Letterio Barbera

Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease

PURPOSE The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease. METHODS From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures. RESULTS Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 +/- 49 minutes for IFB, 218 +/- 54 minutes for UAFB, 279 +/- 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 +/- 49 ml for IFB, 390 +/- 316 ml for UAFB, 563 +/- 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis. CONCLUSION Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease.

Detection of Chlamydia pneumoniae but not of Helicobacter pylori in symptomatic atherosclerotic carotids associated with enhanced serum antibodies, inflammation and apoptosis rate ☆

BACKGROUND AND PURPOSE Numerous seroepidemiological and pathological studies linked Chlamydia pneumoniae and Helicobacter pylori with atherosclerosis. However, analyses of these infectious agents in the pathogenesis of stroke are either lacking or contradictory. Therefore, we evaluated the detection rate of C. pneumoniae and H. pylori in normal carotids vs. atherosclerotic carotids and compared these findings with serology, plaque morphology, inflammatory cell infiltrates and apoptosis rate. METHODS The study was performed on 40 morphological normal carotids from autopsy and 20 advanced atherosclerotic carotids from endarterectomy after stroke. Serum IgG antibody titre was measured by enzyme immunoassay (H. pylori) and microimmunofluorescence (MIF) technique (C. pneumoniae). Immunohistochemistry (IHC) and Western blotting were performed to identify C. pneumoniae, H. pylori, to characterize plaque morphology (macrophages and smooth muscle cells) and the inflammatory infiltrate (T- and B cells) and to detect apoptosis (TUNEL staining). RESULTS C. pneumoniae was found significantly more frequently in atherosclerotic than in normal carotids (P=0.001), which correlated with elevated C. pneumoniae IgG-antibody titres (P=0.048). Although H. pylori was not detected in carotids, elevated H. pylori antibody titres were significantly associated with the degree of atherosclerosis (P=0.001). The C. pneumoniae infected carotids displayed a slightly enhanced infiltrate of T cells and apoptosis rate, but no morphological changes. CONCLUSION C. pneumoniae but not H. pylori, was detected by IHC primarily in symptomatic carotids, without specific morphological differences. Correlation of C. pneumoniae in-situ-detection and IgG antibodies suggested a possible connection between respiratory-tract and endovascular infection. The C. pneumoniae associated T-lymphocytes and apoptosis rate indicate an immune-mediated inflammatory process, involving vascular walls.

Ultrasound elastography for the age determination of venous thrombi: Evaluation in an animal model of venous thrombosis

The exact age determination of venous thrombi is important if thrombolytic therapy or surgical thrombectomy is considered. Clinical symptoms as well as duplex-ultrasound and phlebography are unreliable in this respect and do not allow an exact age estimation. Ultrasound elastography can provide information about the elastic properties of thrombi. Since thrombus elasticity decreases with age due to the organisation process, it should be possible to use elastography to stage the degree of organisation and thereby determine the age of venous thrombi. Experimental venous thrombi aging 1, 3, 6, 9, 12 and 15 days were created in a porcine model by laparoscopic ligation of the infrarenal Vena cava in combination with transfemoral infusion of thrombin. The thrombosed iliac veins were explanted and embedded in gelatine, after that they underwent examination by ultrasound elastography. In addition, histological evaluation of the thrombi was performed. Elastography demonstrated a decline in thrombus elasticity between days 6 and 12 with the 12-day-old thrombi being about 3 times harder then the 6-day-old thrombi. This correlated with the histological findings, which demonstrated a marked increase in fibroblast and collagen production in the clots during this time, with the 12- and 15-day thrombi showing signs of advanced organisation. In conclusion, in an experimental setting, ultrasound elastography was helpful in determining the exact age of venous thrombi. The differences in elasticity were most pronounced between days 6 and 12, which is also the most relevant time frame when considering invasive therapies in human venous thrombosis.

The clonality of nodules in recurrent goiters at second surgery

Introduction: Some studies showed that in multinodular goiters clonal and polyclonal nodules coexist. The clonality of nodules in recurrent goiters is, however, still unknown and may contribute to help explain the pathogenesis of this thyroid disease. Methods and results: The clonality of 14 nodules derived from recurrent goiters was assessed by means of an X-chromosome-inactivation method. Of 14 nodules, 10 showed a polyclonal pattern, 3 were clonal and, in 1 case, the result remained unclear. The mean age of the patients with recurrent goiter at the time of their first operation was significantly lower than the mean age of 50 patients who underwent thyroid surgery for the first time over the same period of time (34.6±10.9 years vs 53.7±13.5 years; P<0.05). The mean interval between first and second operation was 18 years. Conclusion: The finding that nodules in recurrent goiters are predominantly polyclonal suggests that these lesions have their origin in a de novo proliferation of different cohorts of thyrocytes due to unknown growth stimulating molecular events.

Video-assisted crossover iliofemoral obturator bypass grafting: A minimally invasive approach to extra-anatomic lower limb revascularization

Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique.

Laparoscopic thrombendarterectomy of the infrarenal aorta.

The aim was to perform a totally laparoscopic thrombendarterectomy (TEA) of the infrarenal aorta to reduce the trauma connected to the surgical approach. A 52-year-old man was referred to our institution with severe claudication. Angiography revealed a subtotal stenosis of the infrarenal aorta. Because the lesion was not suitable for an interventional procedure, a TEA was planned. The surgery was performed through six ports using a transperitoneal approach with pneumoperitoneum. The laparoscopic TEA was carried out according to the standards of open vascular surgery. The surgery time was 285 minutes, the crossclamping lasted 105 minutes, and the blood loss was 100 mL. The angiographic and functional results were excellent. The patient experienced a rapid recovery and was discharged after 6 days. This case report shows the feasibility of totally laparoscopic TEA of the infrarenal aorta. The well-known advantages of minimally invasive techniques in abdominal surgery with regard to the decrease of surgical trauma may also be valid in aortic surgery for occlusive disease.

Comparison of laparoscopic aortic clamps in a pulsatile circulation model.

PURPOSE This study was designed to evaluate the fatigue characteristics and the safety and effectiveness of laparoscopic aortic clamps in a pulsatile circulation model. METHODS A heart-lung machine was used to create a pulsatile circulation model with bovine aortas resembling the vessels being cross-clamped. Four different models (A-D) of laparoscopic aortic clamps were investigated, and three identical probes of each model underwent testing. Preliminary examinations were conducted to define the size and thickness of the bovine aortas that would allow effective cross-clamping and to detect gross material or functional deficits of the clamps. Then, the instruments were placed in the circulation model, which was set at a frequency of 82/min and a pressure of 200/120 mm Hg. Each clamp was subjected to these conditions for 120 hours and was opened and closed 40 times to stimulate real-life conditions. Clamping failures and mechanical defects were recorded, and the clamp parts were afterward examined with an electron microscope. RESULTS Two clamp models had to be eliminated from the study after the preliminary examinations. All three probes of model B displayed mechanical defects after a few applications. All probes of model D were excluded because none effectively occluded the aortas. All probes of model A and one probe of model C provided effective cross-clamping during the 120-hour test phase and showed no signs of mechanical failure. Two probes of model C broke after 51 and 57 hours of testing, respectively. Both times, the defect occurred during application of the clamps. The detailed analysis of all instruments after the testing, including electron microscope imaging, revealed that several construction deficits and weak points were responsible for the mechanical failures. CONCLUSION A surprisingly high incidence of clamping failures and mechanical deficits were encountered during the testing. Of the four clamps tested, only one (model A) seemed to be safe and effective enough for routine clinical use. These disappointing results demonstrate the need for further cooperation between vascular surgeons and instrument manufacturers to develop safe and effective laparoscopic vascular clamps.

Spielt die Art der Rezidivprophylaxe für die Schilddrüsenmorphologie nach erfolgter Schilddrüsenresektion eine entscheidende Rolle? Eine prospektive, sonografisch kontrollierte Studie

Uber einen Zeitraum von 5 Jahren wurden 74 Patienten nach erfolgter Schilddrusenteilresektion nachuntersucht. Zur Rezidivprophylaxe erhielt eine Gruppe (n = 37) 100 µg l-Thyroxin tgl., wahrend die zweite Gruppe (n = 37) eine Kombination aus 100 μg l-Thyroxin und 100 μg Jodid bekam. Nach sechs Monaten wurde die Rezidivprophylaxe in beiden Gruppen mit 200 μg Jodid fortgesetzt. In der Gruppe, die bereits in der fruhpostop. Phase Jodid erhalten hatte, konnten sonographisch weniger fokale Parenchymveranderungen nachgewiesen werden (21.6% vs. 32.4%) bzw. war eine Volumenreduktion des Restgewebes von durchschnittlich 11.6 ml (3 Mon. postop.) auf 9.8 ml (60 Mon. postop.) zu finden, so dass sich ein deutlich positiver Effekt des Jodids, fruh postop. verabreicht, auf die Gewebeintegritat des Restparenchyms zeigen lies.

EFFEKT DER WACHSTUMSHEMMUNG VON SCHILDDRUSENKNOTEN DURCH JODID IN ABHANGIGKEIT DER EXPRESSION DES NA+/JODIDSYMPORTERS

Der erste Schritt der Schilddrusenhormonsynthese, der Transport des Jodids in die Schilddrusenzelle, wird durch den Natrium-Jodid-Symporter (NJS), ein transmembranoses Protein katalysiert [2]. Nachdem die Klonierung des NJS-Gens moglich geworden war [4], konnte auch dessen Expression in szintigraphisch unterschiedlichen Schilddrusengeweben untersucht werden, wobei sich eine verminderte Genexpression bei „kalten“ Knoten zeigte, wahrend Knoten mit einem erhohten Tc-Uptake eine entsprechend starkere Expression aufwiesen [1].

Die laparoskopische Anlage aortobifemoraler Bypässe

ZusammenfassungFragestellung: Entwicklung einer laparoskopischen Technik zur transperitonealen Anlage einer aortobifemoralen Bifurkationsprothese bei AVK. Methode und Patienten: In der Zeit vom 1. 2. 96 bis zum 1. 2. 98 wurden 16 Patienten der laparoskopischen Anlage einer aortofemoralen Bifurkationsprothese zugeführt. Über 6 5–12 mm große Arbeitszugänge konnten Exposition, Ausklemmung und Arteriotomie des infrarenalen Aortensegmentes mittels laparoskopischer Instrumente ausgeführt werden. Der fortlaufende End-zu-Seit-Anschluß der primär dichten Dacronprothese erfolgte ebenso vollständig laparoskopisch. Nach retroperitonealem Durchzug der Prothesenschenkel, wurden diese konventionell an den Leistenschlagadern angeschlossen. Ergebnisse: Der Eingriff konnte 13mal auf laparoskopischem Wege beendet werden; 3mal war eine Konversion zur konventionellen Operationstechnik erforderlich. Ein Patient erfuhr eine 16tägige intensivmedizinische Behandlung wegen einer respiratorischen Insuffizienz. Die mittlere Operationsdauer betrug 292±60 min bei einer Abklemmzeit von 74 ±18 min. Der Blutverlust lag bei 566±434 ml, bei 2 Patienten erfolgte eine Fremdbluttransfusion. Die regelrechte Lage und Durchgängigkeit der Bypässe wurde angiographisch dokumentiert. Die Patienten konnten durchschnittlich 9±5,8 Tage nach dem Eingriff entlassen werden. Bisher wurden 15 von 16 Patienten im nicht-invasiven Gefäßlabor nachuntersucht, alle Rekonstruktionen waren offen. Wegen einer hochgradigen Stenose am femoralen Anschluß, war in einem Fall eine Revision erforderlich. Schlußfolgerung: Die laparoskopische Anlage einer aortofemoralen Bifurkationsprothese ist möglich, sicher und effektiv. Der technisch anspruchsvolle Eingriff wird mit speziellem Instrumentarium durchgeführt, die Entwicklung eines Klammernahtgeräts sowie eines Retraktors für den Darm wird voraussichtlich den Schwierigkeitsgrad sowie die Dauer der Operation wesentlich verringern können. Möglicherweise wird diese Methode einen Beitrag zur Minimierung des Operationstraumas bei aortofemoralen Rekonstruktionen leisten können.AbstractPurpose: The aim of the study was to apply laparoscopic techniques in reconstructive procedures for aortoiliac occlusive disease. Methods: From February 1996 to February 1998, 16 patients underwent a laparoscopic aortobifemoral bypass procedure (ABF) using the transperitoneal approach. Six, 5 to 12 mm ports were needed to dissect, cross-clamp and divide the infrarenal aorta using specific laparoscopic devices. The aortic anastomosis was made end-to-side. A long curved clamp was then passed from each groin to draw the limbs of the graft into the femoral incision. The distal anastomosis was then performed conventionally. Results: The laparoscopic ABF was performed successfully in 13 of 16 cases. Three times a conversion to open surgery was requested. One patient developed respiratory insufficiency requiring prolonged treatment on the ICU. Mean operative time was 292±60 min; the aorta was crossclamped for 74±18 min. Two patients needed transfusions of red blood cells. In the study group, blood loss averaged 566±434 ml. The bypass patency and the correct positioning of the graft were assessed by angiography. The patients were discharged 9±5.8 days after surgery. At follow-up after 4.5±4 months, 15 patients were examined noninvasively in the vascular laboratory. All grafts were patent, and the ischemic symptoms had resolved in 14 patients. One patient with recurrent claudication had severe stenosis of the left distal anastomosis. Conclusions: The laparoscopic aortobifemoral bypass is a feasible, safe and effective procedure. Specific laparoscopic instruments are required for the challenging procedure. The development of vascular staplers and retraction devices will probably reduce the operative time and the technical challenge. In the future this operative technique may gain relevance as a minimally invasive procedure for severe aortoiliac occlusive disease.