Infection of the graft in vascular surgery for the restoration of blood supply to the legs

Hippokratia 1998, 2(3):99-109

Th. Gerasimides

Abstract
Infection of the incision and graft after vascular surgery for the restoration of the blood supply to the legs is a very serious local complication that may endanger the leg or even patient's life if it reaches the anastomoses. The infection is usually introduced into the body during the operation; most often occurs in the groin and involves inflammation of the lymph nodes and vessels. The incidence of deep infection of the incision varies between 0,6 and 2.0% of vascular surgery cases. This can be reduced below 1.0% with a preventive antibiotic regimen, but above all by strict adherence to the principles of asepsis and antisepsis in the operating theatre. When the suppuration involves the lower limbs (groin, thigh, lower leg), the clinical picture presents the classic signs of inflammation. Total mortality is 10-30%, rising to 70% when the posterior peritoneal cavity is infected. The infection can be treated by opening up the incision, surgically cleaning it, locally applying antiseptics and administering antibiotics. Under certain conditions the graft can be retained in up to 60% of superficial infections, especially when it is autologous. Heterologous grafts (Dacron, PTFE) must be removed in 40-50% of cases due to serious bleeding or thrombosis of the graft. One possibility is the Zuhlke method of replacing the graft and covering it with a flap of muscle. The Erhrenfeld method involves replacement in the same position, using previously blocked arterial sections after retrograde endarterectomy, and is successful in 87% of an admittedly small number of cases. The preferred method in the case of graft infection is removal of the septic graft followed by an aseptic bypass using extra -anatomical grafts (axillo - femoral, sub -diaphragmal ascending aortic - femoral, femoral - femoral, obturator bypass, external knee bypass).In conclusion, it seems that infections of the incision and graft continue to occur, and that the small drop in the incidence of amputation and mortality in recent years can be further improved by a strict adherence to the principles of asepsis and antisepsis in the operating theatre, and with appropriate preventive chemotherapy.

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Transmissible Spongiform Encephalopathies

Hippokratia 1998, 2(3):110-124

N. Flaris, A. Constantinidou

Abstract

A few decades ago, Creutzfeldt - Jakob disease was an obscure form of dementia, unknown to most physicians. However, today it is a well known disease and the most common form of transmissible spongiform encephalopathies or prion diseases in humans. The recent outbreak of bovine spongiform encephalopathy (madcow disease) in England, the recognition of a new variant of Creutzfeldt - Jakob disease, which is probably related to bovine spongiform encephalopathy, and their presentation by the press and media were mainly responsible for that change. Since 1920, when Creutzfeldt -Jakob disease was first described, until recently the diagnosis of the disease was based on morphological criteria, the most specific of which is the spongiform change of the grey matter. The recognition of the transmissibility of the disease and the identification of prion protein (PrP) as an important element of the responsible infectious agent led to a new classification of the spongiform encephalopathies in humans and animals, and new methods of their diagnosis. Our review will focus on the description of the different forms of the transmissible spongiform encephalopathies, the evolution of our understanding of these diseases during the past decades, and the pathogenetic relationship of the prion protein and these diseases.

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The effect of alcohol on metabolism of normal people and diabetic patients

Hippokratia 1998, 2(3):125-134

D. Karamitsos

Abstract

Alcoholic beverages are included in various amounts in the everyday life of most of the people and can affect the glycemic control of diabetic patients. For many reasons such as toxic action on b-cells, increased tendency for hypoglycemia, caloric content, deterioration of chronic diabetic complications, dyslipidemia, hyperuricemia to mention only the metabolic effects, the diabetic patients must avoid the consumption of alcohol especially in the night.

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Successful management of thyroid cancer and Hodgkin lymphoma in a renal transplant recipient.

Hippokratia 1998, 2(3):139-143

Gr. Miserlis, G. Vergoulas, V. Papanikolaou, G. Imvrios, M. Leontsini, D. Takoudas, A. Antoniadis

Abstract

The aim of this case report was to describe the course and successful management of a renal transplant recipient, who presented thyroid cancer and Hodgkin lymphoma. The male patient KN, who was 35 years old, had an uneventful cadaver renal transplantation on 8th of April 1990 and was put on quadruple sequential immunosuppression. Two months later he presented Epstein - Barr virus infection (fever, headache, serologic conversion) while having normal graft function (Scr 1, mg/dl). Gancyclovir iv (DHPG) (5 mg/KgBW/12h) for 14 days and acyclovir p.o. (800 mgx4/d) for two months were given. At the same time azathioprine and cyclosporine were reduced drastically and patient's symptoms disappeared. Seven months later the patient presented thyroid cancer. Left thyroid lobe was dissected and he was put on thyroxin. On 20th of November 1993 patient's clinical examination revealed palpable neck lymph nodes and hepatosplenomegaly. Histological examination of the lymph nodes showed Hodgkin lymphoma, type 3, gradeIIA. At the same time thyroid right lobe was dissected because of relapse of thyroid cancer in situ. Azathioprine and cyclosporine were stopped and chemotherapy (MOPP/ABV) with local irradiation was given. Patient's clinical course was uneventful until 1997, when he had an acute rejection episode for which he was given methylopredisolone pulses. Today the patient has stable renal function (Scr 1,8 mg/dl), normal hematologic picture and he is under triple drug immunosuppression. During the nine year follow-up he became father twice and has a full time work. This case report, the first in the literature, shows that successful management of thyroid cancer and Hodgkin's lymphoma in transplant recipient is feasible without impairment of graft function.

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Repair of inguinal hernia with one day hospitalization (day - care)

Hippokratia 1998, 2(3):135-138

H. Frizis, I. Prionidis, K. Konstadinidis, G. Chatzitheoharis

Abstract

The classical surgical techniques of the inguinal hernia repair were based on approximation of tissues not normally overlapped. The recognition of this conceptual mistake led surgeons to the "tension - free" repair of the inguinal canal. The application of this method under local anesthesia without hospitalization (day - care) proved to be safe and cost - effective with better surgical results compared to the old fashioned method.The aim of this study was to test the safety and the efficacy of the method comparing our results with those of specialized centers with large series of patients treated on a day - care basis.During a 4 year period, 1994-1998, in the First Surgical Department of the Hippokration General Hospital, 161 patients undergone inguinal hernia repair with the "tension - free" method by Lichtenstein on a day - care basis.
The review of our results led us to the conclusion that the method can be applied with excellent results in every day practice. Moreover we believe that the method of day - care can be applied to other surgical diseases as well, leading to the improvement of health services and the reduction of the cost.

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