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1/386. Acute torsion of the renal transplant after combined kidney-pancreas transplant.

    BACKGROUND: Surgical complications after combined kidney and pancreas transplantation are a major source of morbidity and mortality. Complications related to the pancreas occur with greater frequency as compared to renal complications. The occurrence in our practice of two cases of renal infarction resulting from torsion about the vascular pedicle led to our retrospective review of similar vascular complications after combined kidney and pancreas transplantation. methods: charts were reviewed retrospectively, and two patients were identified who experienced torsion about the vascular pedicle of an intra-abdominally placed renal allograft. RESULTS: Two patients who had received combined intraperitoneal kidney and pancreas transplantation presented at 16 and 11 months after transplant, respectively, with abdominal pain and decreased urine output. One patient had radiological documentation of abnormal rotation before the graft loss; unfortunately, the significance of this finding was missed. diagnosis was made in both patients at laparotomy, where the kidneys were infarcted secondary to torsion of the vascular pedicle. Both patients underwent transplant nephrectomy and subsequently received a successful second cadaveric renal transplant. CONCLUSIONS: The mechanism of this complication is a result of the intra-abdominal placement of the kidney, length of the vascular pedicle, excess ureteral length, and paucity of adhesions secondary to steroid administration. These factors contribute to abnormal mobility of the kidney. Technical modifications such as minimizing excess ureteral length and nephropexy may help to avoid this complication.
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2/386. Acoustic trauma from the bone cutting burr.

    The amplitudes of the stapes footplate movements were determined in human temporal bones when the ossicular chain was drilled with a cutting and a diamond burr. High movements result in comparison to physiological data. The frequency distribution resembles the dB (A) curve. The intensity compared to sound pressure levels on the ear drum is higher than I30 dB. The pressure is constant over the period of contact between the burr and the ossicle. Most likely these unphysiologic movements of the stapes footplate can cause inner ear damage as we had to admit in a case of facial nerve decompression.
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3/386. The clinical superiority of continuous exposure versus short-pulsed carbon dioxide laser exposures for the treatment of pearly penile papules.

    Treatment of pearly penile papules was performed both with a conventional continuous-wave (CW) and a newer generation high energy pulsed carbon dioxide laser. When compared to the short pulsed laser, the CW laser, using relatively low power densities, provided superior hemostasis and improved visualization of the operative field. Despite the increase in thermal injury, wound healing was not compromised. The results of this case report support the CO2 laser in CW mode as the infrared laser treatment of choice for exophytic lesions with increased vascularity.
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4/386. The challenge of arteriovenous fistula formation following disk surgery: a collective review.

    Five cases of arteriovenous fistula formation are added to the 68 found in previous reports. A review of the English-language literature revealed that the L4-5 disk space was most frequently involved, the right common iliac artery injured most often, and the right and left common iliac veins and inferior vena cava injured with similar frequency.
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5/386. Directional coronary atherectomy in acute myocardial infarction.

    To date, application of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI) has had limited reports. In eleven patients with AMI, DCA was applied. In three of these patients, DCA was used as a stand-alone procedure without use of thrombolytic agents. In each case a guidewire was placed across the stenosis, and in eight patients balloon angioplasty was utilized as a predilating modality prior to DCA. The thrombolytic agent urokinase was utilized in five of these eight patients, either before, during, or after angioplasty and/or DCA. DCA success (defined as ability to cross the lesion, reduction of less than or equal to 20% in stenosis and thrombolysis--when a thrombus is present) was achieved in 10 of 11 patients. One patient had persistent abrupt reclosure of an LAD lesion, accompanied by hemodynamic compromise, necessitating intra-aortic balloon pump insertion and subsequent emergent coronary artery bypass graft surgery. Final angiograms revealed residual stenoses less than or equal to 20%, and adequate thrombolysis. Significant cardiac events were limited to one emergent CABG, Q wave MI in four patients, and non-Q wave MI in two patients. Clinically all eleven patients improved, survived the AMI/CABG, and were discharged. This clinical experience demonstrates the feasibility and safety of DCA application in selected patients who experience acute myocardial infarction.
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6/386. A new, safer lasing technique for laser-facilitated coronary angioplasty.

    in vitro studies during cold pulsed-wave laser angioplasty have demonstrated production of gas bubbles within the target tissue, creation of shock wave and formation of multi-layer dissections accompanied by an increase in the plaque and vessel wall temperature. These processes account for certain complications of coronary lasing, including acute vessel closure, dissections, spasm, and even perforation. The traditional lasing technique in which a large number of pulses is continually emitted across the lesion, may in fact contribute to the development and acceleration of the above mentioned processes. To overcome the shortcomings we have developed a new, safe lasing technique that consists of multiple trains of a small number of pulses each. Between laser sessions the laser catheter is retracted into the guiding catheter and nitroglycerin is injected intracoronary, thus providing time for dispersion of produced gas bubbles, cooling of the target artery, and adequate coronary vasodilatation. This new technique results in a significant reduction of laser associated complications.
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7/386. Abdominal pulsatile tumor after endovascular abdominal aortic aneurysm repair.

    A 70 years old patient was successfully treated for infrarenal aortic aneurysm by an endovascular bifurcated prosthesis. Three months later, because of dysuria, he underwent urological examination revealing an abdominal pulsatile tumor. Thereafter, the patient was sent to our emergency ward with suspected symptomatical endoleak. Radiological screening by computer tomography and magnetic resonance angiography showed good post-operative results without endoleak. Patient was treated with antispasmodic medication and is doing well today. Because endovascular repair of aortic aneurysm, in contrast to an open approach, does not eliminate the aneurysm itself, post-operative abdominal palpation can be ambiguous. magnetic resonance angiography--without the need of nephrotoxic contrast medium--compares favourably to CT and provides excellent pictures with less artefacts for post-operative screening of endoleak. If reperfusion can be excluded, pulsation is due to the transmission of the blood-pressure wave to the thrombosed aneurysm.
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8/386. Induced hypothermia: electrocardiographic abnormalities.

    hypothermia was induced intermittently in a patient to combat hyperpyrexia. The electrocardiogram taken during the hypothermic phase displayed typical abnormalities and consisted of: pronounced sinus bradycardia, marked prolongation of the Q-T interval, muscle tremor artifact, and the characteristic "Osborn wave." Spontaneous rewarming resulted in disappearance of the electrocardiographic alterations, underscoring the functional and reversible nature of the abnormalities.
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9/386. Intestinal blind pouch- and blind loop- syndrome in children operated previously for congenital duodenal obstruction.

    A follow-up study of 27 children operated for congenital duodenal obstruction (CDO) in the years 1953--71 is presented. Nine children belonged to the intrinsic and 18 children to the extrinsic group of CDO. A total of 7 retrocolic, isoperistaltic, side-to-side duodeno-jejunostomy, 7 Ladd's operation, 8 duodenolysis, 2 reduction of midgut volvulus, 2 duodenostomy a.m. Morton and one gastro-jejunostomy were performed at the age of 1 day--15 years. The clinical and radiological examinations were performed 3--21 years (mean 10 years 2 months) after these operations. In 3 cases there was a moderate duodenal dilatation, but reoperation was not necessary. During the follow-up period, one boy, now aged 8 years, developed a blind pouch-syndrome in the I portion of the duodenum containing a 5 x 5 cm phytobezoar 4 1/2 years after duodeno-jejunostomy. The frequency of blind pouch-syndrome after duodeno-jejunostomy was thus 1:7 or 14%. One girl, now aged 9 years, developed a blind loop-syndrome in the ileocaecal segment 3 months after side-to-side ileotransversostomy, which was performed from adhesion-obstruction after duodenolysis for malrotation I and CDO. Both the blind pouch- and the blind loop-deformation were resected and the children recovered well. To avoid blind-pouch- and blind loop-deformations in the intestines, the anastomosis must be made wide enough, and especially in the surgery of the jejuno-ileo-colic region an end-to-end anastomosis is preferable.
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10/386. Percutaneous revascularization modalities in heart transplant recipients.

    Accelerated allograft vasculopathy significantly limits the survival of heart transplant recipients. The prevalence of allograft coronary artery disease is as high as 18% by 1 year and 50% by 5 years following heart transplant. heart failure and sudden cardiac death are the two most common clinical presentations. In heart transplant recipients with severe, discrete focal allograft vascular disease, percutaneous balloon angioplasty is a viable palliative option. However, its application is limited by a significant restenosis rate and progression of allograft disease in nontreated segments. Diffuse disease with tapering of vessels may be approached by debulking devices. Emerging revascularization modalities for focal stenoses and some of the diffuse tapering vessels include coronary stents, rotational atherectomy, various wavelength lasers, and, to a lesser extent, directional atherectomy. Conceivably, stents will reduce restenosis rates related to focal, discrete plaques; yet it is unknown whether they will be efficacious in short- and long-term treatment of diffusely diseased segments affected by allograft disease. Accurate assessment of clinical outcomes and long-term evaluation is imperative prior to acceptance of these devices as fundamental interventional tools for treatment of allograft coronary artery disease.
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