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3 Polish Journal of Surgery

3 2010

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Assessment of Early Results of Fibrinolytic Treatment of Acute Ischemia of the Lower Limbs

100%

Łukawski K. , Jeleńska M. , Solonynko B. , Kulisiewicz P. , Szmidt J.

tom 82

nr 6

337-340

Acute ischemia of lower limbs due to thrombosis of large arteries is associated with high mortality and high rate of dangerous complications. Isolated intraarterial thrombolysis may improve prognosis of patients at high operative risk.The aim of the study was to assess early results of local thrombolytic therapy (recombinant tissue plasminogen activator r-tPA) of acute ischemia of lower limbs (duration of ischemia up to 15 days) in patients with poor general condition and with a history of vascular operations.Material and methods. Local intraarterial thrombolysis was performed in 35 patients who had developed acute ischemia of lower limbs due to thrombosis, in Chair and Clinic of General, Vascular and Transplantation Surgery, Warsaw Medical University in the period of time between 2003 and 2006. Twenty six of these patients previously underwent implantation of grafts made of artificial material. Signs and symptoms of ischemia persisted from several hours to 15 days. Nine patients were classified as ASA-IV, 26 patients as ASA-III on the risk scale.Thrombolytic therapy involved local infusion of recombinant tissue plasminogen activator r-tPA (Actylise) through a catheter inserted into the common femoral artery (contralateral to the ischemic limb). When thrombolysis was completed, heparin (given at a prophylactic dose) was started and continued until discharge.Results. Thrombolytic therapy resulted in vessel patency in 18 out of 35 treated patients (51%). Treatment effectiveness increased with shortening of duration of the limb ischemia. During thrombolytic therapy, one patient developed gastrointestinal bleeding that despite treatment resulted in death. In ten treated patients local bleeding from the puncture site was found, treated with compression in 9 patients while one patient required surgical intervention (evacuation of hematoma). Neither death nor limb amputation occurred during the hospitalization of 18 patients after the successful thrombolysis. Three patients required angioplasty due to vascular stenoses found in angiography as the cause of thrombosis. After unsuccessful thrombolysis, necrosis of peripheral parts of the limbs occurred and due to lack of possibility of further vascular reconstruction, amputation was required. Surgical restoration of vessel patency performed in the remaining 12 patients was successful in eight patients, while unsuccessful in the other 4 patients who also required limb amputation. Three deaths occurred in this group, caused by heart failure after the procedure of restoration of vessel patency.Conclusions. Our results indicate that local thrombolytic therapy can be effective in rescuing a limb at risk in patients with contraindications to surgical treatment.

Qualification and Operative Difficulties of Laparoscopic Adrenalectomy

86%

Otto M. , Dzwonkowski J. , Jędrasik M. , Ciąćka T. , Górnicka B. , Życińska K. , Szmidt J.

tom 82

nr 1

38-46

Laparoscopic adrenalectomy (LA) became referential in the treatment of adrenal pathology. However in the majority of tumors biochemical markers and imaging examinations aren't reliable to evaluate existences of the malignant process before the operation. Therefore complete resection of the adrenal gland, without damaging the capsule of the tumor remains as a significant problem.The aim of the study was to introduce the problem involving the qualification of the patients for laparoscopic adrenalectomy, and concerning the post-operative histopathologic evaluation, as well as technical aspects of the conducted laparoscopy.Material and methods. These problems are being discussed based on our experience in laparoscopic adrenalectomy. In the period 29.10.1997 - 31.01.2009 472 laparoscopic adrenalectromies were carried out via lateral transperitoneal approach. Among 457 operated patients in 13 (2.8%) conversion was necessary.Results. The malignant lesions were in 22 (4.8%) patients. 11 (2.4%) had metastases from other origin, 1 (0.2%) had Cushing's syndrome and 3 (0.6%) had pheochromocytomas. In the incidentaloma group 6 (13.1%) primary ardenocortical carcinoma and 1 (0.2%) angiosarcoma were identified.Conclusions. Laparoscopic adrenalectomy via lateral transperitoneal approach is a sufficient and safe surgical treatment of adrenal pathology.

Hypertension Crisis in Adrenal Surgery and Treatment of Postoperative Hypotension

72%

Otto M. , Dzwonkowski J. , Januszewicz A. , Pęczkowska M. , Kański A. , Kasperlik-Załuska A. , Rosłonowska E. , Szmidt J.

tom 82

nr 4

199-211

The aim of the study was to present our experience in the treatment of pheochromocytoma, which can have untypical manifestations or their complete lack. Surgery still is the main treatment. Since introducing minimally invasive method the operative choice between open and videoscopic still remains.The proper diagnosis, preparation and surgical treatment allow to avoid serious cardiovascular complications. In the treatment, pre-or intraoperative hypertensive crisis and hypotension appearing after removing the tumor are the important issues. Based on our study from 29.10.1997 to 31.01.2009 authors are showing methods and principles of preparation and the intra- and post-operative complications associated with performed operation.Additionally the problem of pheochromocytomas, clinically asymptomatic, so-called silent pheochromocytoma is discussed. Evaluated material consisted of 125 patients with pheochromocytoma. 32 (25,6%) were operated by open, classical method, and 93 (74.4%) laparoscopically via lateral transperitoneal approach.Conclusions. 1. The course and the result of surgical treatment of pheochromocytomas depend on proper diagnosis and preoperative preparation. 2. Laparoscopic adrenalectomy through lateral transperitoneal approach should be acknowledge as the referential operation in the treatment of pheochromocytoma. 3. Clinically asymptomatic pheochromocytoma require routine preparation similarly to other forms of pheochromocytoma.