South African Journal of Surgery - Volume 45, Issue 2, 2007
Volume 45, Issue 2, 2007
A prospective comparison of secondary interventions and mortality in open and endovascular infrarenal abdominal aortic aneurysm repair : general surgerySource: South African Journal of Surgery 45, pp 39 –42 (2007)More Less
Endovascular aneurysm repair (EVAR) has provided a safe and effective alternative to the standard open repair of abdominal aortic aneurysms (AAAs). It has, however, been associated with a high requirement for secondary interventions. This prompted us to compare the two procedures with regard to secondary interventions and mortalities. The sample size was 278 patients, of whom 156 had undergone the open operation and 122 had undergone EVAR. The perioperative morbidity and mortality, as well as the major and minor secondary intervention rates, were obtained for these patients. The results suggest that there is no significant difference in secondary interventions and mortality between the two groups, despite the EVAR group being at significantly higher risk.
Cerebral monitoring during carotid endarterectomy - a comparison between electroencephalography, transcranial cerebral oximetry and carotid stump pressure : general surgerySource: South African Journal of Surgery 45, pp 43 –46 (2007)More Less
Objective. Various modalities are used for cerebral monitoring during carotid endarterectomy (CEA). The aim of this study was to evaluate whether transcranial cerebral oximetry (TCO) and carotid stump pressure (SP) are as accurate as electroencephalography (EEG) for monitoring cerebral ischaemia during carotid cross-clamping.
Methods. One hundred consecutive patients who underwent CEA were studied with continuous and simultaneous EEG and TCO. SP was measured for each patient. The percentage decrease of oxygenation on TCO was calculated during cross-clamping and surgery. EEG findings were used as the benchmark to detect cerebral ischaemia and were the indication for insertion of a temporary shunt. The relationship with TCO was observed in terms of percentage decrease in oxygenation.
Results. A total of 6 patients were shunted on the basis of their EEG changes. TCO changed more than 20% in these 6 patients, but an additional 12 patients had TCO changes with a normal EEG. This correlated with a decrease in blood pressure (BP) and was corrected by increasing the BP. The positive predictive values (PPVs) and negative predictive values (NPVs) for shunting based on TCO (as compared with EEG) were 33% and 100% respectively. Thirty-four patients had SP < 50 mmHg, of whom 4 were shunted based on EEG changes. Two of 66 patients with SP > 50 mmHg were shunted based on EEG changes. If a shunting policy had been based on a SP of 50 mmHg, 30 patients would have been shunted unnecessarily (PPV 12%), whereas the non-requirement for a shunt was predicted correctly in 64 of 66 patients (NPV 97%).
There were 2 major strokes: 1 contralateral on day 3 in a patient with bilateral severe stenoses, and 1 ipsilateral in a non-shunted patient with normal EEG, TCO and SP > 50 mmHg.
Conclusion. Compared with EEG, TCO is a practical and non-invasive monitoring system with a high sensitivity (100%) but a low specificity. TCO is more sensitive to a drop in BP and responds earlier to these changes than EEG. SP should not be used as the sole predictor for shunting during CEA.
Emergency endovascular repair for ruptured abdominal aneurysms - a feasibility study and report of 10 cases : general surgeryAuthor J. Van MarleSource: South African Journal of Surgery 45, pp 48 –51 (2007)More Less
Background. Endovascular aneurysm repair (EVAR) has been proved to be effective and safe in the elective management of abdominal aortic aneurysms (AAAs). Initial reports concerning endovascular management of ruptured aneurysms have been promising. Objective. To determine the outcome of endovascular repair of ruptured aneurysms in the local setting.
Materials and methods. Patients who presented with ruptured AAAs were considered for endovascular repair if they were haemodynamically stable and had suitable aneurysm morphology for EVAR.
Results. Ten patients (9 males, 1 female) with a mean age of 74.9 years were treated. All aneurysms were successfully excluded using aorta uni-iliac stent grafts in 7 patients and bifurcated stent grafts in 2 patients. In 1 patient who had had a previous EVAR, a proximal extension device was used. Two patients died in the peri-operative period (30-day mortality of 20%) and 1 patient died after 2 months. Seven patients are still alive. No endo-leaks occurred in any of the survivors.
Conclusion. Endovascular repair of ruptured AAAs is feasible with acceptable peri-operative mortality and short- to medium-term results.
The sternocleidomastoid myoperiosteal flap for the reconstruction of a tracheal defect : general surgerySource: South African Journal of Surgery 45, pp 56 –57 (2007)More Less
The sternocleidomastoid (SCM) myoperiosteal flap offers a relatively simple, single-stage reconstruction of a tracheal defect after conservative resection of an invasive papillary cancer of the thyroid with intraluminal involvement. Vascularised clavicular periosteum provides a viable, pliant, airtight, composite autologous graft with minimal vocal disturbance and a low risk to the parathyroid glands. The operation is not difficult to perform and has an acceptable long-term result even for the occasional operator in the specialised field of tracheal surgery.
Source: South African Journal of Surgery 45, pp 62 –64 (2007)More Less
Malignant melanoma of the vermilion of the lip is a rare entity, and because of the common occurrence of other benign pigmented lesions, it is easily overlooked. Early diagnosis is of the utmost importance, in the first instance to minimise the risk of haematogenous, lymphatic, perineural and trans- (salivary) ductal spread. The second reason for early diagnosis is that surgery is the only effective form of treatment. A number of important clinical lessons were learned from this cohort study of malignant melanoma of the vermillion of the lip. Two observations are of note - first, the absence of palpable regional lymph nodes does not exclude the presence of a malignant melanoma, yet all patients presenting with palpable nodes were suffering from a preterminal disease. Secondly, apart from 1 case (our case 2), melanoma of the lip seems to occur on the lower lip only. There are no clear guidelines regarding the necessary extent of extirpation for malignant melanoma of the vermilion of the lip, but we propose that clear margins of less than 10 mm are probably inadequate and margins of more than 20 mm are unnecessary. Concern about a resection resulting in a 20 mm clear margin all round is seldom justified as excellent methods of reconstruction achieving acceptable mobile, adequately sensate lips are available.