Acta Chir Belg
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Some controversy exists on the best moment to treat symptomatic carotid artery disease. This controversy concerns mainly neurologically unstable patients and patients who suffered a minor stroke. The authors discuss recent literature data on the feasibility and the safety of performing urgent (within 24 to 72 hours) carotid endarterectomy (CEA) in patients presenting repetitive transient ischaemic attacks or progressing stroke. Neurologically unstable patients, suffering ischemic brain deficit caused by carotid artery stenosis, are defined according to the following criteria: two or more transient ischaemic attacks (crescendo TIAs) or a fluctuating neurological deficit evolving no longer than 24 hours (progressing stroke), no impairment of consciousness, cerebral infarct of limited size on diffusion-weighted magnetic resonance imaging of the brain and a carotid artery stenosis of 70% or more on the appropriate side. In the past, these patients were often considered at too high risk to undergo immediate carotid surgery. Many neurologists remain reluctant to confine these neurologically unstable patients for urgent carotid endarterectomy and prefer to stabilise the neurological status, arguing the increased stroke morbidity in the urgent setting. Nevertheless, the natural history of stroke- in-evolution or repetitive transient ischemic attacks is far from benign, exposing the patient to a high risk of subsequent spontaneous stroke, even under best medical treatment. Another controversy exists on the timing of surgery in patients who suffered a minor, non-disabling stroke. Is a waiting period of 6 weeks safe? Once more, the operative risk should be balanced against the anticipated natural history. Published series, and sub-analysis of the recent carotid surgery trials (NASCET, ECST) plaid for carotid surgery within two weeks of a minor stroke. ⋯ Contemporary literature argues that neurologically unstable patients, presenting repetitive transient ischaemic attacks or progressing stroke, should be managed by urgent (within 24 to 72 hours) carotid endarterectomy, even if the peri-operative stroke-death rate is slightly higher than in the elective setting. Despite an inherent increased operative morbidity-mortality, urgent carotid endarterectomy seems to us justified by the fact that waiting for the surgery may lead to the development of a more profound stroke in these neurologically unstable patients. Their only chance for neurological recovery (partial or complete) is in the early phase (12 to 60 hours after the acute onset of the neurological syndrome of crescendo-TIAs or stroke-in-evolution). For patients presenting a minor stroke, with limited brain infarction, carotid endarterectomy should preferentially be done in a semi-urgent fashion, within two weeks.
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Review Case Reports
Legislation and refusal of blood transfusion by a minor Jehovah-Witness in Belgium.
The refusal of blood transfusion by Jehovah's Witnesses in critical situations constitutes an ethical and juridical dilemma. The refusal to receive blood products by Jehovah's Witnesses is based on biblical verses. Recurring arguments to sustain this refusal regard the right to self-determination and the right to freedom of faith. ⋯ Regarding minors, the law on patients' rights in Belgium contains safety mechanisms concerning the preservation of physical integrity. Therefore, a key responsibility has been assigned to the physician. A step-by-step plan and a synoptic diagram are presented.
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Diverticular disease of the colon is a common condition in developed countries. For perforated diverticulitis Hartmann's procedure is a safe and quick treatment option. But intestinal restoration needs further interventions. This leads to high complication rates and cost. Therefore a critical evaluation of surgical treatment options is necessary. ⋯ In emergency surgery for complicated diverticulitis primary anastomosis is not associated with an increased postoperative morbidity. A primary anastomosis reduces the need for further surgical interventions and complex re-operations. Thus, an overall reduction of morbidity, cost, complication rate and hospital stay is possible. Therefore this technique is advantageous for patients and hospitals.
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To investigate whether the indication for the first revascularization (diabetic foot, acute ischaemia, aneurysmal disease, chronic occlusive disease) determines the surgical history and survival time in amputated limbs. ⋯ Our study suggests that the surgical history and limb survival in amputated limbs is disease and stage specific, and determined by the indication of the first revascularisation.
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Pre-incisional infiltration of anaesthetic is proven to reduce postoperative pain in breast cancer surgery. However, studies of post-incisional infiltration for modified radical mastectomy are rare. The purpose of this study was to investigate whether post-incisional infiltration with bupivacaine provides improved postoperative pain relief and a cost-effective benefit. ⋯ Post-incisional wound infiltration with bupivacaine can relieve pain during the first 16 hours after surgery and shorten hospital stay, and it provides a cost-effective benefit.