Rare sequelae of blunt chest trauma

Blunt chest trauma can lead to massive retrosternal haematoma due to injury to blood vessels. A 25-year-old male showed a plain chest x-ray two hours after he had experienced a blunt impact to his sternum. The result was normal. Twelve hours later a second x-ray revealed massive effusion in his right pleural cavity. Computed tomography showed large retrosternal haematoma, but all intrathoracic arteries seemed intact. Operation revealed an injury to the left internal mammary artery. All patients with blunt chest trauma should be diagnosed by means of computed tomography because of the possibility of delayed haematoma and difficulties in assessing the severity of the trauma.Tępy uraz klatki piersiowej może prowadzić do powstania dużego zamostkowego krwiaka z powodu uszkodzenia naczyń krwionośnych. Mężczyzna w wieku 25 lat doznał tępego urazu klatki piersiowej na skutek uderzenia w mostek. Dwie godziny później w szpitalnej izbie przyjęć wykonano u niego zdjęcie klatki piersiowej, na którym nie stwierdzono nieprawidłowości. Dwanaście godzin później z powodu narastającego bólu wykonano ponownie zdjęcie klatki piersiowej, w którym widoczna była duża ilość płynu w opłucnej prawej. W badaniu tomografii komputerowej odnotowano olbrzymi krwiak zamostkowy i krwiak opłucnej, a za pomocą angiotomografii wykluczono uraz dużych naczyń krwionośnych klatki piersiowej. W doraźnej operacji wykazano uraz lewej tętnicy piersiowej wewnętrznej, którą podwiązano. Przebieg pooperacyjny był prawidłowy. Wszystkich chorych po tępym urazie klatki piersiowej należy diagnozować, stosując tomografię komputerową, ponieważ istnieje możliwość powstania krwiaka śródpiersia z opóźnieniem, który jest niewidoczny w klasycznym zdjęciu

The consequences of covering the origin of the left subclavian artery by the coated part of the thoracic stent graft in patients with aneurysm or dissection of the descending aorta

Wstęp. Zastosowanie stentgraftów w leczeniu patologii aorty zstępującej jest metodą powszechnie uznaną. Implantacja stentgraftu, podczas której pokrywa się odejście lewej tętnicy podobojczykowej (LSA) może być przyczyną wystąpienia wielu powikłań, takich jak udar, niedokrwienie rdzenia kręgowego, niedokrwienie lewej kończyny górnej oraz struktur tylnego dołu czaszki. W poniższej pracy przedstawiono częstość występowania powikłań związanych z pokryciem LSA u 60 chorych, u których podczas implantacji stentgraftu do aorty piersiowej pokryto powlekaną częścią stentgraftu odejście lewej tętnicy podobojczykowej. Dodatkowo przedstawiono analizę związku pomiędzy częstością występowania powikłań a wiekiem chorych i typem patologii aorty zstępującej. Materiał i metody. Do badania zakwalifikowano 60 chorych, 12 kobiet i 48 mężczyzn, w wieku 23–83 lat. Średnia wieku wynosiła 56 lat. Spośród badanych 21 chorych operowano z powodu tętniaka prawdziwego, 9 z powodu tętniaka pourazowego, 22 z powodu rozwarstwienia aorty typu Stanford B i 8 z powodu rozwarstwienia typu Stanford A. Chorych oceniano pod kątem występowania udaru, niedokrwienia rdzenia kręgowego oraz objawów niedokrwienia struktur tylnego dołu czaszki oraz niedokrwienia lewej kończyny górnej. Częstość występujących objawów analizowano w podgrupach wyodrębnionych na podstawie patologii aorty będącej przyczyną operacji (tętniak prawdziwy, tętniak pourazowy, rozwarstwienie typu Stanford A i rozwarstwienie typu Stanford B) oraz w podgrupach wiekowych. Wyniki. Spośród 60 badanych chorych u żadnego pacjenta nie obserwowano niedokrwienia rdzenia. U 2 chorych (3,3%) odnotowano udar odwracalny (RIND) u 1 pacjenta (1,6%) — udar trwały. Objawy typowe dla zespołu podkradania, takie jak zawroty głowy, występowały u 10 (16,7%) chorych, zaburzenia równowagi u 2 (3,3%) chorych oraz osłabienie siły mięśniowej u 32 (53,2%) chorych, a gorsze ucieplenie dłoni u 26 (43,3%) chorych. W żadnym przypadku nie obserwowano bólu lewej kończyny górnej, ani spoczynkowego, ani wysiłkowego. Analiza statystyczna wykazała, iż nie istnieje związek pomiędzy wiekiem, ani typem patologii a częstością występowania powikłań. Wnioski. Pokrycie odejścia lewej tętnicy podobojczykowej jest procedurą bezpieczną. W większości przypadków chorzy nie wymagają operacji poprawiającej napływ do lewej tętnicy podobojczykowej. Acta Angiol 2011; 17, 4: 251–263Background. The usage of thoracic endografts in the treatment of thoracic aortic lesions is a universally recognized method. Intentional coverage of the left subclavian artery during deployment of the endograft could be associated with several complications such as stroke, spinal cord ischaemia, left arm ischaemia, and vertebrobasilar ischaemia. This study presents the incidence of complications associated with LSA coverage in 60 patients with LSA covered during placement of thoracic endograft. Additionally, the relationship between incidence of complications and factors such as age and type of pathology is analysed. Material and methods. Sixty patients were qualified to the study, 12 women and 48 men between the ages of 23 and 83 years. The mean age was 56 years. A total of 21 patients were operated on for true aneurysm, 9 for post-traumatic aneurysm, 22 for Stanford B dissection, and 8 for Stanford A dissection. Patients were assessed in terms of presence of stroke, spinal cord ischaemia as well as symptoms associated with left arm ischaemia and vertebrobasilar ischaemia. The incidence of present symptoms was analysed in separate subgroups based on the type of pathology of the aorta due to which patients were operated (true aneurysm, traumatic aneurysm, Stanford type A dissection, and Stanford type B dissection) and age subgroups. Results. In none of the 60 patients enrolled for the study spinal cord ischaemia was observed. Two cases (3.3%) of reversible stroke (RIND reversible ischaemic neurological deficit) and one case (1.6%) of stroke (complete ischaemic stroke CIS) were observed. Regarding symptoms typical for subclavian steal syndrome, dizziness occurred in 10 patients (16.7%), vertigo in 2 patients (3.3%), left arm weakness in 32 patients (53.2%), and coldness — in 26 patients (43.3%). Neither rest pain nor pain after exercise was observed in any case. Statistical analysis did not show any connection between the incidence of complications and age or type of pathology for which the patient had been operated. Conclusions. Planned coverage of the LSA is a safe procedure. In most of cases patients with covered LSA did not require any further reconstructions. Acta Angiol 2011; 17, 4: 251–26

Adrenal-sparing surgery for a hormonally active tumour — a single-centre experience

Introduction: Surgeries that spare the adrenal cortex during adrenalectomy have profound justification. Indications for this type of surgery are fairly strict, and more than 30 years of observations continuously verify the results of the procedure. Material and methods: Of a total of 650 adrenalectomies, 22 (3.4%) were adrenal cortex-sparing surgeries. There were 16 women and six men in this group. In 10 cases, surgery was performed for pheochromocytoma, eight cases involved Conn’s syndrome, and in four cases — paragangliomas located in the para-adrenal region. Secretory activity was identified in all cases. Results: Laparoscopic partial adrenalectomy was performed in 20 patients. Conversion to open laparotomy was necessary in two cases. In patients after bilateral resection of pheochromocytoma surgery, glucocorticoids were supplemented for six weeks. No significant surgical complications were observed in this group. Conclusions: Partial adrenalectomy for minor lesions should be a much more commonly utilised treatment method (of choice). Where bilateral adrenalectomy is necessary, a sparing procedure on one side protects patients from the need for hormonal substitution. The remaining part of the adrenal gland undertakes satisfactory secretory function after six weeks at the latest.

Skuteczność jednostronnej adrenalektomii laparoskopowej w hiperkortyzolemii i subklinicznym zespole Cushinga niezależnych od ACTH — badanie retrospektywne na dużej kohorcie

Introduction: To assess the effectiveness of early unilateral laparoscopic adrenalectomy in ACTH-independent and subclinical hypercor­tisolaemia. Material and methods: We conducted a unicentric, retrospective study. Between 2010 and 2015, 356 laparoscopic adrenalectomies were performed in the Department of General and Endocrine Surgery of the MUW. Hypercortisolaemia was found in 50 (14%) patients, while overt hypercortisolaemia was found in 31 patients. In the hypercortisolaemia group, ACTH-dependent hypercortisolaemia was diagnosed in five (10%) and ACTH-independent hypercortisolaemia in 25 patients (50%). One patient with overt hypercortisolaemia had cancer of the adrenal cortex. The remaining 19 (38%) patients had subclinical Cushing’s syndrome. For our study, we compared patients with ACTH-independent hypercortisolaemia (n = 25) with those with Cushing’s syndrome (n = 19). Patients with ACTH-dependent hyper­cortisolaemia (n = 5) and the patient with cancer of the adrenal cortex (n = 1) were excluded. Results: Patients from both groups (n = 44) underwent a unilateral transperitoneal adrenalectomy. Good early outcomes were observed in 42 patients (93.3%). In one patient, an additional laparoscopic surgery was necessary on postoperative day 0 due to bleeding. In another patient, on day 22 post-surgery, we found an abscess in the site of the excised adrenal gland, which was drained under laparoscopic guid­ance. In three patients (6.8%) with substantial obesity, temporary respiratory insufficiency of varying degrees occurred. We did not observe any thromboembolic complications. All patients with overt hypercortisolaemia and nine patients with subclinical hypercortisolaemia had secondary adrenal insufficiency postoperatively. Conclusions: Transperitoneal unilateral laparoscopic adrenalectomy is an efficient and safe treatment option in patients with ACTH- -independent hypercortisolaemia, both overt and subclinical.Wstęp: Celem pracy była ocena skuteczności wczesnej jednostronnej adrenalektomii laparoskopowej w niezależnej od ACTH i subkli­nicznej hiperkortyzolemii. Materiał i metody: Przeprowadzono jednoośrodkowe, retrospektywne badanie. W latach 2010–2015 wykonano 356 adrenalektomii laparoskopowych w Klinice Chirurgii Ogólnej i Endokrynologicznej Warszawskiego Uniwersytetu Medycznego (WUM). Hiperkortyzo­lemię stwierdzono u 50 pacjentów (14%), natomiast jawną hiperkortyzolemię u 31 pacjentów. W grupie pacjentów z hiperkortyzolemią, hiperkortyzolemię ACTH-zależną zdiagnozowano u pięciu (10%) pacjentów, natomiast ACTH-niezależną u 25 (50%) pacjentów. U jednego z pacjentów z jawną hiperkortyzolemią stwierdzono raka kory nadnerczy. U pozostałych 19 (38%) pacjentów stwierdzono subkliniczny zespół Cushinga. Dla celów niniejszego badania, porównano pacjentów z ACTH-niezależną hiperkortyzolemią (n = 25) z pacjentami z zespołem Cushinga (n = 19). Z badania zostali wykluczeni pacjenci z ACTH-zależną hiperkortyzolemią (n = 5) oraz pacjent z rakiem kory nadnerczy (n = 1). Wyniki: Pacjentów z obu grup (n = 44) poddano jednostronnej adrenalektomii przezotrzewnowej. Dobre wczesne wyniki leczenia zaob­serwowano u 42 pacjentów (93,3%). U jednego z pacjentów konieczna była dodatkowa operacja laparoskopowa z powodu krwawienia w 0. dobie pooperacyjnej. U innego pacjenta, w 22. dobie pooperacyjnej, wykryto ropień w miejscu wyciętego gruczołu nadnerczowego, który został odsączony pod kontrolą laparoskopową. W przypadku trzech pacjentów (6,8%) ze znaczną otyłością, wystąpiła przejściowa niewydolność oddechowa o różnym stopniu nasilenia. Nie zaobserwowano żadnych powikłań zakrzepowo-zatorowych. U wszystkich pacjentów z jawną hiperkortyzolemią oraz u dziewięciu pacjentów z subkliniczną hiperkortyzolemią stwierdzono wtórną niewydolność nadnerczy po operacji. Wnioski: Jednostronna laparoskopowa adrenalektomia przezotrzewnowa jest skuteczną i bezpieczną opcją leczenia pacjentów z ACTH­-niezależną hiperkortyzolemią, zarówno jawną jak i subkliniczną

Original method of treatment applied to the patent with rupturing thoracoabdominal aortic aneurysm, multi-organ insufficiency and advance limb ischemia

W pracy przedstawiono niekonwencjonalny sposób leczenia chorego z pękającym tętniakiem aorty piersiowo-brzusznej II typu Crawforda, niedomogą wielonarządową oraz głębokim niedokrwieniem kończyn dolnych, spowodowanym rozwarstwieniem i zakrzepicą tętniaka w segmencie podnerkowym. Ze względu na zbyt wysokie ryzyko powikłań, wcześniej zrezygnowano z operacji resekcyjnej. Nowe okoliczności — pękanie tętniaka i bóle spoczynkowe kończyn wymusiły podjęcie próby oryginalnego leczenia. Z kilku protez naczyniowych skonstruowano układ, który wszyto do worka zakrzepniętego tętniaka aorty brzusznej. Odnogi przeszczepów zespolono z tętnicami nerkowymi, krezkową górną i obiema udowymi. W kolejnym etapie, przez ramię techniczne wszytego układu, sforsowano miejsce niedrożności i wprowadzono do aorty piersiowej wielosegmentowy stent-graft. Umożliwiło to wyłączenie tętniaka i odtworzenie napływu krwi do nerek, trzewi oraz kończyn dolnych. Na zakończenie niezbędne okazało się wykonanie dodatkowego zespolenia krezkowo-trzewnego. Przebieg pooperacyjny, poza przejściowym pogorszeniem funkcji nerek, był niepowikłany. W rok po operacji stan pacjenta był zadowalający. W dostępnej bibliografii nie ma opisu podobnego przypadku.Presented is nonconventional method of treatment of patent with rupturing thoracoabdominal aortic aneurysm (Crawford type II), with multi-organ insufficiency and critical ischemia lower extremities due to dissection and thrombosis in the infra-renal part of an aneurysm. Due to high risk for surgery the patient was previously disqualified from the surgical treatment. On the new circumstances, that is the rupturing of an aneurysm and rest pain extremities forced us to try, to give it a chance for original method of treatment. From several vascular prostheses a special system of branches was constructed, it was then anastomosed by one and into coagulated sack of infra-renal part of an aneurysm. The branches of this system were then anastomosed with the renal arteries, mesenteric superior artery and with both common femoral arteries. In the second step through the technical branch of the system (conduit), the multi-segmented stent-graft was forced through the occluded aneurysm, thus restoring the blood flow to the kidneys, abdominal viscera and lower extremities. At end of the procedure there was a need for additional mesenteric to celiac anastomoses. In postoperative period transient functional renal impairment was observed, with no other adverse complications. After 12 months follow up the patient was found in the satisfactory condition. In bibliography there is a lack of description of the similar case

The role of computed tomography in the diagnostics of diaphragmatic injury after blunt thoraco-abdominal trauma

BACKGROUND: Diaphragmatic injuries occur in 0.8-8% of patients with blunt trauma. The clinical diagnosis of diaphragmatic rupture is difficult and may be overshadowed by associated injuries. Diaphragmatic rupture does not resolve spontaneously and may cause life-threatening complications. The aim of this study was to present radiological findings in patients with diaphragmatic injury. MATERIAL AND METHODS: The analysis of computed tomography examinations performed between 2007 and 2012 revealed 200 patients after blunt thoraco-abdominal trauma. Diaphragmatic rupture was diagnosed in 13 patients. Twelve of these patients had suffered traumatic injuries and underwent a surgical procedure that confirmed the rupture of the diaphragm. Most of diaphragmatic ruptures were left-sided (10) while only 2 of them were right-sided. In addition to those 12 patients there, another patient was admitted to the emergency department with left-sided abdominal and chest pain. That patient had undergone a blunt thoracoabdominal trauma 5 years earlier and complained of recurring pain. During surgery there was only partial relaxation of the diaphragm, without rupture. The most important signs of the diaphragmatic rupture in computed tomography include: segmental discontinuity of the diaphragm with herniation through the rupture, dependent viscera sign, collar sign and other signs (sinus cut-off sign, hump sign, band sign). RESULTS: In our study blunt diaphragmatic rupture occurred in 6% of cases as confirmed intraoperatively. In all patients, coronal and sagittal reformatted images showed herniation through the diaphragmatic rupture. In left-sided ruptures, herniation was accompanied by segmental discontinuity of the diaphragm and collar sign. In right-sided ruptures, predominance of hump sign and band sign was observed. Other signs were less common. CONCLUSIONS: The knowledge of the CT findings suggesting diaphragmatic rupture improves the detection of injuries in thoraco-abdominal trauma patients

Results of General Surgical Treatment of Patients Over 80 Years of Age in Single-Site Experience

The aim of the study was to evaluate the results of general surgical treatment of patients over 80 years of age.Material and methods. Three hundred and four patients aged 80 to 105 years with general surgical disorders, treated in 2005-2009, were retrospectively included in the study. The collected information included demographic data, coexisting diseases, the mode of admission, the diagnosis, the method and result of treatment, and also potential complications and 30-day mortality. The data were subjected to statistical analysis.Results. The study group included 186 women and 118 men. Two hundred patients (65.8%) were admitted in an emergency setting. The most common causes of immediate hospitalisation were: mechanical ileus (26.5%), gastrointestinal bleeding (22%), trauma (16%), and gall-bladder disorders (8.5%). The remaining 104 (34.2%) patients were operated upon on an elective basis. An emergency operation was required by 121 (60%) of the patients admitted in an emergency setting; the remaining ones were treated conservatively. Hernia plasties (27.5%), cholecystectomies (15.3%), colorectal resections (13.2%), strumectomies (11.2%) and endoscopies (6.1%) predominated among elective surgeries.The total number of complications and mortality were 19.4% and 14.5%, respectively. The number of complications and mortality were significantly higher in the group of patients admitted in an emergency setting (25.5% and 20.5%, respectively) than in patients admitted on an elective basis (8.7% and 2.9%, respectively), p<0.01.The mean duration of hospitalisation was 9.7 days (1 to 60 days), with a small difference between the groups of patients treated on an elective and emergency basis (8.5 and 10.4 days), p=0.181.Conclusions. The results of surgical treatment of elderly patients do not significantly differ from the results of treatment of the general population. Much worse results, coupled with a significant increase in mortality, are observed in patients admitted and treated on an emergency basis

Location and Incidence Rate of Anastomotic Aneurysms – own Clinical Material and Literature Review

Anastomotic aneurysms occurs at various levels of arterial system. Determining their location and incidence rate required investigation of large patient clinical material. Material and methods. In the years 1989-2010 in local centre 230 anastomotic aneurysms were operated in 180 patients. Results. For 187 (81.3%) patients anastomotic aneurysms were localised in the groin, while for remaining 43 (18.7%) they occurred in other localisations. In aortic arch branch they occurred four times (1.7), in descending aorta - three times (1.3%), in abdominal aorta - 14 (6.1%) and in iliac arteries - 6 (2.6%). While for anastomosis with popliteal artery they were diagnosed in 16 (7%) patients. Own clinical material was compared with literature data. Conclusions. Anastomotic aneurysms in over 80% of cases occur in the groin, remaining percentage corresponds to other localisations

Anastomotic aneurysms- 20-years of experience from one center

Anastomotic aneurysms may develop after any type of vascular surgery, in different areas of the arterial system, and require reoperation. The frequency of occurrence of the above-mentioned is estimated at 1-5%. Material and methods. During the period between 1989 and 2010, 180 patients with 230 anastomotic aneurysms were subject to surgical intervention at the Department of General and Thoracic Surgery, Warsaw Medical University. The study group comprised 21 (11.7%) female and 159 (88.3%) male patients, aged between 30 and 87 years (mean age - 62.8 years). In relation to the number of anastomoses aneurysms were diagnosed in 2.1% of cases. Twenty-four (10.4%) patients were diagnosed with recurrent aneurysms. Results. Surgical procedures performed were as follows: artificial prosthesis implantation (119), reanastomosis (40), patch plasty (25), graftectomy (19), prosthesis replacement (9), and stent-graft (7) implantation. 195 (84.8%) aneurysms were subject to planned surgery, while 35 (15.2%) required emergency intervention. 77.8% of patients were diagnosed with aseptic aneurysms, while the remaining 22.2% with infected perioperative aneurysms. Good treatment results were obtained in 149 (82.8%) patients. Limb amputations were performed in 19 (10.5%) cases. Twelve (6.7%) patients died as a consequence of infection and general complications. Conclusions. Vascular reoperations are a difficult clinical problem and are burdened with a high rate of complications. The above-mentioned often require complex treatment, in order to improve therapeutic results