Rupture Of Major Vessels Research Articles

Massive retroperitoneal hematoma caused by intercostal artery bleeding after blunt trauma: a case report

BackgroundThe occurrence of massive retroperitoneal hematoma caused by intercostal artery bleeding is exceedingly uncommon.Case presentationA middle-aged male presented to the hospital after a fall. Computed tomography scan revealed a massive retroperitoneal hematoma without any evidence of organ or major vessel rupture. The angiogram revealed extravasation from a branch of the twelfth intercostal artery, and successful transcatheter arterial embolization was performed on this specific artery.ConclusionsThe possibility of intercostal artery rupture should be considered in cases of retroperitoneal hematomas, and accurate diagnosis can be achieved through imaging studies. Transcatheter arterial embolization represents an effective treatment modality.

Improved Early Detection Models of Pharyngocutaneous Fistula after Total Laryngectomy.

Early detection of pharyngocutaneous fistula (PCF) after total laryngectomy (TL) could prevent severe complications such as major vessel rupture. We aimed to develop prediction models for detecting PCF in the early postoperative period. We retrospectively analyzed patients (N = 263) who received TL between 2004 and 2021. We collected clinical data for fever (>38.0 °C) and blood tests (WBC, CRP, albumin, Hb, neutrophils, lymphocytes) on postoperative days (POD) 3 and 7, and fistulography on POD 7. Clinical data were compared between fistula and no fistula groups, and significant factors were selected using machine learning. Using these clinical factors, we developed improved prediction models for PCF detection. Fistula occurred in 86 (32.7%) patients. Fever was significantly (p < 0.001) more common in the fistula group, and ratios (POD 7 to 3) of WBC, CRP, neutrophils, and neutrophils-to-lymphocytes (NLR) were significantly higher (all p ≤ 0.001) in the fistula group than in the no fistula group. Leakage on fistulography was more common in the fistula group (38.2%) than in the no fistula group (3.0%). The area under curve (AUC) of fistulography alone was 0.68, but predictive models using a combination of fistulography, WBC at POD 7, and neutrophil ratio (POD 7/POD 3) showed better diagnostic performance (AUC of 0.83). Our predictive models may detect PCF early and accurately, which could reduce fatal complications following PCF.

Thyroid Gland Flap for Prevention of Pharyngocutaneous Fistula After Total Laryngectomy.

Pharyngocutaneous fistula (PCF) is the one of the major complications after total laryngectomy (TL), which can result in saliva leakage, rupture of major vessels, and increased hospitalization. Several flaps have been tried to prevent PCF during TL, and they are usually associated with donor site morbidity and uncertain viability in case of previously irradiated patients. This study aimed to report a novel bilateral pedicled thyroid gland flap (TGF) technique for delicate and effective reinforcement of neopharynx suture line after TL. Bilateral pedicled TGF was performed for the reinforcement of neopharynx T-shape suture sites after TL in this case series. A total of five cases of the TGF were performed during TL, with four of them being salvage setting following previous chemoradiation therapy (CRT). The well-adapted and viable TGF status was confirmed by post-operative computed tomography scan and normally preserved thyroid hormone levels in all patients. No post-operative infections, hemorrhage, hypothyroidism, hypoparathyroidism, or PCF were reported. The TGF is an effective and reliable flap in TL patents and should be considered as a method in neopharynx reconstruction, even in salvage TL following prior CRT.

Microsurgical training: vascular control and intraoperative vessel rupture in the human placenta infusion model.

Microsurgery is a challenging discipline. Regular lab training under the operating microscope has been the environment where most surgeons have mastered the skills and techniques inherent to most microneurosurgical procedures. However, some critical scenarios remain difficult to master or simulate. We describe a step-by-step method for how to build a low-cost, feasible, and widely available model that allows residents to familiarize themselves with demanding critical situations such as intraoperative rupture of major vessels. After delivery, nine fresh human placentas were transferred to the lab. The umbilical vein was cannulated for normal saline infusion. Several hands-on procedures were performed under direct microscope vision. Operating microscope setup, allantoic membrane splitting, vascular dissection and vessel injury, and repair exercises were simulated and video recorded. Indocyanine green was administered to simulate intraoperative angiography. The model can be setup in less than 15min, with minimal cost and infrastructure requirements. All the exercises described above can be conducted with a single placenta. Umbilical vein cannulation adds realism and allows quantification of the volume of saline required to complete the exercise. The final check with indocyanine green simulates intraoperative angiography and allows the assessment of distal vessel patency. Minimal infrastructure requirements, simplicity, and easy setup models provide a suitable environment for regular training. The human placenta is inexpensive and widely available, making it a feasible model for residents training. Neurosurgery residents may benefit from this model to familiarize with microsurgery and critical scenarios in a risk-free environment without time or resource constraints.

Risk factors and Incidence of wound dehiscence after neck dissection in patients with head and neck cancer

Background: Wound dehiscence is a complication after neck dissection (ND) in patients with head and neck cancer (HNC). We investigated the incidence, risk factors, and etiology of wound dehiscence among patients who underwent ND. Methods: A retrospective cohort study was performed on HNC patients, excluding those with thyroid cancer, who underwent surgery first in GSVM medical college, Kanpur. Results: The clinical charts of 60 patients were reviewed, 38 were male (63.33%) and 22 female (36.6%). The demographic and clinical characteristics are presented in Table I. out of 60 patient 12 take neoadjuvent CT and 2 neoadjuvent Rt. Out of 60 patients, 54 (90%) did not develop any complications, while 6 (10%) experienced some type of wound complication. The major complications that required surgical revision were wound dehiscence (6 cases, 10%).four patients who had previously received CRT and who developed wide cervical skin flap necrosis required secondary closure 8-10 day post surgery. No major vessel rupture was observed. Conclusions: Based on our results, we predict that certain groups of patients are at high risk for wound dehiscence after major HNC surgery. Preventive measures or close monitoring in these patients may be required to reduce the likelihood of postoperative wound dehiscence. Furthermore, even though additional research is required, we would consider changing the prophylactic antibiotic regimens according to the causative organisms.

Extracorporeal cardiopulmonary resuscitation for aortic rupture secondary to purulent pericarditis

Background: Extracorporeal Cardiopulmonary Resuscitation (ECPR) has been increasingly usedfor failed conventional CPR. Successful use in sudden major vessel rupture hasn't been reported. Cases of community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) pericarditis associated with major vessel rupture however are limited in number1 with a reported mortality of 20–30%.2 Here we present a case of CA-MRSA pericarditis that was complicated by aortic rupture in which ECPR was successfully utilized. Methods: A four-year-old boy presented with fever, abdominal pain and vomiting for one day. He had a fall from a tricycle with potential abdominal injury the day before and had a small gluteal abscess present for four days. Examination showed slight tachycardia, mild tachypnea and low-grade fever. CBC showed neutrophilic leukocytosis. Initial chest x-ray, electrocardiogram, and abdominal tomography scan were normal. He was managed with analgesics and covered with ceftriaxone. Chest CT done on the third day due to tachypneashowed pericardial and bilateral pleural effusions. Echocardiography showed a large pericardial effusion with a collapsing atrium, indicating tamponade. Emergency pericardiocentesis retrieved 120 ml of serosanguinous fluid. A pigtail catheter was left in-situ. Intravenous vancomycin was added to the antibiotic coverage. Pericardial fluid culture grew MRSA. He showed clinical improvement, and inflammatory markers showed progressive decrease. Pericardial drain was removed after five days as the drained fluid became minimal. Subsequent echocardiograms showed only debris in the pericardial space.Five days later while looking well, he coughed, desaturated, and became hemodynamically unstable. He was resuscitated for 55 minutes, during which he mostly had pulseless electrical activity. Bedside sternotomy was done during resuscitation to initiate central ECMO as part of ECPR. The pericardial sac was bulging, and when opened, around 500 ml of fresh blood with clots came out. Blood jets were coming from the ascending aorta which was found ruptured and covered with a thick layer of organized pus. Pus was removed from around the superior vena cava, right ventricle and ascending aorta, and the aorta was sutured.The patient was connected to femoral VA ECMO as the aortic wall was very friable. Results/outcome: The patient was decannulated from ECMO after 3 days and discharged from hospital after 2 months. At discharge, he was alert, communicating and had generalized weakness. MRI brain showed hypoxic ischemic changes. Conclusion: This is the first pericarditis case reported to develop aortic rupture, and the first to survive after a pericarditis-associated major vessel rupture, with utilization of ECPR and timely surgical repair. One case ofMRSA purulent pericarditiswith pulmonary trunk rupture was reported in a 68 year old woman who expired due to massive bleeding and difficulty of surgical repair.3 Although pericardiectomy should be considered from the outset in the management of purulent pericarditis,4 surgical intervention was not considered initially as the aspirated pericardial fluid was visually serosanguinous andsubsequent echocardiograms didn't show reaccumulation. Prior to admission, there was a small gluteal abscess, which probably served as the portal of entry for the MRSA but was dry at the time of admission and was not sampled.

Posterior Unlocking of Facet Joints Under Endoscopy Followed by Anterior Decompression, Reduction, and Fixation of Old Subaxial Cervical Facet Dislocations: A Technical Note

Besides the facet joints interlocking, the fibrous tissue or bony callus around the dislocated segments make the reduction for this kind of old injury to be more challenging and different from that of acute injuries. This study is aimed to present 4 cases of old subaxial cervical facet dislocations (SCFD) that were successfully treated with posterior unlocking under endoscopy followed by anterior decompression, reduction, and fixation. Between January 2017 and December 2017, 4 patients with old SCFD who underwent posterior unlocking of facet joints under endoscopy followed by anterior decompression, reduction, and fixation were enrolled. A cervical collar was prescribed for 4 weeks postoperatively. Postoperative follow-up evaluations were conducted at 2, 6, and 12 months, including neck visual analogue scale score and neck disability index, radiography, and computed tomography. The operative time averaged 145 minutes (range, 130-155 minutes). No deterioration of neural function, major vessel rupture, or iatrogenic injury to esophagus occurred. Intraoperative blood loss averaged 45 mL (range, 40-50 mL). Hospital stay for all patients was only 4 days. The neck visual analogue scale score and neck disability index were improved at the final follow-up, and interbody fusion was satisfactory without any radiologic sign of instability or internal failure. For patients with old SCFD, the unlocking of facet joints via the posterior approach under endoscopy followed by anterior decompression, reduction, and fixation is an alternative technique.

Injektion von Bauchfett bei radiogenen Wundheilungsstörungen

Wound healing complications in irradiated tissues represent a major clinical challenge. Fistula or even major vessel rupture may occur. The injection of adipose tissue derived stem cells seem to be a promising therapeutical strategy. The article describes the clinical case of a patient suffering from a pharyngo-cutaneous fistula after laryngectomy and radiotherapy. The patient was successfully treated by the injection of fat tissue.

Complications after neck dissection

Introduction: Neck dissection has been a well-established procedure used to eradicate metastases to the regional lymph nodes of the neck. Most of the complications are inevitable, and various efforts have been made to try and reduce complications by modifying the aggressive surgical procedure. A systematic review of 82 patients who underwent neck dissections has been done. The objective of this study is to report the various complications, complication rates in various neck dissection procedures and to seek improved patient care and outcome. Materials and Methods: A retrospective analysis of complications in 82 patients who underwent neck dissection from May 1, 2010 to December 31, 2013. Results: Out of 82 patients 16 (19.51%) experienced some complication and 7 (8.53%) patients had significant complications that required surgical revision. No major vessel rupture was observed. Conclusion: A careful preoperative assessment, meticulous surgical technique, high-quality postoperative care and appropriate rehabilitation are the cornerstones of preventing and managing complications.

Continuing Professional Development: Major trauma and catastrophic haemorrhage

Overview Major trauma is a leading worldwide cause of mortality, killing or seriously injuring thousands of people each day. Casualties have the potential to die immediately as a result of massive head injury or rupture of major vessels, or shortly afterwards as a result of progressive blood loss and hypoxia. A third group survive the initial insult, but succumb to their wounds days or weeks later as a result of secondary conditions including multiple organ failure and sepsis. This Continuing Professional Development (CPD) module will focus on the rapid assessment and timely management of casualties of major trauma, with particular emphasis placed on the catastrophically haemorrhaging patient. Learning Outcomes After completing this module you will be able to: • Define the concepts of major trauma and catastrophic haemorrhage • Appreciate the range of traumatic injuries sustained in the United Kingdom • Revise the pathophysiology of haemorrhage and hypovolaemic shock • Understand the management of the traumatically injured patient • Learn about a range of recent developments in trauma care

Six1 transcription factor is critical for coordination of epithelial, mesenchymal and vascular morphogenesis in the mammalian lung

Six1 is a member of the six-homeodomain family of transcription factors. Six1 is expressed in multiple embryonic cell types and plays important roles in proliferation, differentiation and survival of precursor cells of different organs, yet its function during lung development was hitherto unknown. Herein we show that Six1−/− lungs are severely hypoplastic with greatly reduced epithelial branching and increased mesenchymal cellularity. Six1 is expressed at the distal epithelial tips of branching tubules as well as in the surrounding distal mesenchyme. Six1−/− lung epithelial cells show increased expression of differentiation markers, but loss of progenitor cell markers. Six1 overexpression in MLE15 lung epithelial cells in vitro inhibited cell differentiation, but increases the expression of progenitor cell markers. In addition, Six1−/− embryos and newborn mice exhibit mesenchymal overproliferation, decreased Fgf10 expression and severe defects in the smooth muscle component of the bronchi and major pulmonary vessels. These defects lead to rupture of major vessels in mutant lungs after birth. Treatment of Six1−/− epithelial explants in culture with recombinant Fgf10 protein restores epithelial branching. As Shh expression is abnormally increased in Six1−/− lungs, we also treated mutant mesenchymal explants with recombinant Shh protein and found that these explants were competent to respond to Shh and continued to grow in culture. Furthermore, inhibition of Shh signaling with cyclopamine stimulated Six1−/− lungs to grow and branch in culture. This study provides the first evidence for the requirement of Six1 in coordinating Shh–Fgf10 signaling in embryonic lung to ensure proper levels of proliferation and differentiation along the proximodistal axis of epithelial, mesenchymal and endothelial cells. These findings uncover novel and essential functions for Six1 as a critical coordinator of Shh–Fgf10 signaling during embryonic lung development. We propose that Six1 is hence critical for coordination of proper lung epithelial, mesenchymal and vascular development.

Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels

Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option. After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy. The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH. The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.

Traumatic major muscle loss in the upper extremity: reconstruction using functioning free muscle transplantation.

Traumatic crushing injuries of the muscle compartments will occasionally cause major muscle or muscle-group loss with concomitant irreparable nerve injuries. Those cases with or without the availability of local muscle transfers form another indication for functioning free muscle transplantation (FFMT). The authors report their experience with 20 FFMTs in 14 patients with severe muscle loss from 1986 to 1996. They were selected because all their major muscle loss was primarily due to muscle avulsion, avascularity, and necrosis, but not secondarily due to nerve injury or ischemic injury. The motor nerves innervating these muscles were either disrupted after muscle debridement or avulsed from the neuromuscular junction concomitantly. The initial injury in this series was so severe that in many cases amputation was advised. Fractures were present in almost half the cases (6/14). Half the cases required revascularization due to rupture of major vessels (7/14), and the need for free-tissue transfer for soft-tissue coverage was demonstrated in over two-thirds (8/14). All FFMTs were innervated by the motor nerve which originally innervated the lost major muscle(s), and to replace palmar arm compartment (elbow flexors, 6 cases), palmar forearm compartment (finger flexors, 6 cases), and dorsal forearm compartment (finger extensors, 8 cases). Postoperative follow-up ranged from 3 to 12.5 years (average: 8.3 years). The success rate, i.e., achieving M4 muscle strength, was nearly 90 percent (18 of 20 FFMTs). Two cases with sub-optimal results were performed in the acute stage for the purpose of soft-tissue coverage and functional results. These reconstructions make the originally compromised limb useful for most activities of daily living. This type of injury should be recognized as providing a good prognosis after application of the FFMT, and arbitrary amputation should be avoided.

Anaesthesia for caesarean section in a patient with Ehlers-Danlos syndrome and mitral valve prolapse

We report the successful use of single-shot spinal anaesthesia for elective caesarean section in a multigravid woman with Ehlers-Danlos syndrome, complicated by mitral valve prolapse. This is a rare inherited collagen disorder that has been reported to have a high pregnancy-related morbidity and mortality, particularly from uterine rupture and uncontrolled bleeding from friable vessels, coagulopathy and major vessel rupture. The literature concerning obstetric anaesthetic management for different types of Ehlers-Danlos syndrome and the management of mitral valve prolapse in pregnancy are reviewed.

Gastric transposition for pharyngolaryngo-oesophageal cancer: the Unicamp experience.

Carcinomas of the pharyngo-oesophageal junction continue to be a challenge to head and neck surgeons. We report a series of 30 patients who underwent gastric transposition for advanced pharyngo-oesophageal tumours, with personal insights about the surgical technique and the need for neck and mediastinal node dissection. The median hospital stay was 21.6 days, with resumption of oral feedings around the 16th day in 91.7 per cent of the surgical survivors. Ten patients had multiple primary tumours (33.3 per cent), with 20 per cent of synchronous carcinomas. Serious local and systemic complications occurred in 17 patients (56.7 per cent), the most important being tracheal complications, cervical and systemic infections, fistulas, rupture of major vessels and pulmonary embolus. Post-operative deaths occurred in 20 per cent of the patients. The locoregional control of disease was significant (only 14.2 per cent of deaths from regional recurrence) but 64.2 per cent of the patients died from distant metastasis. Survival without disease was 13.3 per cent at five years. Gastric transposition was judged to be the procedure of choice for palliation or occasional cure in patients with pharyngo-oesophageal tumours.

Use of omentum pedicled graft to protect great vessels in gastric transposition for pharyngoesophageal cancer.

Transmediastinal gastric transposition and pharyngogastric anastomosis is perhaps one of the most widely accepted methods for restoration of the alimentary continuity after pharyngoesophageal resection. The need of neck dissection, mediastinal tracheostomy, and previous radiotherapy may favor exposure and rupture of major vessels. Protection with omentum may prevent this complication. A comprehensive review of omentum flap use in surgery was undertaken. A modified omentum pedicled flap was used in 6 out of 36 patients submitted to total pharyngolaryngoesophagectomy and gastric transposition (PLE&GT). None of the patients had major vessel rupture as compared with a 13% carotid and innominate artery rupture of a series of 30 patients previously operated on without omentum pedicled flap protection. The omental pedicled flap, performed as described, may provide reliable protection for carotid and innominate artery exposure, adding little time to the procedure.

Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.

Rupture of major vessels after radiation.

Rupture of irradiated large vessels is an uncommon complication which tends to occur in carotid, aorta, and femoral arteries, in decreasing order of incidence. It particularly affects men subjected to surgery and radiotherapy for epidermoid carcinomas in oropharynx, esophagus, or genitalia. Contrary to some opinion, radiation is not the most significant cause; this "spontaneous" arterial rupture can occur without radiation. The perforation is not associated with tumor invasion of arterial wall, as has been claimed. Surgical complications, especially necrosis of skin flaps, infection, and fistulas are most important etiologically. Only 2 of the 11 instances that we describe appear to have been caused mainly by radiation. The perforation is usually fatal, but several patients, including 3 of our series (2 carotid, 1 femoral), have been saved by hospital personnel aware of this complication. To prevent it, prolonged exposure or infection of arteries, whether irradiated or not, should be avoided.

Connective tissue defect in the chick resulting from copper deficiency.

SummaryChicks reared for 4 weeks on a modified non-fat milk diet deficient in copper developed mild anemia, leg weakness, bone deformities and a high incidence of subcutaneous hemorrhage. Mortality amounted to 23% and most deaths resulted from internal hemorrhage associated with rupture of major vessels. Histologic studies suggest a derangement of connective tissue metabolism with the major defect in elastic tissue.

Postoperative rupture of major vessels after radical pelvic operation

Postoperative rupture of major vessels after radical pelvic operation