Open Reconstructive Surgery Research Articles

Open reconstructive surgery for renal artery aneurysm

THE OBJECTIVE was to evaluate the immediate results of open reconstructive operations for renal artery aneurysm.METHODS AND MATERIALS . From March 2019 to September 2023, 55 patients with visceral artery aneurysms were operated at the Department of Vascular Surgery at the Pavlov University. 4 patients with renal artery aneurysms were operated on by open surgical method and 5 patients underwent endovascular operation. There are two clinical cases of open reconstruction of renal artery aneurysm in situ and one ex vivo. In all cases, the indication for the operation was the presence of a symptomatic aneurysm. For in situ reconstructions, a retroperitoneal thoracophrenopararectal access to the tenth intercostal space on the left side with the opening of the left pleural cavity and partial diaphragmatic cavity and a transverse laparotomy of «chevron» type were used. Autovena was used as a bypass. For surgery of the renal artery ex vivo laparoscopic nephrectomy with autotransplantation of the kidney was performed. In the near postoperative period, we made the assessment of the patency of the reconstruction zone using MSCT angiography, the analysis of indicators of renal function.RESULTS . All the observations noted satisfactory near-term results – the reconstruction zone is unobstructed, indicators of renal function without negative dynamics, absence of clinical manifestations of this pathology. Long-term results (observed for more than 4 years) were traced in one patient. During this period, normal renal function and adequate functioning of the reconstruction zone are maintained.CONCLUSION . Open reconstructive surgery in the surgical treatment of renal artery aneurysm remains relevant due to the inability in some cases to perform its endovascular correction without high risk of ischemic damage to the parenchyma of the kidney.

Treatment of renal artery fibromuscular dysplasia with drug-eluting balloon angioplasty and intravascular imaging: a case report

Fibromuscular dysplasia (FD) is a segmental, non-inflammatory and non-atherosclerotic disease of vascular smooth muscle of unknown etiology, which leads to stenosis of smalland medium-sized arteries. The choice of surgical treatment tactics for renal artery FD depends on the severity of clinical manifestations and the response to the conservative drug treatment used. Young age, female sex, high blood pressure with failure to achieve target values with therapy, as well as the absence of atherosclerotic involvement of other arterial systems gives reason to suspect renal artery FD. According to modern guidelines, the invasive treatment of hemodynamically significant renal artery stenoses includes transluminal drug-eluting balloon angioplasty. In this disease, renal artery stenting is not recommended. However, stent implantation is required if balloon angioplasty did not give the optimal result or in case of periprocedural complications, such as arterial dissection. Open reconstructive surgery is indicated for complex anatomy of the related artery, macroaneurysms in which stent grafts are ineffective, refractory intimal fibroplastic lesions, increased risk of endovascular treatment, or after unsuccessful endovascular intervention. The article presents a case of a young patient with renal artery FD, renovascular arterial hypertension, who successfully underwent renal artery transluminal drugeluting balloon angioplasty.

Open airway surgery for post-COVID laryngotracheal stenosis

IntroductionThis study reports our experience with open reconstructive surgery in patients with laryngotracheal stenosis (LTS) following prolonged intubation and/or tracheostomy in the context of COVID-19.MethodsAll patients underwent a preoperative endoscopic airway assessment. Posterior glottic lesions were graded according to the Bogdasarian classification, subglottic-tracheal lesions according to the Cotton-Myers classification and postoperative complications reported by the Clavien–Dindo classification. We report postoperative outcomes and functional results in this patient subset.ResultsWe include 14 patients diagnosed to have post COVID LTS, one female and 13 males. This group was compared with a control group, diagnosed with LTS following prolonged intubation. In the COVID group, mean age of patients at the time of the airway surgery was 52.1 ± 16.8 years (range: 13.7–76.3). More than half the patients were multi-morbid with hypertension and obesity being the most common conditions. Eleven patients had multi-site stenoses. Open surgical interventions performed were tracheal resection and anastomosis, laryngotracheal reconstruction and extended cricotracheal resection, and postoperative complications were seen in 12 (85.6%) patients. 70% patients with pre-existing tracheostomy were decannulated. Oral swallowing was not tolerated in one-fifth of the patients and a significant number of them have poor voice quality.ConclusionPost-COVID pandemic, airway surgeons are seeing an increased number of patients with complex LTS, and we report significant postoperative complications in this patient subset. Decannulation rates, voice and swallowing results are poor in patients with glottic involvement as compared to isolated tracheal stenosis.

Prognostic value of the intraoperative D-dimer level in arterial blood in open reconstructive operations on the aortoiliac segment

The objective was to assess the prognostic value of D-dimer level in peripheral venous blood and arterial blood to the risk of developing complications in the short-term period after open reconstructive surgery on the aortoiliac segment.Methods and materials. The study included 89 patients who were determined the D-dimer level in peripheral venous blood, as well as arterial blood intraoperatively.Results. Statistically significant differences in the D-dimer level were established depending on the presence or absence of early postoperative complications.Conclusions. The intraoperative D-dimer level in arterial blood has a predictive ability in relation to the development of early postoperative complications.

THE NEAREST AND SHORT-TERM RESULTS OF TREATMENT OF PATIENTS WITH OCCLUSIVE-STENOTIC LESIONS OF THE MAIN ARTERIES OF THE INFRARENAL AORTA

Resume. The aim of the study. To analyze the immediate and short-term results of treatment of patients with occlusive-stenotic lesions of the main arteries of the lower extremities after using modern types of surgical approaches and technologies.
 Materials and methods. The immediate and short-term results of treatment of 420 operated patients were analyzed. Since 2019, 198 patients (the main group) have been treated using the updated ESVS international guidelines. Both groups of patients (the main group and the comparison group) were comparable in terms of sex, age, location of the lesion, and type of surgical intervention.
 98 (23.3 %) patients were operated on by the open method, 243 (57.9 %) by the endovascular method, 79 (18.8 %) by the hybrid method. We evaluated such indicators as: postoperative thrombosis, limb amputations, mortality, as well as repeated operations performed due to complications or unsatisfactory results of the primary operation.
 Results and their discussion. The analysis of the immediate results of surgical interventions showed that the largest number of complications was found in the group of patients with multilevel occlusive-stenotic lesions of arteries, which correlates with the data of international studies. The direct effectiveness of endovascular interventions is higher than that of open revascularization and hybrid operations, and the trauma of miniinvasive endovascular techniques is significantly less compared to the methods of open reconstructive surgery.
 As a result of the analysis of the short-term results of surgical interventions, it was found that the largest number of complications was found in the group of patients with multilevel occlusive-stenotic lesions of the arteries. The short-term effectiveness of endovascular interventions is higher than that of open revascularizations and hybrid operations, but has a clear tendency to decrease, unlike open operations, the results of which have a clear tendency to improve.
 Conclusions. The selected tactics and selected surgical intervention technologies allow to increase the efficiency of treatment of patients in the immediate postoperative period and reduce the number of postoperative complications in the main group from 10.5 % to 4.9 %, repeated operations from 9.72 % to 3.06 %, amputations from 5.4 % to 1.84 % and mortality from 3.89 % to 1.84 %.
 In the short-term postoperative period, the number of postoperative complications decreased from 11.59 % to 3.84 %, reoperations from 11.11 % to 3.04 %, amputations from 4.83 % to 2.3 %, and mortality from 3.38 % to 1.53 %.

Laparoscopic Ureteral Reimplantation after Failed Open Surgery: Incorporating the Psoas Hitch Maneuver for Sufficient Tunnel Length.

Failure after open ureteral reimplantation has been reported to occur in 2 to 7% of cases. While a second open reconstructive surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The objective of this study is to describe a modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation reinforced with a psoas hitch. A retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between September 2012 and April 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications, and outcomes were reviewed. Either ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches or a cross-trigonal extravesical approach was utilized, depending on the length of the ureter. In all cases, a psoas hitch was performed to gain a longer submucosal tunnel and relieve tension, thus facilitating an efficient antireflux mechanism. Seventeen patients underwent a laparoscopic ureteral reimplantation after failed open surgery. Median age at second surgery was 106 months (interquartile range [IQR]: 53-122.5). Ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches was performed in 11 cases and cross-trigonal extravesical approach in 6 cases. Median ureteral diameter before the redo surgery was 16 mm (IQR: 14.5-18.5) and after surgery was 6 mm (IQR: 3.5-8.5) (p < 0.001). Postoperative mercaptoacetyltriglycine renal scan showed a nonobstructive pattern and stable renal function in all cases. Laparoscopic ureteral reimplantation with incorporation of a psoas hitch after failed open reimplantation is safe and effective.

Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series

BackgroundIatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy.MethodsTwenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively.ResultsAll cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016).ConclusionEndourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

Endovascular treatment of false aneurysm of axillary artery in obese women with epilepsy. 5 years follow up.

False aneurysms of arteries in upper extremities are relatively rare. They occur in 2 % of all false aneurysms, and axillary artery aneurysms are very uncommon. Open reconstructive surgery of axillary aneurysms bares the high risk of local and general complications. Progress in endovascular surgery and especially miniaturizationn of delivery systems for stents and stentgrafts enables their application in the treatment of small size, peripheral arteries. Our paper presents a case of extremely obese – 170 kg, 57 years old women, who presented with massive, false aneurysm of left axillary artery, being the consequence of epilepsy attack. She was successfully treated with endovascular deployment of covered stent Viabahn™ ø 6mm x 50mm (W.L. Gore), performed with randez-vous technique. After 5 years long follow up, the stentgraft is patent, in correct position, without radiological signs of migration or endoleaks.

Moderate grade subglottic stenosis in children: Laryngotracheal reconstruction versus cricotracheal resection and anastomosis.

ObjectiveThe surgical treatment of choice of pediatric moderate subglottic stenosis (major grade II and minor grade III SGS or 60–80% lumen obstruction) remains controversial. Laryngotracheal reconstruction (LTR) (with anterior ± posterior grafts for airway expansion) and partial crico-tracheal resection (PCTR) are the mainly described open surgical techniques. We reviewed our pediatric cases with moderate subglottic stenosis to determine the efficacy of LTR versus PCTR.MethodsA retrospective study of all children between 0 and 18 years that underwent open reconstructive airway surgery between 2012 and 2019. Children who had either acquired or congenital moderate subglottic stenosis (late grade II and early grade III: 60–80% lumen obstruction) were selected.ResultsTwenty-six children with moderate-grade subglottic stenosis were included. Seventeen were treated with LTR and nine with PCTR. No significant differences were observed between LTR and PCTR-treated cases. Decannulation rates were similar, as well as the functional results.ConclusionBoth LTR and PCTR are valid treatment options for moderate subglottic stenosis. This study indicates to perform the surgery that is most suitable for the characteristics of the patients’ stenosis, the surgeons’ expertise and preference, and the working infrastructure.

Changes in deep femoral artery topography during open revascularization of the lower limbs

To study topographic changes of femoral triangle arteries during open revascularization of the lower limbs. A retrospective study included 30 men aged 59.6±3 years with atherosclerotic femoropopliteal occlusion and chronic lower limb ischemia IIb-III stage according to the Pokrovsky-Fontaine classification. All patients underwent open reconstructive interventions. Ten patients underwent above-knee femoropopliteal replacement with a synthetic prosthesis, 10 patients - above-knee femoropopliteal bypass with a synthetic prosthesis, 7 patients - above-knee femoropopliteal bypass with autologous vein, 3 patients - below-knee femoropopliteal bypass with autologous vein. Control group consisted of 30 healthy mean aged 60±2 years. Ultrasound was carried out using the Esaote My Lab Alfa scanner (3-12 MHz linear transducer and 3-5 MHz convex transducer). In healthy volunteers, deep femoral artery always arose from common femoral artery under the angle ≤30° in all cases (20° - 93.3% of cases, 30° - 6.7% of cases). In patients with previous surgical treatment, angle of deep femoral artery varied from 35 to 80°. After femoropopliteal bypass grafting with autologous vein, angle of deep femoral artery varied from 35 to 45° (35° - 8 patients, 40° - 1 patient, 45° - 1 patient). After femoropopliteal bypass grafting with a synthetic prosthesis, angle of deep femoral artery increased up to 40-50° (40° - 2 patients, 50° - 8 patients). In case of previous femoropopliteal replacement with a synthetic prosthesis, angle of deep femoral artery increased up to 70-80° (70° - 7 patients, 75° - 2 patients, 80° - 1 patient). Normally, angle of deep femoral artery does not exceed 30°. Open reconstructive surgery on femoropopliteal arteries increases this value from 30° to 80°. Minimal changes are observed after femoropopliteal bypass grafting with autologous vein.

Revascularization in Diabetic Foot Ulcer and Outcome

Diabetes is a major public health problem regionally and globally. In 2019, the International Diabetes Federation estimated that 465 million (9.3%) people worldwide had diabetes, and by 2045, the number may rise to 700 million (10.9%) [1]. The pooled prevalence of diabetes in the general population of Bangladesh is 7.8% and prevalence of pre-diabetes is 10.1% [2]. Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. The lifetime risk for foot ulcers in people with diabetes is estimated to be 15% [3]. Development of diabetic foot ulcer is attributed to many interacting factors, the most common ones being peripheral neuropathy and Peripheral Arterial Disease (PAD) [4]. PAD is an important precipitating factor in the outcome of diabetic foot ulcer [4]. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration [5]. Diabetic patients with PAD commonly show involvement of the arteries below the knee, especially at the tibial and peroneal arteries, and involvement of the profunda femoris [6]. Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organized rapidly to ensure revascularisation without delay. Foot ulcer in patients with diabetes is associated with an increased risk of lower limb amputation, and thus the primary aim of treatment for ischemic foot ulcer is limb preservation [4]. Invasive revascularization, including open reconstructive surgery and/or endovascular intervention, is the most effective treatment that may improve peripheral circulation and remedy symptoms [4]. The basic aim of any successful revascularization is to achieve pulsatile flow to the foot. The two methods currently available are peripheral bypass surgery and peripheral angioplasty [7]. Current literature shows that percutaneous transluminal angioplasty (PTA) is the first choice of procedures in revascularization of the lower limb [7].

Women’s Preference for Cosmesis of Incisions Used for Open Versus Robotic Lower Urinary Tract Reconstructive Surgery

OBJECTIVE: To compare the cosmetic appeal of incisions used for open (Pfannenstiel or Vertical midline) versus robotic-assisted laparoscopic lower urinary tract reconstructive surgery in women.&#x0D; STUDY DESIGN: Cross-sectional descriptive study&#x0D; PLACE AND DURATION: Outpatient Urology Clinic of Western General Hospital, Edinburgh Scotland, UK from 1st February 2019 till 28th February 2020. &#x0D; METHODS: All patients were provided illustrations of Pfannenstiel incision (incision at “bikini line”- (A), Vertical midline laparotomy incision (incision from midline symphysis to umbilicus –( B), Robotic-assisted laparoscopic incisions-variation I- (C) and Robotic-assisted laparoscopic incisions-variation II (-D). Patients were asked to rate each incision in order of their preference. Chi square distribution was used to compare mean previous surgeries and no previous surgeries between different preferred incisional groups and ages of the patients.&#x0D; RESULTS: One hundred patients with mean age were 53.11±15.05 years with minimum 19 years and maximum 84 years and mean BMI was 28.18±7.05 kg/m2 with minimum 15.6 and maximum 55 kg/m2 calculated. Out of 100 patients (1st preference of incision), 78% preferred incision A, 3% preferred B incision and 16% &amp; 3% patients preferred incision C and D respectively. Similarly (2nd preference of incision) 3% patients preferred incision A, 19% preferred B incision and 56% &amp; 22% patients preferred incision C and D respectively. The mean comparison between first preferred incision with second preferred incision with respect of surgeries (previous surgeries and no previous surgeries) showed significant difference p≤0.05 (chi value=167.692, p=0.000). Relation of preferred incisions with respect to ages of the patients showed no significant difference (Pearson relation value -0.182 and p=0.069).&#x0D; CONCLUSION: Overall, open incisions were preferred over robotic incisions. Patient perception of the "visibility" of abdominal incisions and previous experience in term of surgical scars may be the distinguishing issue to explain the difference in the preferences between open versus robotic-assisted laparoscopic incisions in women.

Reconstructive surgeries on the larynx and cervical trachea in children

Introduction. One of the urgent problems in pediatric surgery and otorhinolaryngology is stenosis of the upper respiratory tract in children. Among many causes leading to airway narrowing , basic ones are: cicatricial stenosis, bilateral vocal cord paralysis and volumetric formations.Diagnostics. Currently, fibroscopy of the upper respiratory tract is a gold standard of this pathology examination.Methods. There are many surgical techniques to treat upper airway stenosis, but currently there is no any unified approach to the choice of surgical tactics. The given article presents an overview on modern techniques of reconstructive surgery which have demonstrated good and excellent results and a high percentage of decannulation. Among them, there are two basic ones - endoluminal surgery and open surgery. Recently, reports on the effectiveness of microsurgical interventions have been published , namely, reinnervation of the larynx to restore vocal cords. The most effective endoscopic surgeries in pediatrics are balloon dilation, bougienage and CO2- laser treatment. Patients with stenosis of stages III-IV, with extended stenosis, marked laryngomalacia, larynx and trachea deformity because of unsuccessful previous surgeries are recommended to have open reconstructive surgery. Laryngoplasty, laryngoplasty with T-tube and crico-tracheal resection are regarded as a choice option in case of ineffective previous surgeries.Conclusion. Thus, type of surgical intervention, indications and patient’s age for surgery are chosen individually for each patient with upper respiratory tract stenosis.

A new dimension of success in the management of airway disease in children with neurological deficit

ObjectivesAnomalies of the larynx and trachea can cause respiratory distress in infants and older children. Depending on its nature, degree and extent of the disease invasive open surgery is indicated. Non-airway-related co-morbidities increase the challenges in its treatment. Neurological deficit poses a great challenge as it is associated with hypotonia and causes diminished laryngeal coordination. The definition of success in treatment of laryngotracheal disease has always focused on the post-operative functional outcomes: breathing, voice swallowing. The aim of this study is to describe a new dimension of success in the management of laryngotracheal disease in children with moderate neurological deficit, where the expected functional gain is less than in otherwise healthy children. MethodsThis retrospective observational study includes all patients who have undergone open reconstructive airway surgery between 2012 and 2017. Control patients without neurological deficit and cases with moderate neurological deficit were included. Functional outcome data was obtained from clinical records and two questionnaires were filled in by the parents of the children: one the pediatric voice-handicap index (pVHI) and a quality of life questionnaire. ResultsThirty-two children were included of which ten had moderate neurological deficit. Both groups revealed post-operatively an improvement in the functional outcomes: breathing, voice and swallowing, however, as expected, a trend was observed towards less functional improvement in children with neurological deficit. Both groups reveal a remarkable gain in quality of life (QoL). ConclusionIndicating the QoL to be an unidentified, dimension of success in the management of laryngotracheal disease in children with moderate neurological deficit.

Outcomes of balloon dilation for paediatric laryngeal stenosis.

SUMMARYObjectiveBalloon dilation (BD) is a minimally invasive endoscopic treatment for paediatric laryngeal stenosis (LS) with reduced morbidity compared to open surgery. We retrospectively describe our experience in a cohort of children with chronic LS.MethodsFourteen children (median age: 28.5; range: 2-81 months) with chronic LS (multilevel in 8) were treated with tubeless total intravenous anaesthesia under spontaneous ventilation.ResultsGrade III LS was preoperatively detected in 12 children; the remaining 2 had grade IV stenosis. Six had prior tracheotomy, and one received it during the first intervention. Dilation laryngoplasty was the primary treatment in 11 children and was used as an adjuvant treatment in 3 after open reconstructive surgery. The median number of dilations was 2 (range: 1-6). There were no postoperative complications. At the end of the follow-up (median: 20.5; range: 2-46 months), detectable laryngeal lumen widening and/or respiratory improvement occurred in 12 children. Two of 7 patients with tracheostomy were decannulated.ConclusionsBalloon laryngoplasty is a valuable therapeutic option to improve laryngeal patency in children with chronic multilevel LS, both as a primary and secondary adjuvant treatment after reconstructive surgery.

Subglottic cysts: The Great Ormond Street experience in 105 patients.

The aim of the study was to assess the contemporary presentation and management of subglottic cysts and make recommendations on the treatment of these patients. Retrospective case series of 105 patients between October 1999 and November 2017 from a paediatric teaching hospital. Ninety-one percentage (n = 96) had a history of prematurity, with a mean gestation of 27.2weeks (SD ± 4.1). A history of intubation was found in 99% (n = 104) of cases [median 18days (range = 1-176)]. Presenting symptoms were: Stridor 57.1%, (n = 60), difficult intubation 14% (n = 15), recurrent croup 11.4% (n = 12), failed extubation 7.6%, (n = 8), hoarseness/weak cry 10.5% (n = 10). Ninety percentage (n = 94) underwent intervention for management of SGCs with 86% (n = 81) treated with cold steel marsupialisation and 14% (n = 13) with CO2laser. Recurrent cysts occurred in 56% (n = 53) of cases. Treatment modality did not affect recurrence (p = 0.594Δ). Sixty-six percentage (n = 69/105) of patients had one or more concurrent airway pathology at MLB. Most frequent was subglottic stenosis 47% (n = 49), with 16% (n = 8) subsequently requiring open reconstructive airway surgery. Mean duration of follow-up was 47.6months (SD ± 38.3). SGC are an uncommon, reversible cause of upper airway obstruction and should be considered in the list of differential diagnoses in patients with a history of prematurity and perinatal intubation, presenting with stridor. While concurrent SGS is common, adequate symptom improvement in such cases may be achieved with SGC removal alone. Management is by surgical marsupialisation. Recurrence and additional airway pathologies are common and may necessitate longer-term treatment in centres with paediatric airway expertise.

Balloon dilatation for paediatric airway stenosis: Evidence from the UK Airway Intervention Registry.

ObjectivesTo assess the safety and efficacy in routine clinical practice of balloon dilatation procedures in the treatment of paediatric airway stenosis.DesignObservational data collection in prospective online research database.SettingAcute NHS Trusts with ENT department undertaking complex paediatric airway work.ParticipantsChildren (<18) undergoing balloon dilatation treatment for airway stenosis.Main outcome measuresAirway diameter, complications, hospital resource usage.ResultsFifty‐nine patients had 133 balloon procedures during 128 visits to 10 hospitals. Sixty‐nine (52%) of balloon procedures were conducted with a tracheostomy. Intra‐operative Cotton‐Myer grade decreased in 43 (57%). The mean pre‐balloon subglottic diameter was 4.2 [95% CI: 3.8 to 4.5] mm, and its rate of increase was 0.8 [0.5 to 1.2] mm per year modelled on 30 patients' long‐term data. As the primary treatment of stenosis, the procedural success rate of balloon dilatation (n = 52) was 65% (22% with tracheostomy, 88% without tracheostomy), and 71% as an adjunct to open reconstructive surgery (n = 7). In the 64 hospital visits where a balloon procedure was conducted with a tracheostomy in place, only one in‐hospital complication (lower respiratory tract infection) occurred. For those without a tracheostomy in place, in‐hospital complications occurred in seven of 64 balloon hospital visits, all related to ongoing or worsening stenosis. Six out‐of‐hospital complications were deemed related to ongoing or worsening stenosis following the procedure, and two complications were a combination of lower respiratory infection and ongoing or worsening stenosis.ConclusionsBalloon dilation increases the size of the airway intraoperatively and is associated with long‐term increase in airway diameter. Safety outcomes mostly relate to ongoing or worsening stenosis and are more common in patients without a tracheostomy.

AUTOVENOUS REVASCULARIZATION OF THE LOWER EXTREMITY ARTERIES IN PATIENTS WITH VARIANT ANATOMY OF THE PERIPHERAL BLOOD FLOW AND THE PROGRESSIVE ATHEROSCLEROTIC PROCESS

Obliterating diseases of the lower extremity arteries occupy a high proportion in the structure of cardiovascular morbidity in the population among the developed countries. The steadily progressing course of obliterating atherosclerosis leads to the critical lower limb ischemia and causes an unfavorable prognosis for preserving the extremity, as well as the patient's life. Nowadays, there are two ways of surgical management of this pathology: endovascular and open reconstructive interventions. The choice of the method is based on a comprehensive keeping of the patient-specific records, including the anatomical characterization of the arterial bed lesions. In case of extended occlusion of the superficial femoral artery, the open reconstructive surgery using a large saphenous vein as a transplant is recommended. This circumstance is confirmed by the autovein patency in the long term compared with a synthetic prosthesis according to the results of randomized clinical trials. Therefore, with the formation of a distal anastomosis below the gap of the knee joint, the patency of the autovein and synthetic prosthesis after 5 years is 71% and 44% respectively. In this article, we represent a clinical case of successful treatment of a patient with progression of atherosclerotic lesions of the infrainguinal segment arteries. A staged revascularization of the femoral-popliteal segment arteries using technique of a reversed vein on both lower extremities after attempts of the conservative treatment and x-ray endovascular intervention was performed. A feature of this case is the creation of a new bifurcation of the popliteal artery during the formation of a distal anastomosis below the fissure of the knee joint under the contitions of a high discharge of the anterior tibial artery.The given clinical case demonstrates the advantages of invasive surgical tactics with the aim of preserving the limb and improving the patient's quality of life.

ВИВЧЕННЯ ГЕНЕТИЧНИХ АСПЕКТІВ РИЗИКУ ТРОМБОЗУ ШУНТІВ ПІСЛЯ ОПЕРАЦІЙ НА АРТЕРІЯХ НИЖНІХ КІНЦІВОК

Introduction. Critical limb ischemia is a serious threat, and even after surgery for revascularization, only 45% of those operated on retain both extremities within 1 year. During this time, unfortunately, in 30% of cases, the affected limbs are amputated, and the remaining 25% of critical ischemia cases result in death. Purpose. In order to improve the treatment outcomes of patients with peripheral arterial disease (PAD), the relationship between hemocoagulation-related gene polymorphism and the risk of shunt thrombosis after reconstructive arterial disease has been studied. Materials and Methods. The study included 40 patients who had previously undergone open reconstructive surgery for peripheral arterial disease, who were divided into two groups. The main criterion for inclusion of the patient in the main group was thrombosis of the shunt at any time after reconstructive surgery, and in the comparison group ­– the absence of thrombosis after peripheral arterial bypass at least 1 year after reconstructive surgery. All patients with polymerase chain reaction were analyzed for the presence of the following hereditary thrombophilia: Leiden factor G1691A, prothrombin G20210A, FGB G (-455) A, ITGA2 C807T, ITGB3 T1565C, PAI-1 5G (-675) 4G and MTHFR. Discussion. The study found a relationship between FGB G (-455) A, ITGA2 C807T and ITGB3 T1565C gene mutations and thrombosis after peripheral arterial bypass. It has been statistically proven that when there is at least one of the thrombophilia such as FGB G (-455) A, ITGA2 C807T and ITGB3 T1565C present in a patient with peripheral arterial disease, the risk of shunt thrombosis will increase in the future. A prospective direction for further research is the study of the question of how differentiated additional prevention of thrombosis of arterial shunts in patients with PLEAD depending on the detected hereditary thrombophilia will affect the frequency of thrombosis of these shunts. The study found that in patients with peripheral arterial disease who are planning to undergo surgery on peripheral arteries, it is advisable to study the presence or absence of thrombophilia bypass as FGB G (-455) A, ITGA2 C807T and ITGB3 T1565C. If these patients have at least one of these thrombophilia, the risk of bypass thrombosis in them is statistically significant in the future. A promising direction for further research may be to investigate how differentiated additional prevention of arterial bypass thrombosis in patients with PAD, depending on the hereditary thrombophilia detected, will affect the frequency of thrombosis of these pass and bypass.

Analysis of a 7‐year national online audit of the management of open reconstructive urethral surgery in men

ObjectiveTo conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK.MethodsBetween 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform. Surgeon‐entered information was collected in 95 fields regarding the stricture aetiology, prior management, mode of presentation, type of surgery and outcomes, with a potential 283 variable responses in the 95 fields. Data were analysed to compare UK practice with that reported in the contemporary literature and with guidelines.ResultsData on 4809 men were entered by 39 centres and 50 surgeons. Field completeness was 70.7%, 74.3% and 53.7% for preoperative, operative and follow‐up data, respectively. Referral for stricture reconstruction frequently followed two prior endoscopic procedures and the stricture was not always assessed anatomically before surgery. Urinary retention was a common symptom in men awaiting reconstruction. Short unifocal strictures of the anterior urethra were the commonest reason for referral, whilst lichen sclerosus and hypospadias generated a significant volume of revisional stricture surgery. Lower numbers of very complex interventions are required for the management of posterior urethral pathology. Although precise criteria for determining success are not clear, management of urethral reconstruction in the UK was found to have a low risk of Clavien–Dindo grade 3 or higher complications, and was associated with outcomes similar to those reported in contemporary series except in the management of posterior urethral fistulae.ConclusionsOnline databases can provide volume data on the management of reconstructive urethral surgery across a multiplicity of centres in one country. They can also indicate compliance with accepted standards of, and expected outcomes from, this tertiary practice.