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Wawrzyniec Jakuczun, Małgorzata Szostek, Ryszard Pogorzelski, Mieczysław Szostek and Maciej Skórski

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms

Aortic aneurysms, especially when ruputured, constitute a direct life threat. Mortality in emergency surgical procedures has been estimated at 50 to 90%. In the recent years great advances have been achieved in the form of endovascular techniques, which offer effective treatment and are associated with a lower risk of complications and death.

The aim of the study was to evaluate endovascular treatment in patients with hypovolaemic shock due to aortic rupture in the infrarenal segment.

Material and methods. 19 patients with ruptured aortic aneurysms were treated by stentgraft implantation in our department from 2001 to 2006. Bifurcated stentgrafts were used in 6, while aortouniiliac stentgrafts were used in the remaining 13 with consecutive femoro-femoral by-pass grafting.

Results. Good results were obtained in 14 (73.7%) patients operated on while in hypovolaemic shock caused by aortic aneurysm rupture.

5 patients died in the perioperative period (26.3%). The deaths were caused by shock and multiple organ failure.

Conclusions. 1. Advances in vascular surgery offer an effective treatment for patients in hypovolaemic shock due to abdominal aortic aneurysm rupture. 2. New treatment modalities do not lift the surgeon's responsibility to manage shock, which remains the main cause of death in patients with ruptured aortic aneurysms. 3. If the technical conditions for stentgraft implantation are met, endovascular procedures should be the method of choice in cases of ruptured abdominal aortic aneurysm.

Open access

Ryszard Pogorzelski, Małgorzata Szostek, Tomasz Wołoszko, Wawrzyniec Jakuczun, Sadegh Toutounchi, Waldemar Macioch, Mieczysław Szostek and Maciej Skórski

Surgical Treatment for Thoracic Injuries - One Clinic's Experience

The aim of the study was to present one clinic's experience in the treatment of thoracic injuries. Particular attention was paid to the methods for treatment of patients after thoracic injuries.

Material and methods. During the years 1996-2006, 273 patients with thoracic injuries were hospitalized in the clinic; 0.9% of all patients treated during this time. There were 66 women (24.2%) and 207 men (75.8%), aged 17 to 85 years (average: 34.9).

Results. Among all of the thoracic injuries analyzed, the most common was traffic accidents, which made up 111 (40.7%) cases. Next, accidents of violence made up 87 (31.9%) cases, and accidental falls and falls from heights 62 (22.7%) cases. Rare were self-mutilations, crash traumas and gunshot traumas. Isolated injury was observed in 107 cases, and 166 (60.8%) patients had multifocal trauma and multi-organ injuries. 50 patients (18.3%) had acute, penetrating injuries, and 223 patients (81.7%) had blunt thoracic injuries. During hospitalization, other traumas were diagnosed: rib fractures in 107 cases (39.2%), pleurohematoma in 37 cases (13.6%), pneumothorax in 36 cases (13.2%), pneumohemothorax in 26 cases (9.5%), lung contusion in 43 cases (15.8%), posttraumatic aorta aneurysm in 31 cases (11.4%), and contusion of the heart or great vessels in 8 cases (2.9%).

The applied treatment was: pleural cavity drainage in 86 cases (27.8%), immediate thoracotomy in 24 cases (8.8%), laparotomy in 23 cases (8.4%), stent-graft implantation in posttraumatic aneurysms in 30 cases (11%), and other specialized operations in 46 cases (16.9%). Qualified surgical treatment was performed in 176 cases (64.5%) out of 273. Multispecialized treatment was used in 46 cases (16.8%). 16 patients died (5.9%), most directly after admission to the hospital.

Conclusions. 1. Over 30% of patients need no surgical treatment after thoracic trauma. 2. The most common coexisting injuries with thoracic trauma are cranio-cerebral injuries and bone fractures. 3. The main cause of death is oligovolemic shock due to heart and great vessels contusion.

Open access

Tomasz Wołoszko, Ryszard Pogorzelski, Tomasz Brzeziński, Małgorzata Szostek, Wawrzyniec Jakuczun, Mieczysław Szostek and Maciej Skórski

Abdominal Injury. Pathogeniesis and Outcome of the Treatment

Abdominal injuries seem to appear rather not frequently. In a presented material their prevalence does not exeed 0.3% of all patients. In spite of that they are significant problem of surgical wards on duty for in many cases surgical intervention is necessary.

The aim of the study was to assess the extent of required surgical treatment and the results of injury management.

Material and methods. 95 patients with abdominal injury were treated in our clinic between years 1996 and 2006. There were 29 women (30.5%) and 66 males (69.5%) in this group at the age ranging from 17 to 91 years /mean-44 years/. The reasons of the injury were as follow: traffic accidents in 33 patients (34.7%), sudden collapse and the fall from the height in 25 patients (26.3%) and the assault in the rest 32 patients (33.7%). Blunt abdominal trauma was diagnosed in 69 patients (72.6%) while penetrating one in 26 persons (27,4%). Isolated injury to abdominal cavity concerned 35 cases (36,8%) and in the rest 60 cases (63,2%) were poly-trauma patients. Abdominal trauma was accompanied most frequently by chest trauma (34 cases-35.8%), then by head injury (32 cases - 33.7%) and bone fracture (29cases -30.5%). In 24cases (25.3%) all the mentioned injuries appeared simultaneously. Diagnosis was based on physical evaluation and ultrasound examination. In selected cases computed tomography was done. As the result of performed evaluation the diagnosis was made and 53 patients (55.8%) were operated. In 18 patients splenectomy was performed because of its rupture, the following 14 patients required suture of the intestine, 13 patients required drainage of intraperitoneal haematomas and ruptured mesocolon. 8 patients had injury to the liver and kidney. 42 patients (44.2%) were treated conservatively.

Results. All of the operated patients survived and were discharged home. There were 8 deaths (8.4%) in the group treated conservatively. Six of them appeared just after the admission to the clinic or in the emergency room and two of them in the fist several days of patients stay. The reason of all the deaths was profound posttraumatic shock due to multi-organ injury.

Conclusions. 1. Intraperitoneal hemorrhage and peritonitis due to gastrointestinal tract injury are the most frequent indications for surgery in patients with abdominal trauma. 2. The main reasons for unsuccessful treatment of isolated abdominal injuries are multi-organ injury and postraumatic shock.

Open access

Patryk Fiszer, Ryszard Pogorzelski, Sadegh Toutounchi, Małgorzata Szostek, Ewa Krajewska, Wawrzyniec Jakuczun, Robert Tworus and Maciej Skórski

Results of General Surgical Treatment of Patients Over 80 Years of Age in Single-Site Experience

The aim of the study was to evaluate the results of general surgical treatment of patients over 80 years of age.

Material and methods. Three hundred and four patients aged 80 to 105 years with general surgical disorders, treated in 2005-2009, were retrospectively included in the study. The collected information included demographic data, coexisting diseases, the mode of admission, the diagnosis, the method and result of treatment, and also potential complications and 30-day mortality. The data were subjected to statistical analysis.

Results. The study group included 186 women and 118 men. Two hundred patients (65.8%) were admitted in an emergency setting. The most common causes of immediate hospitalisation were: mechanical ileus (26.5%), gastrointestinal bleeding (22%), trauma (16%), and gall-bladder disorders (8.5%). The remaining 104 (34.2%) patients were operated upon on an elective basis. An emergency operation was required by 121 (60%) of the patients admitted in an emergency setting; the remaining ones were treated conservatively. Hernia plasties (27.5%), cholecystectomies (15.3%), colorectal resections (13.2%), strumectomies (11.2%) and endoscopies (6.1%) predominated among elective surgeries.

The total number of complications and mortality were 19.4% and 14.5%, respectively. The number of complications and mortality were significantly higher in the group of patients admitted in an emergency setting (25.5% and 20.5%, respectively) than in patients admitted on an elective basis (8.7% and 2.9%, respectively), p<0.01.

The mean duration of hospitalisation was 9.7 days (1 to 60 days), with a small difference between the groups of patients treated on an elective and emergency basis (8.5 and 10.4 days), p=0.181.

Conclusions. The results of surgical treatment of elderly patients do not significantly differ from the results of treatment of the general population. Much worse results, coupled with a significant increase in mortality, are observed in patients admitted and treated on an emergency basis.

Open access

Patryk Fiszer, Sadegh Toutounchi, Ryszard Pogorzelski, Ewa Krajewska, Witold Cieśla and Maciej Skórski

Laparoscopic Adrenalectomy - Assessing the Learning Curve

Laparoscopic adrenalectomy (LA) has become the "gold standard" for treatment of most of adrenal tumors in last few years. It has many benefits comparing to open surgery, but still is considered as complicated procedure requiring experienced surgical team.

The aim of the study was to assess the learning curve of laparoscopic adrenalectomy and the outcome of the first consecutive 154 LA.

Material and methods. 154 consecutive patients undergoing LA between 2007 and 2010 were reviewed. Collected data included: patients demographics, clinical and histological diagnosis, side and length of operation, conversions to open surgery, complications and hospitalization time. Learning curve was evaluated by dividing all patients into three groups (group I - first 50 patients, group II - second 50 patients and group III last 54 patients). Differences between the groups were analyzed.

Results. There were 154 LAs performed. Indications for LA were hormonally inactive adrenal adenoma(n=57), Conn's syndrome (n=30), Cushing's syndrome (n=28), pheochromocytoma (n=27), adrenal cyst (n=8), and others (n=4). Mean tumor size was 45.28 mm. There were 79 left-sided and 75 right-sided procedures and the average time of hospitalization was 4.64 days. Mean operative time was statistically different between the groups (216.2 min. - 164.6 min. - 131.9 min.; p<0.01) as well as the number of conversions to open surgery (18% - 4% - 3.7%; p=0.013). There was not any significant difference in the number of complications between analyzed groups (2% - 2% -3.7%).

Conclusion. To improve the outcome of LA it is necessary to perform approximately 40 to 50 procedures.

Open access

Ryszard Pogorzelski, Patryk Fiszer, Sadegh Toutounchi, Ewa Krajewska, Małgorzata M. Szostek, Robert Tworus, Wawrzyniec Jakuczun and Maciej Skórski

Anastomotic aneurysms may develop after any type of vascular surgery, in different areas of the arterial system, and require reoperation. The frequency of occurrence of the above-mentioned is estimated at 1-5%.

Material and methods. During the period between 1989 and 2010, 180 patients with 230 anastomotic aneurysms were subject to surgical intervention at the Department of General and Thoracic Surgery, Warsaw Medical University. The study group comprised 21 (11.7%) female and 159 (88.3%) male patients, aged between 30 and 87 years (mean age - 62.8 years). In relation to the number of anastomoses aneurysms were diagnosed in 2.1% of cases. Twenty-four (10.4%) patients were diagnosed with recurrent aneurysms.

Results. Surgical procedures performed were as follows: artificial prosthesis implantation (119), reanastomosis (40), patch plasty (25), graftectomy (19), prosthesis replacement (9), and stent-graft (7) implantation. 195 (84.8%) aneurysms were subject to planned surgery, while 35 (15.2%) required emergency intervention.

77.8% of patients were diagnosed with aseptic aneurysms, while the remaining 22.2% with infected perioperative aneurysms.

Good treatment results were obtained in 149 (82.8%) patients. Limb amputations were performed in 19 (10.5%) cases. Twelve (6.7%) patients died as a consequence of infection and general complications.

Conclusions. Vascular reoperations are a difficult clinical problem and are burdened with a high rate of complications. The above-mentioned often require complex treatment, in order to improve therapeutic results.

Open access

Ryszard Pogorzelski, Tomasz Wołoszko, Małgorzata Szostek, Waldemar Macioch, Jerzy Leszczyński, Wawrzyniec Jakuczun, Andrzej Małek, Maciej Skórski and Mieczysław Szostek

Anastomotic Aneurysms in the Groin - Results of Surgical Treatment

The aim of the study. The authors introduce single-center results of surgical treatment of 84 aneurysms in 79 patients. Anastomotic aneurysms belong to group of pseudoaneurysms which appear in places after vascular anastomosis.

The most common location of this kind of pseudoaneurysm is the groin (85%). The next most common location is the proximal anastomotic place with the aorta or iliac common artery (12%), which constitutes from 1 to 5% of all vascular abnormalities. Usually, these need to be surgically treated.

Material and methods. The authors present surgical treatment results of 79 patients with 84 pseudoaneurysms: 10 women (12.7%) and 69 men (87.3%) ranging in age from 44 to 81 years old, with an average age of 64.7 years old.

The frequency of this pathology in all patients with vascular diseases treated in our Department was 1.6% and 7.7% in patients after surgical anastomosis in the groin. Eleven patients (13.9%) with aneurysm rupture and four (5.1%) with thrombosis and acute ischemia of the lower limb needed an emergency operation. The remaining 64 patients (81%) were operated on according to the plan.

The most common operations were: vascular by - pass, secondary suture of anastomosis, and covering the lost part of the anastomosis with a patch. This treatment was used in 66 cases (84.5%), and 18 patients (22.8%) needed early secondary operation. 18 patients (22.8%) had a vascular prosthesis infection.

Results. A good treatment result of anastomotic aneurysms was observed in 64 patients (81%).

In 10 cases (12.7%), amputation was needed due to lack of blood recirculation in the limbs.

Five patients died because of MODS due to vascular prosthesis infection.

Conclusions. 1. The most important complication resulting in surgical treatment failure is vascular prosthesis infection and the progress of peripheral arteriosclerosis. 2. Distant vascular anastomosis dehiscence may show that the anastomosis was done using too much tension or that there were dakron physicochemical changes due to the aging process.

Open access

Ryszard Pogorzelski, Tomasz Wołoszko, Andrzej Małek, Małgorzata Szostek, Wawrzyniec Jakuczun, Sadegh Toutounchi, Waldemar Macioch, Jerzy Leszczyński and Maciej Skórski

One-Centre Study Investigating a need for an immediate vascular surgery in patients over 80 years of age - comparison analysis of the results

According to the observation made by the study authors, every year there is an increasing number of patients advanced in years who require surgical management of their vascular disease. They constitute more than 4% of all patients. The similar situation is our medical centre, where the number of the hospitalisations of octogenarians increases with every subsequent year. In spite of many concomitant diseases we propose them immediate operation. Then it seems to be important a comparison two ways of treatment: immediate and elective ones.

The aim of the study was evaluation of the results obtained in the treatment of vascular diseases requiring an immediate surgical intervention.

Material and methods. In the years 2005-2007, there were 150 patients treated for arterial diseases. The group consisted of 87 men (58%) and 63 women (42%), with a mean age of 83.6. All the patients were divided into two groups: patients undergoing an elective surgery (n = 113), and those operated on immediately (n = 37). For both these groups was performed the comparison analysis, concerning the most important concomitant disorders, having an unquestionable influence on the final results of the operative treatment

Results. The comparison analysis of deaths, amputations, and hospitalisation period in the elective and immediate surgeries revealed the following: 5.3% vs 21.6% (p = 0.006), 7.9% vs 13.5% (p = 0.33), and 15.8 vs 9.8, respectively.

Conclusions. Immediate vascular surgery is especially needed by older women. Culture and customs are the reasons for treatment delay in Poland, with its direct effects on the treatment results.

Open access

Ewa Krajewska, Sadegh Toutounchi, Patryk Fiszer, Witold Cieśla, Ryszard Pogorzelski, Tomasz Bednarczuk, Andrzej Cieszanowski, Izabela Łoń and Maciej Skórski

Adrenal Tumors - Diagnostics and the Factual Situation

The study presented three cases of patients diagnosed with adrenal tumors subject to surgical intervention during the past 6 months in our Department. The patients presented with radiological diagnostic difficulties, as to the character and location of the primary tumor.

The aim of the study was to demonstrate differences between radiological examination results and the factual situation observed during the adrenalectomy. In all the presented cases patients' were subject to laparoscopic intervention. In two cases conversion to open surgery was necessary. The histopathological results of the surgically removed samples were as follows: leiomyoma, myoperycytoma and pheochromocytoma. In selected cases imaging examinations might be of limited value, especially when determining the character and location of the primary lesion of the adrenal gland.

Open access

Ryszard Pogorzelski, Patryk Fiszer, Sadegh Toutounchi, Małgorzata M. Szostek, Ewa Krajewska, Wawrzyniec Jakuczun, Robert Tworus and Maciej Skórski