Continuous Quantitative Monitoring of Mural, Platelet-Dependent, Thrombus Kinetics in the Crushed Rat Femoral Vein

A new in vivo method to study the size and dynamics of a growing mural thrombus was set up in the rat femoral vein. The method uses a standardized crush injury to induce a thrombus, and a newly developed transilluminator combined with digital analysis of video recordings. Thrombi in this model formed rapidly, reaching a maximum size 391 ± 35 sec following injury, after which they degraded with a half-life of 197 ± 31 sec. Histological examination indicated that the thrombi consisted mainly of platelets. The quantitative nature of the transillumination technique was demonstrated by simultaneous measurement of the incorporation of 111In labeled platelets into the thrombus. Thrombus formation, studied at 30 min interval in both femoral veins, showed satisfactory reproducibility overall and within a given animal

With this method we were able to induce a thrombus using a clinically relevant injury and to monitor continuously and reproducibly the kinetics of thrombus formation in a vessel of clinically and surgically relevant size

Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature

Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.

Surgery in Belgium

To fully understand the present state of surgery in Belgium, it is necessary to know the structure of the Belgian State, the type of education, the statutory health insurance system, and the professional bodies representing surgeons. One of the most important problems is the excessive number of physicians, which recently led to the establishment of limits on the number of candidates receiving medical certification. Surgical training modalities are described and the results of a retrospective study concerning the quality of training are detailed. The continuing medical education and peer-review system (accreditation) is presented.

[Transposition of the gluteus maximus muscle for sphincter replacement in anal incontinence]

The replacement of the external anal sphincter by gluteus muscle in fecal incontinence is described in 4 cases. All patients, three children and one adult, had been operated on previously because of different types of anal atresia and suffered from fecal incontinence grade IV. They all showed a congenital defect of the somatic sphincter. The absent external and sphincter muscle was repaired by transposing innervated and vascularized gluteus muscle. In all cases active anal continence was achieved proven by clinical and electromanometric measures. The results, compared to other techniques, are discussed.

Continuous quantitative monitoring of mural, platelet-dependent, thrombus kinetics in the crushed rat femoral vein

A new in vivo method to study the size and dynamics of a growing mural thrombus was set up in the rat femoral vein. The method uses a standardized crush injury to induce a thrombus, and a newly developed transilluminator combined with digital analysis of video recordings. Thrombi in this model formed rapidly, reaching a maximum size 391 +/- 35 sec following injury, after which they degraded with a half-life of 197 +/- 31 sec. Histological examination indicated that the thrombi consisted mainly of platelets. The quantitative nature of the transillumination technique was demonstrated by simultaneous measurement of the incorporation of 111In labeled platelets into the thrombus. Thrombus formation, studied at 30 min interval in both femoral veins, showed satisfactory reproducibility overall and within a given animal. With this method we were able to induce a thrombus using a clinically relevant injury and to monitor continuously and reproducibly the kinetics of thrombus formation in a vessel of clinically and surgically relevant size.

The effects of cryopreservation on membrane integrity, membrane transport, and protein synthesis in rat hepatocytes

The cryopreservation of hepatocytes is of particular interest as a step in the possible treatment of some inborn disorders of metabolism. This study examines the metabolic damage that occurs as a result of the freeze-thaw procedures and during subsequent incubation periods of isolated rat hepatocytes. Even for freshly prepared hepatocytes, the presence of 1.8 M of Me2SO during incubation led to a rapid decline in viability. Optimal recovery after cryopreservation was obtained when incubation was started after the progressive removal of Me2SO. A buffer medium characterized by an intracellular electrolyte composition (Euro-Collins) proved particularly beneficial to the membrane integrity, probably by protecting the (Na+,K+)ATPase pump activity. The interpretation of viability using the trypan blue exclusion test was generally confirmed by the metabolic analysis of protein synthesizing activity and membrane transport function which are regarded as more rigorous tests of functional viability. The incorporation of L-[U-14C]isoleucine into the proteins of fresh hepatocytes during the first hour of incubation progressively leveled off over the next 2 hr. The cryopreserved hepatocytes showed a similar pattern although at a lower level of activity. Even after 3 hr of preincubation, the subsequent addition of labeled isoleucine still indicated a residual protein synthesizing activity. The active transport of alpha-amino[1-14C]isobutyric acid through the cell membranes reached a peak value after 60 min of incubation of fresh hepatocytes, and after 40 min of incubation of cryopreserved cells, followed by a steep decline as expression of rapid membrane deterioration. Again, the membrane transport pattern for the cryopreserved samples occurred at a lower level of activity. After preincubation of fresh and cryopreserved hepatocytes for 180 min, subsequent addition of labeled alpha-aminoisobutyric acid did not show any further significant metabolic activity. Initially the amino acid availability appeared to control protein synthesizing activity while, as membrane transport became seriously damaged, incorporation leveled off with only a low metabolic activity remaining. Although cryopreserved hepatocytes were susceptible to faster deterioration during subsequent incubation, considerable metabolic activity was retained. However, fresh and cryopreserved hepatocytes expressed metabolic functions at significantly different activities. Moreover, the differences between fresh and cryopreserved cells varied with the particular cellular function being examined.

[Surgery of foreign bodies in the esophagus in case of failure of noninvasive extraction technics]

In the period 1957-1987, 240 corpora aliena in the esophagus were treated. The foreign body could be extracted under endoscopy in 228 cases (95%). In 12 cases the non-invasive extraction technic failed, so we have to remove the foreign body surgically. The most difficult bodies to extract by endoscopic way are the big, the sharp or pointed ones. On the surgical point of view, the way of approach depends on the level of the impacted body. The problem of post-operative fistula and abscess formation after surgery, can be avoided by a correct technic, exclusion of underlying pathology, an adequate drainage and consequent infection treatment.

Renal cadaveric transplantation in diabetics using total lymphoid irradiation or cyclosporin A. A controlled randomized study. Leuven Collaborative Transplantation Group

A total of 20 renal transplant patients with end-stage diabetic nephropathy entered a randomized controlled trial comparing preoperative, fractionated total lymphoid irradiation (TLI) (radiation dose, 20-30 Gy) with postoperative cyclosporin A (CsA). Both groups received postoperative low-dose methylprednisolone maintenance therapy. The 3-year patient and graft survival was similar for both groups (100% and 71% in the TLI and 75% and 75% in the CsA group, respectively). Rejection crises occurred significantly more frequently (P less than 0.01) in the TLI-treated recipients. The incidence of infectious or diabetic complications was not significantly different in both groups. It is concluded that TLI and CsA are both effective treatment modalities for cadaveric renal transplantation in diabetics; CsA, however, is superior in preventing rejection crises.

Immunological and clinical observations in diabetic kidney graft recipients pretreated with total-lymphoid irradiation

In a feasibility study, twenty patients with end-stage diabetic nephropathy were treated with fractionated total-lymphoid irradiation (TLI, mean dose 25 Gy), before transplantation of a first cadaveric kidney. During radiotherapy, only one patient had a serious side effect (bone marrow depression). After transplantation four patients died (one of a myocardial infarction, one of ketoacidosis, and two of infections occurring during treatment of rejection crises). One graft was lost because of chronic rejection. The other 15 patients have a functioning graft (mean follow-up 24 months) and receive low-dose prednisone alone (less than 10 mg/day, n = 11) or in conjunction with cyclosporine (n = 4) as maintenance immunosuppressive therapy. A favorable clinical outcome after TLI (no, or only one, steroid-sensitive rejection crisis) was significantly correlated with a high pre-TLI helper/suppressor lymphocyte ratio, a short interval between TLI and the time of transplantation, and the occurrence of functional suppressor cells early after TLI. The most striking immunological changes provoked by TLI consisted of a long-term depression of the mixed lymphocyte reaction and of the phytohemagglutinin, and Concanavalin A or pokeweed-mitogen-induced blastogenesis. A rapid and complete recovery of the natural killer cell activity was observed after TLI. A permanent inversion of the OKT4+ (T helper/inducer) over OKT8+ (T suppressor/cytotoxic) lymphocyte ratio was provoked by a decrease of the OTK4+ subpopulation, together with a supranormal recovery of the OKT8+ lymphocytes. A majority of the latter lymphocytes did also express the Leu 7 and the Leu 15 phenotype.

[The surgical treatment of the post-phlebitis syndrome]

Between 1978 and 1983 a total of 62 Linton procedures were performed in 53 patients. The results are presented. 62% suffered from an insufficient superficial venous system for longer than 10 years. 34% had an active ulcer at the time of operation. Pre-operative preparation and operative technique are extensively dealt with. Post-operative wound necrosis occurred in 22.5%. This was mainly due to extensive subcutaneous dissection and tissue removal. Recurrent ulcer occurred in 4.8%.

The sonographic aspects of haemobilia. Clinical and experimental study

The sonographic aspect of the gallbladder in seven cases of haemobilia is analysed. The changes include a diffuse echogenic gallbladder content during the initial stage. Later, irregular shaped inhomogeneous non shadowing masses are seen in the dependent parts of the lumen. This variable aspect was studied in an experimental model by percutaneous injection of blood in the gallbladder of Guinea pigs. The hyperechoic gallbladder content, seen early after injection is a transitory phenomenon which seems related to red cell aggregation before coagulation occurs. During the later stage the intraluminal masses were shown by histology to represent bloodclots. In a patient the observation of such a rapid evolution from diffuse hyper-reflectivity to less reflective masses is strongly suggestive of haemobilia.

Thromboembolic complications and haemostatic changes in cyclosporin-treated cadaveric kidney allograft recipients

The incidence of thromboembolic complications was compared retrospectively in 90 cadaveric kidney allograft recipients treated with cyclosporin and low-dose steroids and the same number of cadaveric kidney allograft recipients treated with azathioprine, antilymphocyte globulin, and high-dose steroids. In the cyclosporin group, 17 thromboembolic complications occurred in 13 patients: 10 pulmonary emboli, 1 renal vein thrombosis, 3 deep vein thromboses, and 3 haemorrhoidal thromboses. In the azathioprine group, the only thromboembolic complication was 1 episode of superficial thrombophlebitis. Haemostatic tests in cyclosporin-treated and azathioprine-treated patients and normal subjects (10 in each group) showed increased concentrations of factor VIII C, fibrinogen, antithrombin III, and protein C in the cyclosporin-treated patients. Adenosine-5'-diphosphate-induced platelet aggregation was also significantly enhanced in the cyclosporin group. The effect of cyclosporin on haemostasis may predispose to thromboembolic complications.

[Chronic recurrent subareolar abscess formation]

Chronic recurrent subareolar abcedation. Chronic recurrent subareolar breast abscess is an unfrequent disease of the breast. The surgeon must be acquainted with the syndrome, otherwise it may lead to unnecessary mutilation. The condition usually develops in younger women, but has no relation with lactation. Inverted nipples are a constant finding. The evolution is a chronical one, with acute exacerbations. Small abscesses rupture spontaneously or necessitate surgical drainage or disappear with antibiotics. The basic pathological factor is squamous metaplasia of the lining epithelium of the milksinus. The ampulla is plugged with keratine debris and leads to abscess formation in the retroareolar space. Chronic recurrent subareolar abscesses have to be distinguished from commedomastitis, also called ductal ectasia. The treatment is different for acute and chronical forms. In the acute form antibiotics are administered and eventually incision and drainage of the abscess are performed. In the chronical form excision of the diseased milksinus and fibrotic tissue with the nipple is mandatory. We do not hesitate to excise the majority of the milksinuses.

Importance of HLA-DR matching in polytransfused cadaveric kidney transplant recipients. A prospective one-center study

Since August 1978 prospective HLA-DR typing has been performed in 157 donor-recipient pairs. All recipients received pretransplant blood transfusions. This study shows that HLA-DR matching can significantly improve the survival of cadaveric kidney allografts, even in polytransfused recipients. Patients receiving kidneys with no HLA-DR incompatibilities have a one-year graft survival of 97%, versus 86% for recipients with 1 HLA-DR incompatibility and 73% for recipients with 2 HLA-DR incompatibilities. The cumulative dose of corticosteroids during the first year after transplantation is significantly lower in patients with no DR-incompatibilities. HLA-A and B matching have no additional effect on graft survival.

A scanning electron microscopic study of microvascular anastomoses on irradiated vessels: short-term effect of irradiation

Experiments were carried out to determine the effect of previous irradiation on microvascular arterial anastomoses. The study focused on regeneration of endothelial cells and thrombus formation. Careful examination with scanning electron microscopy (SEM) showed a difference between irradiated animals and a control group. In the irradiated group one can notice a decreased regeneration, a greater amount of fibrin and platelets, and a higher incidence of microthrombi.

[Microsurgery in 1982. Importance of the technique in the different surgical specialties and training possibilities (author's transl)]

Recently microsurgical techniques have become standard procedures in microvascular surgery especially in plastic surgery and hand surgery and peripheral nerve surgery. In gynecology and urology microsurgery has improved the results of infertility surgery by two or three times. Microsurgical training in vascular and nerve repair should be undertaken by every fellow in plastic and reconstructive surgery of handsurgery. Gynecologists and urologists should be aware of the possibilities of microsurgery and have the opportunity during their training to participate on these procedures. They should however not need to have full knowledge of the technical details and refer patients to specialized infertility microsurgery centers.

[Surgery of the intrathoracic goiter (author's transl)]

One is often obliged to resect intrathoracic goiters. This is not directed towards functional problems but towards the local compression on other organs in the vicinity. Goiters that extend through the cervicomediastinal inlet are of this kind. In cases where the major part is in the mediastinum there still exists a continuity with the cervical part. Most cases can be resected by a cervicostomy. The vascularization comes from the neck except in true thoraic goiters. This makes it possible to ligate the vessels before extracting the gland. In difficult cases a mid sternotomy may be useful so that all thoracic goiters can be operated safely.

[Diaphysal pseudarthrosis of the tibia (author's transl)]

The authors analyse the etiology and treatment of 18 pseudarthroses of the tibial diaphysis occurring in a series of 320 fractures of this bone. This complication seldom appears in simple fractures treated by a plaster cast (two cases out of 144). In addition to classical and well known factors, it appears that pseudarthrosis occurs more frequently after traction-immobilization (10 cases out of 73), when the fragments had to be repositioned on many occasions under plaster cast, or in cases of open fractures. The treatment by bone grafting, principally in-lays, with or without plates and visses, yield satisfactory results.

[Traumatic rupture of the diaphragm. Clinical experience (author's transl)]

The increased number of automobile casualties increases the frequency of traumatic rupture of the diaphragm. Because of associated serious lesions, diagnosis is easily overlooked. The authors report on 11 cases and give an appraisal of the literature. In 6 patients, diagnosis was made late. The authors discuss the physiopathology, symptoms, clinical data and means of diagnosis. Roentgenography is very important. Surgical cure is always recommended because of the danger of delayed strangulation of the hernia.

[Reimplantation of fingers (author's transl)]

Three fingers have been reimplanted at present, bij means of microsutures of digital arteries and veins. The help of the surgical microscope is essential to this technique. In case of traumatic amputation of many fingers, with a neat minimal section, the chances of success are particularly good with a low risk of infection.

[Post-traumatic bronchial stenosis (author's transl)]

The authors have performed plastic reconstruction of a bronchus in a 16 years old patient, 6 1/2 weeks after rupture of the right stem bronchus. This had occurred during a blunt trauma to the thorax. In the acute phase the patient appeared completely cured by suction of the pneumothorax. Later occlusion of the bronchus with total atelectasis appeared. Respiratory function tests, blood gas analyses and pulmonary scintigrams were performed before and 12 weeks after the operation. The authors discuss the data from the literature pertaining to traumatic rupture of the bronchus in its acute phase and during progressive stenosis, for which surgery is warranted. Repair of the stenotic bronchus will make the lungs capable of assuming satisfactory hematosis.

Prolongation of allogeneic heart graft survival in the rat after implantation on portal vein

In rats, heart allografts with venous drainage via the portal vein were performed and compared with similar grafts draining into the inferior vena cava. A new technique was developed using the complete thoracic descending aorta and ligation of all its branches. The descending thoracic aorta was anastomosed to the recipient's abdominal aorta below the left renal vein. The pulmonary artery was implanted on the portal vein in an end to side fashion. In two rat strain combinations the allograft survival time was significantly prolonged when compared to that of the control grafts with pulmonary-caval anastomosis. The presumed mechanism for this prolonged graft survival might be the sequestration or degradation of transplantation antigens in the liver during their first passage through this organ. In this way only a small amount of antigen reaches the systemic circulation.