endovascular management of arterioenteric fistulas: a systemic review and meta-analysis of the literature".

Aortoenteric or arterioenteric fistulas are lifethreatening but fortunately very uncommon lesions, so few physicians will have experience with a large number of these patients and their problems. Kakkos et al. have reviewed this high-risk problem in a systemic review and meta-analysis. Their conclusions are that (1) endovascular management of these fistulas can achieve satisfactory short and midterm results better than open surgery, (2) there is a high rate of recurrent bleeding and sepsis, and (3) further study of the role of intestinal repair is warranted. This report demonstrates the seriousness of the disease and the difficulty in treating these lesions. We have had the experience, unfortunately, of seeing a number of patients with these concerns involving the duodenum, small bowel, and colon. When the patient is at high risk for emergent surgery, it has been our belief that temporization may lead to a less risky and better result. Thus, endovascular stents have been utilized in temporizing procedures to stabilize and improve the patients’ condition. These stents, however, are intended to be temporary—weeks or months. The patient, once stabilized, is then prepared for an open surgical procedure. At surgery, the old graft and the stent are removed, and the duodenum or small bowel is closed per primum. The colon, when involved, is treated with a colostomy, and the infected vascular bed is debrided and soaked with povidone iodine and antibiotics. A new synthetic graft is then inserted in the old bed and wrapped with omentum. No subclavian-femoral grafts or oversewing of the end of the aorta are utilized. Intensive care and long-term antibiotic therapy have been successful in avoiding morbidity and mortality. We thank the authors for their extensive review of this difficult problem and presentation of a possible approach for the septic or bleeding arterioenteric fistula patient.

Visceral Arterial Obstructive Disease

The gastrointestinal tract makes up a large portion of the intracavitary abdominal organs. The arterial and venous supply of the lower esophagus, stomach, duodenum, small bowel, and colon seldom cause major ischemic problems. However, major ischemic problems are cause for significant concern when they occur on an acute basis. The chronic vascular obstructive process is much less dramatic and may go unnoticed until profound effects (e.g., weight loss and abdominal pain) take place. The liver, pancreas, and spleen may also have occlusive vascular disease on both arterial and venous bases. We concentrate in this chapter on the gastrointestinal tract and to a lesser degree on the liver and pancreas.

Non-Traumatic Thoracic Aortic Aneurysms in the Community Hospital

Aneurysms involving the thoracic aorta have been highly lethal in the past. The treatment modalities previously available have not been highly successful and have been accompanied by serious side effects. In the past few years, the surgical approach has been utilized to a much greater degree. The results of this surgery have shown continuous improvement with a decrease in both the rate of complications and mortality. Improvement in surgical technique, better defini tion of the anatomy, improved treatment of complications, and knowledge of the techniques for decreasing the incidence of problems have increased the survival of patients with this problem. Most such patients and reports of their problems and subsequent surgical results come from university or teaching centers. We, therefore, have reviewed our patients as seen in the community hospital setting and they are herein reported.