Significance of ligature of early detected insufficient perforated lower extremities veins as a cause of the varicous syndrome

Background/Aim. Perforated veins (PV) connect surface and deep veins net. Insufficient perforated veins (IPV) are considered to be one of the causes of the venous stasis syndrome. Ligating IPV removes increased pressure transmission from the deep veins to the surface veins system and prevents the occurrence of varicosis, as well. The aim of the study was to determine surface veins diameters prior and after the surgical operation on IPV, and to confirm good results of the treatment with this method in removing causes of the surface veins varicosis. Methods. The study included 30 patients of both sexes (25 males and 5 females), mean age 30.10 ± 10.24 years. The patients were classified in accordance with CEAP (clinical severity, etiology or cause, anatomy, pathophysiology) classification as those with the initial varicous syndrome based on IPV. Any of the patients were submitted to color Doppler echophlebography. In case of diameter ≥ 3.5 mm PV were marked as IPV. All of the IPV were divided into two groups, the group I being with ostium in the stem of Vena Saphena Magna (VSM) or Vena Saphena Parva (VSP), while the group II was with ostium in the venous tributors. VSM and VSP diameters at the level of IPV ostium, bellow and above (1 cm) the ostium were measured prior to IPV ligature, and 30 days after the surgical intervention. Results. Comparing the results the highest ligature effects were shown at the level of IPV ostium in the stem of VSM and VSP of both groups (p < 0.0001) with the highest diameter reduction. There was a smaller reduction of diameter in the proximal and distal segment of ostium in the group I, while there was no diameter change in the distal segment of ostium in the group II. Conclusion. Saphenous stem diameter reduction at the level of ostium, proximally and distally of the confluence, confirms the significance of IPV ligature before pronounced varicosis appears

External transluminal drainage of the pancreatic duct due to fistula caused by postbioptic pancreatic necrosis

Background. Pancreatic fistulas are not frequent after the needle biopsy of the pancreatic head. The aim was to present a patient with this type of fistula who was managed using the surgical method never previously applied in our surgical practice. Case report. In our patient, pancreatic fistula appeared at the site of the needle biopsies due to the development of the necrosis. Since the conservative treatment with octreotide and the total parenteral nutrition were without result, we turned to the surgical treatment by placing a silicone prosthesis along the pancreatic duct into the duodenum, next through the Roux-en-Y flexure to provide the external drainage of a pancreatic juice. Postoperatively, applying the conservative treatment, pancreatic fistula disappeared, and a silicone prosthesis was removed three weeks later. Conclusion. The described surgical procedure can be successful in managing fistulas which occur after the pancreatic necrosis

Innominate artery war injury

Aim. A case is reported of successfully surgically treated explosive war injury to the innominate artery. Case report. A 26 - year-old soldier was injured in combat by a fragment of mortar shell. In the field hospital, the wound gauze packing was applied, followed by orotracheal intubation and thoracic drainage. The soldier was admitted to MMA six hours later. Physical examination, on admission, revealed huge swelling of the neck, the absence of pulse in the right arm and the right common carotid artery. Chest x-ray revealed hemopneumothorax of the right side and the foreign metal body in the projection of the right sternoclavicular joint. Due to the suspicion of large vessel injury, a median sternotomy was immediately performed. Surgery revealed disrupted bifurcation of the right innominate artery, so the ligation was performed. Aortography was performed postoperatively, followed by the reconstruction of innominate bifurcation with synthetic grafts. Control aortography showed good graft patency, and the patient was discharged from the hospital in good general condition with palpable pulses and mild anisocoria as a sole neurological sequela. Conclusion. A rare and life-threatening injury was successfully managed, mainly due to the rational treatment carried out in the field hospital that helped the injured to survive and arrive to the institution capable of performing the most sophisticated diagnostic and therapeutic procedures

Significance of the determination of doppler sonography haemodynamic indices for the assessment of distal perfusion in patients with critical ischemia of lower limbs

Background/Aim: The perfusion of tissue, especially the muscles of the lower limbs (LL), implies the blood flow that carries enough nutrition, energy materials and oxygen. The aim of this study was to determine whether the decreased Doppler sonography parameters, resistance index (RI), and pulsatility index (PI) were significant as indicators of irreversible ischemia of LL. Methods. In 40 patients (mean age 66±14.9 years, 21% women and 79% men) with the signs of critical ischemia of LL, Lariche-Fontaine class III and IV, we performed contrast angiography of the LL arteries, and perfusion scintigraphy of LL using, thallium-201, while we performed Doppler sonography to determine resistance index (RI), as well as pulsatility index (PI). After that, all the patients were treated with vasodilatation using Bergmann's solution within a 10-day period. Following that, all the patients underwent the determination of haemodynamic indices RI and PI applying the methods of Doppler sonography. The obtained values of RI and PI indices revealed no clinical recovery which suggested the irreversibility of critical ischemia (unsuccessful therapy in 100% of the patients), and clinical recovery which suggested the reversibility of the disease (unsuccessful therapy in 80% of the patients). Results. The obtained values of PI = 0-0.3 and RI = 0-0.25 for the examined LL arteries were the indicators of irreversible ischemia. A significant correlation between the values of RI in the distal parts of a. tibialis anterior and posterior was proved, as well as between the decreased perfusion of LL determined by tallium-201 (p < 0.05, r = 0.43), and a tibialis anterior (p = 0.05, r = 0.38). There was, however, no statistically significant correlation between the angiographic values and perfusion scintigraphy of LL. Conclusion. The obtained values of haemodynamic RI and PI indices should be a novel approach for introducing a new criteria for the assessment of reversible and irreversible critical ischemia of LL using the method of Doppler

Living unrelated donor kidney transplantation: A fourteen-year experience

Background. In countries without a national organization for retrieval and distribution of organs of the deceased donors, problem of organ shortage is still not resolved. In order to increase the number of kidney transplantations we started with the program of living unrelated - spousal donors. The aim of this study was to compare treatment outcome and renal graft function in patients receiving the graft from spousal and those receiving ghe graft from living related donors. Method. We retrospectively identified 14 patients who received renal allograft from spousal donors between 1996 and 2009 (group I). The control group consisted of 14 patients who got graft from related donor retrieved from the database and matched than with respect to sex, age, kidney disease, immunological and viral pretransplant status, the initial method of the end stage renal disease treatment and ABO compatibility. In the follow-up period of 41 ± 38 months we recorded immunosuppressive therapy, surgical complications, episodes of acute rejection, CMV infection and graft function, assessed by serum creatinine levels at the beginning and in the end of the follow-up period. All patients had pretransplant negative cross-match. In ABO incompatible patients pretransplant isoagglutinine titer was zero. Results. The patients with a spousal donor had worse HLA matching. There were no significant differences between the groups in surgical, infective, immunological complications and graft function. Two patients from the group I returned to hemodialysis after 82 and 22 months due to serious comorbidities. Conclusion. In spite of the worse HLA matching, graft survival and function of renal grafts from spousal donors were as good as those retrieved from related donors