Open Surgical Treatment Research Articles

Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review.

Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs. A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications. We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups. Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.

A modified procedure of T-tube maneuver to treat tracheal total obstruction involving ablative bronchoscopy sparing open surgical intervention

ObjectivesThe study objectives were to test an innovative T-tube procedure involving ablative bronchoscopy for the treatment of total airway occlusion and to orchestrate a safe and nontraumatic maneuver to treat intricate subglottic stenosis amenable for substituting the conventional surgical intervention. MethodsThis was an uncontrolled single-center cohort study on 1254 patients from January 2001 to June 2021. Patients underwent the modified T-tube procedure treatment for tracheal stenosis. Only 42 patients were included in the study because they had full records for subglottic total occlusion sitting tracheostomy. The ablative bronchoscopy, aided by a fixed suspending laryngoscope, was applied to retunnel their total airway occlusion. T-tube revision and removal were conducted under general anesthesia with laryngeal mask airway aid during follow-up. ResultsThe primary outcome was 90-day mortality. The secondary outcome was 90-day morbidity. The 42 patients included in the study had a mean age of 52.29 years (range, 9-84 years) with 22 men (52.38%). Their mean length of hospital stay was 13.67 days (range, 2-45 days). Their mean operation time was 73 minutes (range, 43-256 minutes). Their mean length of the tracheal stenosis was 2.8 cm (range, 0.8-6.3 cm). Outcomes were good in 29 patients (69.05%), satisfactory in 10 patients (23.81%), and considered failures in 3 patients (7.14%). A total of 16 patients (38.10%) underwent decannulation, and 3 patients (7.14%) were shifted to a Shiley tracheostomy. All 42 patients had a median follow-up of 6.2 years (range, 1.5-16.3 years). ConclusionsThe modified T-tube procedure, which offered both resilience and versatility, improved the conventional technique in treating those patients experiencing total tracheal stenosis and who were unqualified for conventional open surgery.

The Treatment of Patients With an Unruptured Abdominal Aortic Aneurysm and a Concomitant Malignancy—Short- and Long-Term Results.

Having cancer adversely effects the outcome of treatment for an unruptured abdominal aortic aneurysm (AAA). A retrospective secondary analysis was performed on the basis of anonymized data from AOK, a German nationwide statutory health-insurance carrier. Data were evaluated from all of the 20 683 patients who underwent either endovascular (EVAR, 15 792) or open surgical (OAR, 4891) treatment for an unruptured AAA in the years 2010-2016. It was determined in each case whether the patient had a known cancer at the time of the procedure to treat AAA. The analysis concerned patient characteristics, periprocedural complications, and survival after the procedure up to 31 December 2018. 18 222 patients were free of cancer. In accordance with the known 6:1 sex ratio of AAA, 85.3% of the cancer-free patients and 92.8% of those with cancer were men. At the time of their AAA procedure, 1398 had cancer of the intestine (n = 318), lung (n = 301), prostate (n = 380), or bladder or ureter (n = 399). One-year survival after the AAA procedure was 91.5% in cancer-free patients and 84%, 74.4%, 85.8%, and 85.5% in the patients with the respective types of cancer just mentioned. Having cancer was a significant risk factor for periprocedural mortality (OR 1.326, p = 0.041) and for long-term survival (HR 1.515; p < 0.001). Having cancer is a risk factor for periprocedural mortality and long-term survival in patients undergoing treatment for an unruptured AAA. This implies that the indications for surgery should be considered with care, particularly in patients with lung cancer, whose 5-year survival rate is only 37.2%.

Identification of Surgical Instruments Using a Low Frequency Magnetic Field

Abstract Background: As part of a open surgical intervention, it is desirable to identify, track and count the surgical instruments used, in order to document and potentially optimize the process. In the past, various technologies have been proposed to this end, as e.g. RFIDs attached to or included in the instruments, contact-less identification by image analysis or (bar-, QR-) codes, or counting by human resources, but all of them having their individual drawbacks. Objective: We present and evaluate a new method to identify metallic-conductive surgical instruments using Low Frequency (LF) magnetic fields. Method: The investigated LF magnetic field approach is based on the IndLoc system developed by the Fraunhofer IIS - originally for metallic asset identification within the field of supply chain management - and is applied on small collection of 13 typical surgical tools (four scissors, two needle holders, four tweezers, two retractors, a bone curette) for open surgery. Results: 9 out of the 13 instruments can be correctly identified, two pairs (2 short and 2 medium tweezers) are too self-similar and could not discriminated correctly from each other. Conclusion: These initial experiments show that an LF-based identification of metallic surgical tools is feasible, but the system needs to be modified (with more and smaller coils) to increase the geometrical resolution to better distinguish between self-similar and potentially more objects.

Open reconstruction of severe superior vena cava syndrome with right internal jugular-Superior vena cava bypass using femoral vein.

Current treatment of chronic benign superior vena cava syndrome (SVCS) is endovascular with angioplasty/stenting1Rizvi A.Z. Kalra M. Bjarnason H. Bower T.C. Schleck C. Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment.J Vasc Surg. 2008; 47: 372-380Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar,2Wilson L.D. Detterbeck F.C. Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes.N Engl J Med. 2007; 356: 1862-1869Crossref PubMed Scopus (355) Google Scholar. Open surgical bypass is typically considered for patients who fail endovascular therapy3Picquet J. Blin V. Dussaussoy C. Jousset Y. Papon X. Enon B. Surgical reconstruction of the superior vena cava system: Indications and results.Surgery. 2009; 145: 93-99Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,4Kalra M. Sen I. Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome.Surg Clin North Am. 2018; 98: 321-335Abstract Full Text Full Text PDF Scopus (20) Google Scholar. This report illustrates the surgical treatment of symptomatic SVCS. The patient consented to the publication. A 31-year-old male patient presented with recurrent edema and dilated veins of the upper extremities, head, neck, and chest, with concomitant severe headache. His history was significant for previous left lower extremity osteomyelitis six years before, being treated with antibiotics through a left upper extremity peripherally inserted central catheter (PICC). Symptoms of SVCS developed three years later. He was treated with bilateral subclavian and innominate vein stenting extending into the superior vena cava (SVC). Despite oral anticoagulation since the first intervention, the patient had multiple in-stent reocclusions and seven reinterventions with only temporary symptom improvement. Physical examination evidenced facial edema, plethoric facies, and dilated veins in the chest and abdomen. Computed tomography venogram (CTV) demonstrated occlusion of all stents. The right internal jugular vein (RIJV) was patent at the upper-neck level, close to the carotid bifurcation and the SVC was also patent caudally to the azygos vein. A left upper extremity and central venogram were performed and attempts were made to cross the occluded stents, without success. The patient then agreed to proceed with an open reconstruction. A RIJV to SVC bypass was performed using the patient´s right femoral vein, which had 8 mm in diameter, via a median sternotomy and a right neck incision (01:39). The suitable diameter of the vein-graft relies upon the main vessels’ diameter and patient´s anatomy, although a minimum dimeter of 6 mm is generally accepted. After the SVC anastomosis, a Valsalva maneuver was performed, and the clamp was opened with the patient in Trendelenburg position to minimize the risk of air embolism. At the two-year follow-up, a patent bypass was demonstrated with symptoms resolution. Annual follow-up with duplex ultrasound will be pursued. Open surgical treatment of SVC syndrome is associated with long-term symptoms relief and is an excellent option for patients who fail endovascular treatment. The femoral vein-graft was an excellent conduit with a good size-match to the RIJV, durable results and symptoms resolution. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTBmNTRkMDM4ODYxZjBkNTkxYTBlMWZlNDc5OGU3NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTk5NzY2fQ.cmFN_OFbjDH4lOiwl1zKkjrgnyVQ2yXQnj_hVfumqU1CX0DvODIdqDnFjP8WKhsd08e_hL8cEQf62356emnlqTr0YQ3Taf7QzqEzXDSXdshLabCLWCJSBJImuFBTwhSNEbChKp9VtQEQaGgQFyoxmim8ywtDZOp91FbZKEyqSzPRGpQZ1TaQTnYdofXOPWy6HWHwpA7L72nUSdtDa6DKZAo-7fV2qqKuAhpR-b2_-TYFZ5QDsM4894KbXMoSfpiuH1MyYN3E2RcS1dja_5IiR_wUucRBjC65wTnhE2xRmiUL_0CZXxMNdfGKpq8bBaTg1GNl69QgdXWvXJkmViQ8Mw Download .mp4 (86.14 MB) Help with .mp4 files

Open surgical treatment of unicameral bone cysts : Aretrospective data analysis.

Avariety of treatment options for unicameral bone cysts (UBC) exist. The controversy of open management of UBC is discussed. The aim of this study was to analyze asingle institution's experience in the open surgical treatment of UBC. By retrospective analysis of the Vienna Bone and Soft Tissue Tumor Registry, 119 patients with open surgery and histologically verified UBC with amean follow up of 4.8 years (range 1-30 years) were included. Lesion treatment failure was defined as surgically addressed UBC undergoing revision surgery due to persistence or recurrence. Local revision-free survival for lesion treatment failure was 93% after 1 year, 80% after 2 years, 60% after 5 years and 57% after 10 years. Of the patients 34 (29%) had at least 1 revision surgery due to lesion treatment failure. We found that patients with lesion treatment failure were younger (p = 0.03), had UBC with less minimal distance to the growth plate (p = 0.02) and more septation chambers in radiologic imaging (p = 0.02). Patients with open revision surgery were less likely to require a second revision due to lesion treatment failure than patients with percutaneous revision surgery (p = 0.03). Open surgery for UBC can only be recommended as reserve treatment in younger children with actively growing lesions. Open UBC surgery carries arelatively high risk of almost 30% of lesion treatment failure and therefore the indications should be limited to extensive osteolysis with high risk of pathological fractures, lesions with displaced pathological fractures, and lesions with an ambiguous radiological presentation that require tissue collection.

Open Surgical Treatments of Osteoporotic Vertebral Compression Fractures.

With an aging population, the osteoporotic vertebral compression fracture (OVCF) has become a constant concern for its physical and neurological complications, such asspinal kyphosis and refractory pains. Compared with traditional conservative treatments, the open surgery is more superior in some ways because of its direct decompression and correction. Various operation methods applying to different indications have been developed to deal with different fracture situations, including anterior, posterior, and combined surgery. In this review, we have concluded the latest developments of the surgery treating OVCF and the internal fixation as references for spinal surgeons of the choice of suitable treatments.

Informed Consent in the Stroke Care Continuum

Acute stroke management has become increasingly complex, incorporating medical, endovascular, and open surgical treatments that are potentially implemented across multiple hospitals for the same patient. Hospitals work in ever‐expanding networks to provide cost‐effective stroke care, balancing capital and labor costs, expertise, and catchment reach. As these systems and care pathways become more complex and attention is placed on the need to protect privacy, the importance of engaging patients and the community in medical decisions that carry forward from one institute to the next has likewise increased. As each node in the care pathway requires a varying degree of patient input and fulfillment of legal requirements, clinicians would benefit from a fundamental understanding of informed consent and contemporary shared decision‐making. While consent is commonly obtained, clinicians may not be aware of how different levels of consent are appropriate depending on the circumstances. In this essay, we explore the origins of informed consent and its relation to contemporary shared decision‐making. We will then review the acute stroke care continuum, and argue when simple consent, informed consent, and shared medical decision‐making ought to be used to ensure that care is delivered in a matter consistent with ethical practice. This framework is one particular approach to decision‐making and consent that we believe is supported by the arguments in this essay. Unless otherwise stated, the medical practice regarding consent discussed herein is applicable to the United States and may vary in other jurisdictions. Furthermore, consent for research is performed under a different paradigm and will not be explored herein.

Open surgical treatment for aortic arch and coronary artery aneurysms associated with immunoglobulin G4-related disease: a case report

BackgroundImmunoglobulin G4-related disease (IgG4RD) is a systemic autoimmune disease characterized by a dense lymphoplasmacytic infiltrate containing IgG4-positive plasma cells that can cause aneurysms in various organs and tissues. There have been many reports of IgG4RD aneurysms; however, the surgical procedures adopted remain controversial. Herein, we report a case in which surgical treatment for IgG4-related aneurysms was successful.Case presentationAn 83-year-old woman with IgG4-related disease developed multiple aneurysms, including thoracic aortic aneurysm (TAA), right coronary artery aneurysm (CAA), abdominal aortic aneurysm, and common iliac artery aneurysm. Enhanced computed tomography (CT) revealed progressive enlargement of the TAA, while positron emission tomography-CT revealed intense 18F-fluorodeoxyglucose uptake around the TAA and CAA, suggesting the presence of adhesive tissue caused by adventitial inflammation around the aneurysms. Open aortic arch replacement with frozen elephant trunk procedure and coronary artery bypass grafting with ligation of the coronary artery were performed to treat the TAA and CAA. No surgical complications occurred. The postoperative CT scan showed no endoleak around the open stent graft and the coronary artery was patent. The patient is being followed up on an outpatient basis after discontinuing steroid therapy.ConclusionsWe report the successful surgical treatment of IgG4-related multiple aneurysms. Our findings reveal that the main site of inflammation in aneurysms of IgG4RD is the adventitia and the frozen elephant trunk procedure is useful for avoiding complications.

Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy

BackgroundAcute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations.MethodsThe clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis.ResultsIn total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality.ConclusionsMorbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.

Double-Wound O-Ring Retraction for Chylothorax Surgery in Dogs.

A suitable wound retraction is crucial for open surgical treatment of chylothorax in dogs. A single paracostal approach for transabdominal/transdiaphragmatic thoracic duct ligation and cisterna chyli ablation is an effective procedure. For the procedure, the use of stay sutures and handheld or automatic soft tissue retractors is recommended. However, it is often necessary to adjust the retractors several times during the surgery to provide sufficient exposure of the thoracic duct. This prolongs the operation and increases infection risk. In this report, we describe the modified application of two o-ring elastic wound retractors (O-WRs) in three large breed dogs with idiopathic chylothorax. We conclude that the O-WRs provide a static circumferential vision of the operation field and good access to the cisterna chyli, especially to the thoracic duct. The usage of other surgical instruments is not hampered by the O-WRs, and the elastic rings are not damaged by the metal instruments. Once placed in the diaphragmatic area, indeed, they do not require further manual retraction.

Trigger Finger or De Quervain Tenosynovitis after Surgical Treatment for Carpal Tunnel Syndrome.

Objective To evaluate the open surgical treatment for carpal tunnel syndrome as a risk factor for the development of stenosing tenosynovitis that results in trigger finger and De Quervain disease. Materials and Methods A retrospective study analyzing the medical records of patients submitted to open surgical release of carpal tunnel syndrome between 2010 and 2021 in a secondary- and tertiary-level hospital. The following data were collected: pathological history, duration of the follow-up after the surgical treatment for carpal tunnel syndrome, development of trigger finger or De Quervain tenosynovitis, affected fingers, and the interval between the end of surgery and symptom onset. Results We evaluated 802 patients of both genders and with a mean age of 50.1 (±12.6) years. The mean follow-up was of 13 (±16.4) months. The mean time until the development of trigger finger was of 61.4 months, and of 73.7 months for De Quervain disease. The incidence of development of De Quervain disease was of 4.12%, and for trigger finger it was of 10.2%. The most affected digits were the thumb (47.6%), the middle (24.4%), and the ring finger (8.54%). Age was the only factor that showed an association with the risk of developing trigger finger, with an increase of 2% for each increase in age of 1 year. Conclusion The incidence rates for the development of De Quervain disease (4.12%) and trigger finger (10.2%) after the surgical treatment for carpal tunnel syndrome were like those described in the literature. Only age was a factor that influenced the development of trigger finger.

Gender disparities in patients with aortoiliac disease requiring open operative intervention

ObjectivePeripheral artery disease is known to affect males and females in different proportions. Disparate surgical outcomes have been quantified after endovascular aortic aneurysm repair, arteriovenous fistula creation, and treatment of critical limb ischemia. The aim of this study is to objectively quantify the sex differences in outcomes in patients undergoing open surgical intervention for aortoiliac occlusive disease. MethodsPatients were identified in the aortoiliac occlusive disease Vascular Quality Initiative database who underwent aorto-bifemoral bypass or aortic thromboendarterectomy as determined by Current Procedural Terminology codes between 2012 and 2019. Patients with a minimum of 1-year follow-up were included. Risk differences (RDs) by sex were calculated using a binomial regression model in 30-day and 1-year incidence of mortality and limb salvage. Additionally, incidence of surgical complications including prolonged length of stay (>10 days), reoperation, and change in renal function (>0.5 mg/dl rise from baseline), were recorded. Inverse probability weighting was used to standardize demographic and medical history characteristics. Multivariate logistic regression models were employed to conduct analyses of the before mentioned clinical outcomes, controlling for known confounders. ResultsOf 16,218 eligible patients from the VQI data during the study period, 6538 (40.3%) were female. The mean age, body mass index, and race were not statistically different between sexes. Although there was no statistically significant difference detected in mortality between males and females at 30 days postoperatively, females had an increased crude 1-year mortality with an RD of 0.014 (95% confidence interval, 0.01-0.02; P value < .001. Males had a higher rate of a postoperative change in renal function with an RD of −0.02 (95% confidence interval, −0.03 to −0.01; P < .001). ConclusionsAlthough there was no sex-based mortality difference at 30 days, there was a statistically significant increase in mortality in females after open aortoiliac intervention at 1 year based on our weighted model. Male patients are statistically significantly more likely to have a decline in renal function after their procedures when compared with females. Postoperative complications including prolonged hospital stay, reoperation, and wound disruption were similar among the sexes, as was limb preservation rates at 1 year. Further studies should focus on elucidating the underlying factors contributing to sex-based differences in clinical outcomes following aortoiliac interventions.

Laparoscopic nephrectomy for polycystic kidney disease: Benefit or necessity?

Background. According to foreign and domestic authors, autosomal dominant polycystic kidney disease (ADPKD) is a disease accompanied by a progressive deterioration in the functional state of the kidneys and occupies a significant contribution to the structure of all causes leading to the end stage of chronic renal failure (ESRD). An increase in the volume of the kidneys and the development of complications significantly worsen the quality of life of these patients. Open surgical interventions are accompanied by a more severe course. In this connection, the question of choosing the timing and method of surgical intervention in this group of patients remains relevant.&#x0D; Aim. To evaluate the results of nephrectomy in patients with ADPKD for the period from 2016 to 2022, performed at the Krasnoyarsk Regional Clinical Hospital.&#x0D; Materials and methods. Within 6 years, 22 nephrectomies were performed in 20 patients with ADPKD. Monolateral nephrectomy was performed in 12 cases, simultaneous bilateral surgery was performed in eight patients. The mean age of the patients was 51.3±7.9 years. Mostly nephrectomy was performed by laparoscopic approach (17 patients), lumbotomy operation was performed in three patients. The need for conversion during laparoscopic operations was not noted.&#x0D; Results. Open surgical treatment was performed only because of uncontrolled gross hematuria and suppuration of cysts. All patients were transferred to the intensive care unit after surgery. Repeated surgery due to the development of bleeding was required in 33.3% of cases. The need for an inpatient stage of treatment was 15.1±2.8 days. In one case, a fatal outcome was recorded. Laparoscopic nephrectomy was performed in 17 patients, monolateral in seven patients, staged bilateral in two, and simultaneous bilateral in eight patients. In 41% of cases, in addition to pain and hypertension, nephrectomy was due to the upcoming kidney transplantation. The average volume of removed kidneys was 3138.74±356.30 ml. The average bed-day was 8.86±2.4 days.&#x0D; Conclusion. The increase in the number of patients with ADPKD and ESRD raises the question of the improvement in their quality of life that can be achieved by unilateral or bilateral nephrectomy. However, there are no clearly regulated criteria that determine the indications for these types of surgery. Despite certain difficulties, we believe that laparoscopic nephrectomy in patients with ADPKD and ESRD is the most optimal.

Manejo multimodal de aneurisma cirsoideo. Reporte de un caso y revisión de la literatura

Scalp arteriovenous malformations (AVMs), commonly known as cirsoid aneurysms, are complex collections of arteries and veins that communicate directly. It has been postulated that AVMs occur both through the activation of inactive fistulous lesions and through the formation of new fistulous vascular channels through the canalization of injured vessels. Depending on their size and complexity, a variety of strategies can be used to treat them. The case of a 53-year-old male is presented who came for evaluation due to an increase in the volume of a pulsating lesion that extended from the right parietotemporal region accompanied by holocraneal headache and tinnitus. A cerebral angiotomography was performed in which a lesion composed of ectatic serpentine images, with a right extracranial location, subsequently diagnostic cerebral angiography was performed demonstrating a right frontoparietal fistulous and plexiform arteriovenous shunt fed by afferents from the right superficial temporal, posterior auricular, occipital and middle meningeal arteries, with drainage through a varicose and ectatic vein towards the external jugular vein. An endovascular embolization of the arteriovenous shunt was performed via the femoral route in two stages, achieving a “pressure cooker” construction to perform the injection of embolizing fluid and have a subtotal embolization of 93%, with this it was possible to perform a microsurgical resection with a right fronto-parietal-temporal approach resecting the deepest part, leaving the scalp with embolized vessels without resecting. To close the surgical wound, a simple flap rotation was performed to cover the skin defect derived from its resection. The patient underwent post-resection cerebral panangiography, identifying the absence of arteriovenous shunt. Depending on the extent and anatomical complexity of the malformation, clinical manifestations may vary. More than 80% of AVMs will be present at birth and the rest may develop after head trauma or surgical interventions. Appropriate therapeutic intervention is needed through selective angiography, during which endovascular embolization of the major feeding vessels can be performed before open surgical intervention. Volume-based three-dimensional computed tomography reconstructions can be used for further planning. Surgical reduction of post-embolization arterial supply will reduce intraoperative hemorrhage, facilitating total surgical resection. Removal can result in large, full-thickness skin defects that may be difficult to reconstruct without compromising functional and cosmetic results. Keywords: Cirsoid aneurysm; multimodal management; treatment; endovascular; giant

A rare cause of acute abdomen in childhood: coexistence of mesenteric cystic lymphangioma and acute appendicitis

Abdominal cystic lymphangiomas are benign congenital anomalies of the mesenteric and retroperitoneal lymphatics, which are not common in the literature. Diagnosis is usually made by physical examination, ultrasonography, and computed tomography. If a significant portion of adjacent organs is not to be sacrificed, complete surgical removal of the mass is the therapeutic option for symptomatic abdominal cystic lymphangiomas. In this study, a patient with mesenteric cystic lymphangioma who underwent surgical treatment is presented. A result of the radiological examinations performed on a 17-year-old female patient who applied for intermittent abdominal pain and a mass in the abdomen as a result of the well-defined, septated mesenteric cystic lymphangioma and acute appendicitis were detected. The patient underwent a diagnostic laparoscopic procedure and then an open surgical treatment, and excision and resection anastomosis were performed on the mass surrounding the jejunum approximately 100 cm distal to the ligament of Treitz. The patient did not have any postoperative problems and was discharged with recovery on the 5th day after surgery. Mesenteric cystic lymphangiomas should be kept in mind in patients with intermittent abdominal pain and abdominal mass, and surgical treatment should be applied in selected cases, as it may rarely cause serious complications.

On the degree of effectiveness of surgical aids for mechanical jaundice

Relevance. The problem of mechanical jaundice is the most urgent in abdominal surgery. This is primarily because the frequency of this pathology is steadily increasing, and the mortality rate does not have a distinct downward trend. Surgical tactics in case of mechanical jaundice remains multivariate, and a differentiated approach is needed for treating this contingent of patients, which is decisive in improving the results of surgical aids.The aim of the study. To improve the results of treatment of patients with mechanical jaundice of calculous etiology.Materials and methods. The analysis of the results of treatment and specially conducted studies in 554 patients with mechanical jaundice of calculous etiology was carried out. The patients underwent ultrasound, CT, and MRI. The concentration of adrenaline, norepinephrine, dopamine, 11-oxycorticosteroids, histamine, and serotonin, as well as toxic metabolic products were determined. The state of the autonomic nervous system was assessed by determining the autonomic index and mathematical analysis of the heart rate using variational pulsometry.Results. All the patients were operated on. Priority was given to stage-by-stage surgical tactics combining endoscopic decompression of the biliary tract with endoscopic papillosphincterotomy in the early stages of hospitalization and open surgical treatment after cupping the clinic of mechanical jaundice. There was a 3-fold increase in the number of endoscopic interventions. The mortality rate for the entire period decreased by 2.1 times. The reason for the results obtained is the degree of trauma of the operation. The parameters of the musculoskeletal, autonomic nervous, and sympathoadrenal systems were determined in patients divided into three groups. In the first group, primary open surgery on the biliary tract was performed, in the second — endoscopic papillosphincterotomy and abdominal surgery on the biliary tract, in the third — only endoscopic papillosphincterotomy. Endoscopic papillosphincterotomy had the most sparing effect on the functioning of the cardiovascular system and normalization of vegetative homeostasis. The volume of the surgical aid for mechanical jaundice affects the content of the sympathoadrenal system and biologically active substances in the blood plasma. When performing abdominal operations, compared with minimally invasive ones, the concentration of adrenaline, norepinephrine, serotonin, histamine, and 11-oxycorticosteroids in the blood increased by 1.5–2.5 times.Conclusion. The effectiveness and priority of minimally invasive operations for treating mechanical jaundice have been confirmed. The use of endoscopic resolution of biliary hypertension makes it possible to reduce the mortality rate against the background of a steady trend toward normalization of the indicators of the sympathoadrenal system and variational pulsometry.

Efficacy of extracorporeal shock wave lithotripsy for post-transplant kidney stones. Hope or Disappointment?

Nephrolithiasis in a transplanted kidney is an important medical and social problem. The presence of renal calculi may not manifest clinically for a long time due to the peculiarities of the surgical intervention during organ transplantation. Development of chronic urinary tract infection and deterioration of the functional ability of the renal transplant in the presence of kidney stones can lead to graft death, which is an immediate threat to the patient’s life. Existing Russian guidelines on the treatment of urolithiasis currently lack a clear strategy for the management of kidney transplant recipients.Objective: to systematize literature data on analysis of the outcomes of extracorporeal shock wave lithotripsy (ESWL) and other methods in patients with post-transplant kidney stones.Results. Thirty-five publications on the research topic were selected. We summarized the information on various therapy options for patients with stones in transplanted kidney: endourological approach, ESWL, percutaneous nephrolithotripsy (PCNL), open surgical treatment (nephrostomy, pyelolithotomy). A modern foreign algorithm for the management of patients with post-transplant kidney stones depending on the severity of obstruction with sepsis and the size of the renal calculi is presented.Conclusion. 1. The presence of stones in a kidney graft is a clinical situation that requires surgical treatment. 2. In clinical practice, different methods of treatment can be used, such as open intervention, ESWL, PCNL, retrograde transurethral manipulations. 3. In most cases, patient management tactics depend on the clinical picture (presence/absence of obstruction) and the size of the calculi. 4. The use of ESWL, as the most frequently used method, testifies to its efficiency and low-traumatic effect.

Хирургическое лечение аневризмальных костных кист поясничного отдела позвоночника: описание клинического случая

Introduction Pediatric and adolescent patients with aneurysmal bone cyst of the spine are normally treated by orthopaedic, neuro surgeons and oncologists. There is no consensus on the strategy and volume of preoperative and surgical treatment of the condition. There is a higher risk of pathological fracture and secondary neurological complications, tumor recurrence if open surgery is not performed in time. A second surgical intervention can hardly be avoided in such cases. The objective was to report the result of surgical treatment of a patient with aneurysmal bone cyst of the spine. Material and methods Outcome of a patient with an aneurysmal bone cyst of the L3 vertebra is presented. The technique of using therapeutic punctures as a preoperative preparation to be followed by an open surgical treatment is described. Absence of complaints and tumor recurrence, stability of the metal construct and bone fusion were the evaluation criteria. Results The patient was followed for 17 months after open surgery and CT scans showed no recurrence and demonstrated bone fusion at a long term. Discussion Many aspects of the course of the disease are to be considered in the treatment of children and adolescents with aneurysmal bone cyst of the spine. In our opinion, the step in the treatment of aneurysmal bone cyst of the spine should be considered Puncture for therapeutic and diagnostic purposes is to be performed to reduce pathological process is reduced, and the procedure to be followed by surgical intervention to remove the tumor. The strategy of surgical treatment would rely on impaired supporting columns of the spine, the degree of neural structure compression and a secondary spinal deformity. The need and extent of metal fixation is to be evaluated, potential vertebral growth identified, expediency of bone grafting after tumor removal, radical excision of the pathological focus to be considered. Conclusion The clinical case showed an effective combination of surgical techniques in the treatment of an aneurysmal bone cyst of the spine. Preoperative therapeutic puncture of the cyst allowed for reduction of the pathological process (decreasing pressure inside the cyst, thickening the cortical layer of the cyst and delimiting the tumor from the surrounding tissues), decreased volume of surgical intervention and blood loss due to a decreased activity of the pathological process compared to cases of untimely performed open surgery. Metal fixation in combination with bone auto- and allograft was practical for bone fusion.

Choledochal cyst.

Choledochal cyst (CC) or congenital biliary dilatation, has a skewed distribution with hereditary features that is far more common in East Asian females. CC is usually associated with pancreaticobiliary malunion (PBMU) forming a common channel. CC requires early definitive diagnosis, since there is a risk for malignancy occurring in the CC and/or intrahepatic bile ducts (IHBD). Complete CC excision and Roux-en-Y hepaticoenterostomy is required and can be performed by open or minimally invasive surgery with hepatojejunostomy the recommended procedure of choice. Principles of open surgical intervention form the basis of minimally invasive management with laparoscopy and robotic assistance. Current surgical management is associated with fewer early and late complications, such as hepaticoenterostomy anastomotic leakage, cholangitis, anastomosis stricture, and cholangiocarcinoma. Specific features of CC management at Juntendo include: intraoperative endoscopy of the common channel and IHBD for inspecting and clearing debris to significantly reduce post-operative pancreatitis or stone formation; near infra-red fluorescence with indocyanine green for visualizing tissue planes especially during minimally invasive surgery for CC; and a classification system for CC based on PBMU that overcomes inconsistencies between existing classification systems and clinical presentation.