Life-saving Indications Research Articles

КЛИНИЧЕСКИЙ СЛУЧАЙ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ПЕПТИЧЕСКОЙ ЯЗВЫ ГАСТРОЭНТЕРОАНАСТОМОЗА

In the article a clinical case of surgical treatment of peptic ulcer of gastroenteroanastomosis complicated with perforation and gastrointestinal bleeding, is described. The patient was observed with the diagnosis: cholelithiasis, chronic calculous cholecystitis, for which planned laparoscopic cholecystectomy with draining of the abdominal cavity was performed. According to the discharge record, the operation ran without peculiarities. Later the patient was rehospitalized with complaints of weakness, nausea, vomiting, pain in the upper parts of the abdomen; he was diagnosed with ulcer of gastroenteroanastomosis and continuing bleeding that were indications for the surgical intervention for life-saving indications. From the patient words, a part of the stomach was resected more than 20 years before for gastric ulcer. Until the latest time, the patient felt satisfactory, but within 6 months pain in the abdomen reappeared, however, on examination cholelithiasis was identified, and the pain syndrome was attributed to this pathology. Assumably, after the first operation performed in 1995, a complication developed in the early postoperative period in the form of obstruction of gastroenteroanastomosis (anastomositis?), and additional gastroenteroanastomosis was applied. Conclusion. Peptic ulcer of anastomosis is an actual problem of the gastric surgery which may not only appear long time after the operation, but may give the same complications as «essential» peptic ulcer, and really threaten the life of patients. It should be noted that in some cases the intraoperative picture, experience and sensations of a surgeon play a decisive role in the diagnosis of surgical pathology even if they differ from the data of additional methods of examination.

Case report of toxic multinodular goiter with neck compression

We present a case of a 62-year-old patient with multinodular substernal goiter and tracheal compression (up to 5 mm). The multinodular goiter was initially diagnosed 3 years before by a local endocrinologist. The patient had been suffering from difficulty of breathing and exertional dyspnea for two years. He consulted specialists in therapy, pulmonology, cardiology more than once. However, none of the clinicians was able to identify the cause of labored respiration. Eventually an endocrine surgeon diagnosed a case of the complicated multinodular goiter with the development of cervical compression syndrome and tracheal narrowing.Ultrasound study showed the diffuse enlargement of the thyroid gland mainly due to the large left lobe with a total volume of 132,5 cm3. Computed tomography showed the shift of trachea to the right because of its compression by the left lobe and the luminal narrowing up to 5 mm. The patient needed surgical intervention by life-saving indications. He underwent thyroidectomy. The postoperative period was uneventful, the patient did not complain about labored respiration and reported the improvement of physical activity. It is important to keep in mind that patients with multinodular goiter have the potential risk of developing cervical compression syndrome. Current case demonstrates that such patients should be examined by an endocrine surgeon as early as possible in order to perform timely elective surgery.

COVID-19 and Solid Organ Transplantation: A Review Article.

The coronavirus pandemic has significantly impacted solid organ transplantation (SOT). Early in the outbreak period, transplant societies recommended suspending living kidney transplant programs in communities with widespread transmission to avoid exposing recipients to increased risk of immunosuppression, while recommendations were made to reserve deceased-donor kidney transplantation for likely life-saving indications. SOT recipients may be at high risk from COVID-19 disease due to chronic immunosuppressive treatment and other medical comorbidities. Mortality rates reported between 13 to over 30% in SOT recipients. In addition to high rates of complications and mortality attributable to COVID-19 infections, the pandemic has also led to additional complexities in transplantation including new questions regarding screening of donors and recipients, decision making to accept a patient for kidney transplant or wait after pandemic. The clinical implications of COVID-19 infection may also differ depending on the type of the transplanted organ and recipient comorbidities which further impacts decisions on continuing transplantation during the pandemic. Transplant activity during a pandemic should be tailored with careful selection of both donors and recipients. Furthermore, while tremendous strides have been made in treatment strategies and vaccinations, the impact of these in transplant recipients may be attenuated in the setting of their immunosuppression. In this review, we aim to summarize several aspects of COVID-19 in transplantation, including the immune response to SARS-CoV-2, SARS-CoV-2 diagnostics, clinical outcomes in SOT recipients, and end-stage kidney disease patients, transplant activity during the pandemic, and treatment options for COVID-19 disease.

Long-term results of coronary artery bypass graft surgery after stenting of obstructed artery with bare metal stent in patients with acute coronary syndrome and multivessel disease

Non-optimal long-term results of endovascular interventions using bare metal stents and their wide use in Russia in acute coronary syndrome (ACS) make it important to study the influence of the mentioned interventions on the results of coronary artery bypass graft surgery (CABG) performed after stenting of the obstructed artery in patients with ACS and multivessel disease.
 Aim. To study the results of CABG performed at our department in early periods of ACS after stenting of an obstructed artery with bare metal stents versus the results of use of drug coated stents of the 2nd generation, on the basis of the data of NORSTENT study.
 Materials and Methods. The work presents the results of a two-year observation of stepwise treatment of 97 patients with ACS and multivessel disease who were performed stenting of an obstructed artery for life-saving indications followed by CABG not later than in 90 days. Patients of the main group had three-vessel disease of coronary arteries with severity of damage 26.03.2 points on SYNTAX scale. The time from the moment of stenting to complete revascularization was 6417 days. Clinico-demographic parameters of the main group were comparable with those of the comparison group (data of NORSTENT study).
 Results. During observation time two cases of acute myocardial infarction occurred. Repeat revascularization was required in 14 patients (14.4%). The rate of MACCE was 0.1443. Odd ratio (OR) of the risk of MACCE occurrence was 1.61 (95% CI [1.14;2.78]).
 Conclusion. Surgical revascularization of the coronary bed in early periods after stenting of the obstructed artery with bare metal stents in patients with ACS and multivessel disease has 1.6 times (95% CI 1.14;2.78) higher risk for initiation of adverse cardiovascular events, in comparison with endovascular revascularization with use of drug coated stents of the 2nd generation.

An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network study.

SummaryBackgroundCaesarean section prevalence is increasing in Asia and Latin America while remaining low in most African regions. Caesarean section delivery is effective for saving maternal and infant lives when they are provided for medically-indicated reasons. On the basis of ecological studies, caesarean delivery prevalence between 9% and 19% has been associated with better maternal and perinatal outcomes, such as reduced maternal land fetal mortality. However, the specific prevalence of obstetric and medical complications that require caesarean section have not been established, especially in low-income and middle-income countries (LMICs). We sought to provide information to inform the approach to the provision of caesarean section in low-resource settings.MethodsWe did a literature review to establish the prevalence of obstetric and medical conditions for six potentially life-saving indications for which caesarean section could reduce mortality in LMICs. We then analysed a large, prospective population-based dataset from six LMICs (Argentina, Guatemala, Kenya, India, Pakistan, and Zambia) to determine the prevalence of caesarean section by indication for each site. We considered that an acceptable number of events would be between the 25th and 75th percentile of those found in the literature.FindingsBetween Jan 1, 2010, and Dec 31, 2013, we enrolled a total of 271 855 deliveries in six LMICs (seven research sites). Caesarean section prevalence ranged from 35% (3467 of 9813 deliveries in Argentina) to 1% (303 of 16 764 deliveries in Zambia). Argentina’s and Guatemala’s sites all met the minimum 25th percentile for five of six indications, whereas sites in Zambia and Kenya did not reach the minimum prevalence for caesarean section for any of the indications. Across all sites, a minimum overall caesarean section of 9% was needed to meet the prevalence of the six indications in the population studied.InterpretationIn the site with high caesarean section prevalence, more than half of the procedures were not done for life-saving conditions, whereas the sites with low proportions of caesarean section (below 9%) had an insufficient number of caesarean procedures to cover those life-threatening causes. Attempts to establish a minimum caesarean prevalence should go together with focusing on the life-threatening causes for the mother and child. Simple methods should be developed to allow timely detection of life-threatening conditions, to explore actions that can remedy those conditions, and the timely transfer of women with those conditions to health centres that could provide adequate care for those conditions.

Poland: coronary and structural heart interventions from 2010 to 2015.

For the last five years, invasive cardiology in Poland has developed extensively. Currently, 98% of the 161 Polish cathlabs operate in 24/7 mode, 37 of them supported by cardiac surgery departments on-site. A certification curriculum for interventional cardiology operators is supported by dedicated workshops and scientific meetings during national conferences. The rise in the number of coronary angiographies and PCIs was paralleled by an increased use of drug-eluting stents, bioresorbable vascular scaffolds and physiologic assessment of coronary arteries. Radial artery access has become the default option for PCI. A rapid adoption of the EAPCI Stent for Life Initiative resulted in a significant increase in primary PCIs. Unlike coronary interventions, structural heart interventions have evolved unevenly, despite the solid network of Heart Teams set up in the 21 most experienced centres. Left atrial appendage closure is offered in an increasing number of cathlabs. MitraClip therapy remains largely underused (1 procedure/million population/year). Despite the slow growth of TAVI since 2008, the current annual number of 17.1 TAVI procedures per million population is incomparable with countries in Western Europe. A recently introduced EAPCI Valve for Life campaign was followed by a 42.6% annual increase in TAVI procedures and an improvement in patients' access to therapy in life-saving indications.

Implantacja zastawki Melody w pozycję mitralną — u dziecka z nienaprawialnym uszkodzeniem zastawki w przebiegu infekcyjnego zapalenia wsierdzia

We present a case of emergency mitral valve replacement with the first — to the best of our knowledge — use of Melody balloon expandable stented bioprosthesis in a 2-years-old patient with acute endocarditis, subsequent mitral (bicuspid) valve incompetence after aggressive infective destruction, with the symptoms of critical multiorgan failure. The patient with a history of rapid deterioration after 2-weeks-long septicemia in the course of acute endocarditis was operated for life-saving indications. Melody valve was expanded over 16 mm TyShak balloon and implanted into a mitral position (Melody-MVR) with good result. Based on actual knowledge concerning heart valves reconstructions and institutional experience we conclude that infected mitral valve in children should be primary repaired, nevertheless Melody valve could be reasonable considered as a mitral prosthesis in patients with non-reparable conditions.

Фатальный некротизирующий гранулематозный васкулит после бариатрической операции и двусторонней маммопластики

The aim of case presentation. To present a typical case of systemic autoimmune disease related to extremely aggressive medical alterations of the immune status which were carried out not only for life-saving indications, but for cosmetic reasons as well. Summary. The patient (32-year-old female) had a history of persistent irregular febrile fever for two years, renal disease (tubulointerstitial nephritis with papillary necrosis), hemorrhagic vasculitis-like skin involvement and mediastinal lymphadenopathy. Patient underwent multiple investigations aimed for ruling out infectious causes of the disease that yielded negative result, repetitive courses of antibiotics provided transient positive effect at onset of disease. Five years before the origin of symptoms patients underwent sleeve gastrectomy with biliopancreatic shunting for obesity (body weight - 130 kg, BMI - 43.4 kg/m2), cholecystectomy and appendectomy. After that within a year patient lost 55 kg of body weight and developed severe symptoms of malabsorption. In 1.5 years after the fever onset bilateral mammaplasty with silicone implants was carried following which the fever became constant. At transthoracic biopsy of mediastinal lymph nodes demonstrated the pattern of Wegener-type ANCA-negative necrotizing granulomatous vasculitis of small arteries (PCR for mycobacteria and acid fast stain were negative). Despite provided corticosteroid and cyclophosphan treatment, the disease progressed (focal affection of the lungs) and the patient died of brain stem hemorrhage. Autopsy revealed the signs of vasculitis with involvement of the brain, skin, mediastinal lymphnodes, lungs, as well as the signs of chronic inflammation, atrophy of breast gland lobules, embolization of the focal lymphatics by the implant substance, ulceronecrotic enteritis of defunctioning bowel, severe liver steatosis with the chronic vitamin deficiency. Conclusion. The relation of atypical necrotizing vasculitis with yet undescribed clinical presentation with previous bariatric surgery and long-standing malabsorption is highly probable; application of silicone implants with adjuvant-associated immune response were additional resolving factors. Incomplete effect of immunosuppressive therapy indicates the dominant role of autoinflammation in the course of disease. Selection of patients for bariatric and cosmetic surgery should be more careful and involve estimation of the general and immune status of the body.

BASIC PRINCIPLES OF SPINE SURGERY

Any surgical exposure destroys the integrity of the patient’ body, for his own benefit. Sometimes, the spine intervention is performed for urgent life-saving indications and is guided by the Straightforward Principle. In other cases, there are no life-saving indications, but surgery aims to restore function and improve appearance. The first step includes careful preparation and planning of surgery. The main principle is a protection of neural structures of the spinal cord and its nerve roots. Slow incremental correction of spinal deformity is often more effective and safer than fast and dramatic one. The ultimate 3D-harmony of the whole spine as a part of the body is better than just a correction of the Cobb angle. The purpose of any surgical fusion is the achievement of 3D-balance both at the whole body level and at levels of junctional discs above and below the instrumentation. The lecture describes in details patient positioning, approaches, instrumentation and implants, main strategies for deformity correction, analysis of deformities (global and local), different ways of correction, most applicable corrective techniques (compression, distraction, translation, and axial rotation), and postoperative examination with particular emphasis on the spine alignment and the achieved balance. Each patient should be regarded as unique, and its treatment should be personalized. It is important to realize that the most effective and urgent treatment should be delivered in cases complicated by neurological symptoms.

Reduction of maternal and neonatal harm through prevention of the primary Cesarean section

While there are clear life-saving indications for Cesarean section (C-section), rates of this procedure have seen a continued rise without a concomitant improvement in maternal or neonatal outcomes. There is some evidence that outcomes may actually be worse for low-risk C-sections versus vaginal delivery. However, this is not necessarily common knowledge for healthcare providers, and therefore, their patients. Measures to safely reduce the C-section rate target management of labour arrest and specific indications for progression to C-section. In the active phase of the first stage of labour, C-section should be considered only in cases of failure to progress after 4 hours of adequate uterine contraction, or 6 hours of inadequate contraction. In the second stage of labour, expectant management of 3 hours of pushing in nulliparous women and 2 hours in multiparous women is safe and appropriate. Furthermore, manual rotation and operative vaginal delivery in the second stage are reasonable alternatives to C-section. Expectant management is also appropriate for certain non-reassuring fetal heart rate tracings. In post-dates pregnancies, induction of labour reduces both rates of C-section and neonatal mortality. Finally, evidence supports the use of external cephalic version in breech presentation as well as a more conservative approach to suspected macrosomia and multiple pregnancy. Taken together, these measures target the most common indications for progression to C-section and can allow us to safely reduce the C-section rate. Educating patients and physicians on the risks of the procedure and reasonable alternatives can improve outcomes for mothers and neonates.

Statistics on the use of cardiac electronic devices and electrophysiological procedures in 55 ESC countries: 2013 report from the European Heart Rhythm Association (EHRA).

In the last year, for the first time since its initiation, the EHRA White Book on the status of electrophysiology in the European Society of Cardiology (ESC) member countries was published as a full EP Europace supplement and in the form of comparative statistics. Since in the past editions neither comparisons nor trends and changes had been reported, we started to take this further step that was long awaited. The way in which the data are presented gives us the opportunity this year, for instance, to see the impact of new training initiatives, the foundation of working groups, the change in the number of practising centres, and so on. It also helps us to understand and estimate the impact of the economic crisis on the use of cost-intensive therapy such as ablation or pacemaker/implantable cardioverter defibrillator (ICD) implantation. Since the reliability of the data seems to increase with every year, we can base our evaluation on firmer grounds. The methodology has been previously reported.1 It also provides an idea on how reimbursement systems may affect the use of ICDs or implantable pulse generators (IPGs) in terms of reducing or increasing implant rates. The 2012 data in the 2013 edition in fact reveal changes in quite a considerable number of countries and show, for example, that in some countries from the eastern European area the implant rates for ICDs and IPGs by far exceed those of some western countries, meaning that the Gross Domestic Product (GDP) is not necessarily the driver for high or low rates of therapy use. Whereas IPG use and ICD implantations are something that has been widely used in the majority of countries at least for the strongest immediate life-saving indications, catheter ablation is used rather to treat symptoms and therefore would be most likely to …

Perioperative risk factors for vascularized composite allotransplantation: A systematic review and proposal of identity‐defining VCA

Vascularized composite allotransplantation (VCA) is a new dimension in reconstructive surgery. Generally, these procedures are offered for quality of life and functional indications rather than life-saving indications. Controversy exists, therefore, over the indications and risk/benefit ratios of VCA. Transplantation failure is a basic measurable risk of VCA. In this report we attempt to analyze perioperative factors associated with failures. Such factors are generally independent of technical performance and can be assessed to better define regulations applied to VCA. Ninety-one VCA procedures were identified, and 18 (19.8%) of them failed. Significant (P < 0.05) failure rates were associated with idiosyncratic cases (100%), cases performed without psychological screening (56.3%), cases performed without competent social support systems (44%), and cases done in developing countries (52.4%). A substantial but not significant failure rate was observed in cases performed without institutional review (36.4%). These findings suggest that institutional, professional, social, and ethical standards applied to VCA should require clarification of perioperative risk managements for any clinical VCA program, because such managements can be critical factors in determining outcome. The special character of these transplantation procedures suggest the concept of identity-defining vascularized composite allotransplantation (IVCA), for which psychological screening and third-party supervision is recommended.

Successful treatment of life-threatening, treatment resistant Clostridium difficile infection associated pseudomembranous colitis with faecal transplantation

Due to world-wide spread of hypervirulent and antibiotic resistant Clostridium difficile strains, the incidence of these infections are dramatically increasing in Hungary with appalling mortality and recurrence rates. Authors present a case of a 59-year-old patient who developed a severe, relapsing pseudomembranous colitis after antibiotic treatment. Life-threatening symptoms of fulminant colitis were successfully treated with prolonged administration of metronidazole and vancomycin, careful supportive therapy and weeks of intensive care. However, a well-documented, severe relapse developed within a week and this time faecal bacteriotherapy was performed. This treatment resulted in a complete cure without any further antibiotic treatment. In relation to this life-saving faecal transplantation, methodology and indications are briefly discussed. In addition, microbiological issues, epidemiological data and threats associated with antibiotic treatment of Clostridium difficile infections are also covered. Finally, relevant professional societies are urged to prepare a national protocol for faecal transplantation, which could allow introduction of this valuable, cost-effective procedure into the routine clinical practice.

Stent for Life: how this initiative began?

The Stent for Life Initiative was founded in September 2008 as a coalition of the European Society of Cardiology, European Association for Percutaneous Cardiovascular Interventions and Eucomed. The aim is to promote the life-saving indications for percutaneous coronary interventions--especially in all forms of acute myocardial infarction. This article describes how this initiative began.

Misoprostol for safe motherhood: one tablet, two life-saving indications

Misoprostol is a safe, acceptable, feasible, and effective alternative for both postpartum hemorrhage (PPH) and the treatment of incomplete abortion and miscarriage when no other interventions are available, which is often the case in resource-challenged regions. This article reviews the use of misoprostol for these two leading causes of maternal death globally and presents data on the implementation of misoprostol for PPH in Zanzibar as a case study. An evaluation was conducted to assess the uptake of misoprostol in public facilities in Zanzibar through a record review at nine facilities on various indicators from April 2008 to March 2009. For comparison, pre-intervention data were also collected from the same nine facilities for the 12 months preceding the PPH management trainings in April 2008. Following the introduction of misoprostol for PPH, the need for additional interventions among PPH cases significantly declined. The post-intervention period showed significantly fewer blood transfusions, PPH referrals, and PPH-related maternal deaths. Among PPH cases, the need for blood transfusion decreased from 30 (19.2%) in the pre-intervention period to 7 (2.4%) in the postintervention period. Rates of PPH-related referrals and maternal deaths also declined from 7.7% pre-intervention to 3.1% postintervention (P&lt;0.05). Misoprostol has the potential to make an immediate impact on the number of maternal deaths resulting from PPH and treatment of incomplete abortion and miscarriage.

Pediatric coronary artery bypass for Kawasaki, congenital, post arterial switch, and iatrogenic lesions

Background. Pediatric coronary artery bypass (PCAB) has been recently employed for expanding indications to treat acquired, congenital, post arterial switch, and other iatrogenic pediatric coronary artery problems. Methods. Between 1987 and 1998, 3 infants and 13 children (n = 16, mean age 6.1 years, range 2 months–18 years) underwent one or more internal thoracic artery (ITA) to coronary artery (CA) bypass grafts for Kawasaki disease (n = 4), congenital lesions (n = 3), post arterial switch (n = 4), and other iatrogenic obstructions (n = 5). Proximal left main CA arterioplasty was performed concurrently with ITA-CA bypass in 4 patients. Results. Survival is 93.8%. All bypass grafts in surviving patients are patent 2 months–11 years postoperation. The 11 elective patients are well (NYHA I–II). The 5 emergent operations were performed in 2 infants and 3 adolescents who had poor ventricular function prior to ITA-CA bypass due to iatrogenic injuries in 3, congenital critical left main stenosis in 1, and intraoperative iatrogenic coronary injury in 1. The 3 adolescents fared worse, resulting in death in the first, cardiac transplantation in the second, and full recovery in the third. The 2 infants have steadily improving ventricular function. Conclusions. ITA-CA bypass can be successfully performed in infants and children for expanding elective and life-saving indications with excellent results. Poor preoperative ventricular function often persists, especially in those older children with iatrogenic injuries, and may result in death or cardiac transplantation.