Biomedical subjects
A L Estrera
Publications and source records attributed to A L Estrera.
Number needed to treat: analyzing of the effectiveness of thoracoabdominal aortic repair.
BACKGROUND: Number needed to treat (NNT) is a method used to calculate the number of patients who need to be treated to prevent one adverse outcome. To analyze the effectiveness of thoracoabdominal and descending thoracic aortic aneurysm repair, we computed the NNT required to prevent one death. METHODS: Between Jan 1991 and Feb 2003, we repaired 1004 aneurysms of the descending thoracic and thoracoabdominal aorta. We followed the patients from surgery until death. Five-year actuarial survival in our population was computed by the Kaplan-Meier method. Natural history data for comparison were taken from the population-based work of Bickerstaff et al., 1982. NNT was calculated as the reciprocal of the risk difference at 5 years. 95% confidence intervals were computed by the method of Daly. RESULTS: Five-year mortality in the population-based cohort was 87 vs. 39% in our treated population, for a risk difference of 48%. 1/0.48=2, indicating that two patients need to be treated to prevent one death at 5 years (95% CI 1.8-2.5, p<0.0001). CONCLUSION: An NNT of two demonstrates the effectiveness of surgical repair of descending thoracic and thoracoabdominal aortic aneurysms when compared to the natural history. By comparison, carotid endarterectomy for symptomatic lesions >70% has an NNT of 15 to prevent a single stroke or death. NNT can also be applied to aneurysm size criteria to estimate the effort required to prevent death or rupture for a given aneurysm size.
Chronic aortic dissection not a risk factor for neurologic deficit in thoracoabdominal aortic aneurysm repair.
OBJECTIVE: chronic aortic dissection has long been considered a risk factor for neurologic deficit following thoracoabdominal aortic aneurysm (TAA) surgery. We reviewed our experience with regard to aneurysm extent and the use of adjunct, (distal aortic perfusion/cerebrospinal fluid drainage), and examined the impact of these factors on neurologic deficit among chronic dissection and non-dissection cases. METHODS: between February 1991 and March 2001, we repaired 800 aneurysms of the descending thoracic and thoracoabdominal aorta. Seven hundred and twenty-nine cases were elective; 196 chronic dissection, 533 non-dissection. 182/729 (24.9%) were TAA extent II. Among these, 61/182 (33%) involved chronic dissection. Adjunct was used in 507/729 (69.6%). We conducted detailed multivariate analyses to isolate the impact of chronic aortic dissection on neurologic morbidity, with other important risk factors taken into account. RESULTS: overall, 32/729 (4.4%) patients had neurologic deficit upon awakening; 7/196 (3.6%) in chronic dissections, and 25/533 (4.7%) in non-dissections. Adjunct had a major effect, reducing neurologic deficit in TAA extent II from 10/36 (27.8%) to 10/146 (6.9%) (p=0.001). However, in univariate and multivariate analysis, chronic dissection did not increase the risk of neurologic deficit, regardless of extent or mode of treatment. CONCLUSION: in contrast to previous reports, we determined that chronic aortic dissection is not a risk factor in TAA patients.
Determinants of hospital length of stay after thoracoabdominal aortic aneurysm repair.
PURPOSE: Extended hospital length of stay (LOS) and consequent high costs are associated with thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery. In this study, we examined factors that may influence LOS after TAAA repair. METHODS: Five hundred forty thoracic and TAAA repairs were performed by one surgeon between 1990 and 1999. The data were analyzed with multiple linear regression with appropriate logarithmic transformation. The predictor variables included patient demographics, disease extent, severity indicators, intraoperative factors, and postoperative complications. RESULTS: The median LOS was 15 days. Postoperative creatinine level of greater than 2.9 was the most important predictor of LOS, followed by spinal cord deficit, age, and pulmonary complication (all statistically significant with P <.05). A second model constrained to preoperative risk factors showed both age and complete diaphragmatic division to be associated with increased LOS. Preservation of the diaphragm led to reduced LOS by an average of 4 days. The adjunct cerebrospinal fluid drainage and distal aortic perfusion was associated with a decrease in LOS, although it did not reach statistical significance. CONCLUSION: Renal failure, spinal cord deficit, and pulmonary complication were the major determinants of LOS in patients for TAAA repair. This study shows that the preservation of diaphragmatic function and the use of the adjunct distal aortic perfusion and cerebrospinal fluid drainage may reduce hospital LOS.
Staged repair of extensive aortic aneurysms: morbidity and mortality in the elephant trunk technique.
BACKGROUND: Extensive aortic aneurysms (ascending aorta, aortic arch, and descending or thoracoabdominal aorta) require innovative surgical techniques. Some surgeons advocate a single procedure with long periods of profound hypothermia, whereas others use a staged approach. We adopted a two-staged procedure (elephant trunk technique) in 1991 for elective repair of extensive aortic aneurysms. METHODS AND RESULTS: Between February 1991 and May 2000, we performed a total of 1146 aortic aneurysm operations. Of these, 182 (15.9%) operations were first- or second-stage elephant trunk procedures, performed in a total of 117 patients. Stage 1 was completed in all 117 patients. Stage 2 was completed in 65 (55.6%) of 117 patients. Thirty-day mortality rate for the first stage was 5.1% (6 of 117). Mortality rate during the interval between operations was 3.6% (4 of 111), of which 75% (3 of 4) were the result of aneurysm rupture. Thirty-day mortality rate for the second stage was 6.2% (4 of 65). A total of 43 patients did not return for second-stage repair. Among these patients, within an average period of 3.4 years (range, 1.5 months to 4.9 years), 13 of 43 (30.2%) died, 4 of 13 (30.8%) as the result of rupture. Two of 117 (1.7%) first-stage patients had postoperative stroke. No spinal cord dysfunction occurred in second-stage patients. CONCLUSIONS: Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality rates through the use of the elephant trunk technique. Death was most commonly the result of rupture, both in interval patients awaiting scheduled second-stage repair and in patients who did not return. After the first stage, prompt treatment of the remaining segment is crucial to the success of staged repair.
Surgical resection of non-small cell carcinoma after treatment for small cell carcinoma.
BACKGROUND: Development of non-small cell lung carcinoma (NSCLC) in patients previously treated for small cell carcinoma (SCLC/NSCLC) is well described; however, little is known about clinical outcome. METHODS: A single-institution 20-year review was performed. Patient characteristics and survival for SCLC/ NSCLC patients were compared with those for control patients matched for stage, resection, and previous malignancy. RESULTS: One thousand four hundred four patients with small cell carcinoma were identified, and 29 underwent therapy for metachronous NSCLC: 11 of 29 patients underwent surgical resection, 10 of these 11 (90%) were stage I. Compared with surgically treated stage I NSCLC patients, SCLC/NSCLC patients were more likely to have squamous histology (70% versus 35%, p = 0.026); and subanatomic resection (90% versus 17.4%, p < 0.0005). The SCLC/NSCLC patients had significantly poorer survival when compared with stage I NSCLC patients undergoing any resection (24.53 versus 74.43 months, p = 0.003) and stage I NSCLC patients receiving wedge resection (24.53 versus 58.39 months, p = 0.006). Survival was similar to NSCLC patients with a history of previous treated extrathoracic solid malignancy. CONCLUSIONS: Surgical resection for SCLC/NSCLC patients is feasible, but poorer prognosis is noted when compared with stage-matched control patients. Surgical candidates should be carefully chosen, and alternative local control modalities considered.
Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion.
BACKGROUND: Neurologic deficit (paraplegia or paraparesis) remains a significant morbidity in the repair of descending thoracic aortic aneurysm. METHODS: Between February 1991 and February 2000, we operated on 182 patients for descending thoracic aortic aneurysm. For the purpose of this study-to identify the impact of the combined adjuncts distal aortic perfusion and cerebrospinal fluid (CSF) drainage on neurologic outcome-we selected the 148 of 182 nonemergent patients who had received conventional treatment (simple cross-clamping with or without adjuncts). The mean patient age was 61 years, and 49 of the 148 (33%) patients were women. Nine of the 148 patients (6%) had acute type B dissections. We compared the results of 105 of the 148 patients (71%) who received the combined adjuncts of CSF drainage and distal aortic perfusion with the remaining 43 (29%) patients who underwent repair using the simple cross-clamp with or without the addition of a single adjunct. RESULTS: Overall 30-day mortality was 13 of 148 patients (8.8%). Overall early neurologic deficit was 4 of 148 (2.7%): 1 of 105 (0.9%) patients who had received distal aortic perfusion and CSF drainage, versus 3 of 43 (7%) in all other patients (p < 0.04). CONCLUSIONS: In our practice the use of the combined adjuncts of CSF drainage and distal aortic perfusion has all but eliminated the incidence of immediate postoperative neurologic deficit in nonemergent patients with aneurysms of the descending thoracic aorta.
Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair.
BACKGROUND: Neurologic deficit (paraparesis and paraplegia) after repair of the thoracic and thoracoabdominal aorta remains a devastating complication. The purpose of this study was to determine the effect of cerebrospinal fluid drainage and distal aortic perfusion upon neurologic outcome during repair of thoracic and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Between February 1991 and March 2000, we performed 654 repairs of the thoracic and thoracoabdominal aorta. The median age was 67 years and 420 (64%) patients were male. Forty-five cases (6.9%) were performed emergently. Distribution of TAAA was the following: extent I, 164 (25%); extent II, 165 (25%); extent III, 61 (9%); extent IV, 95 (15%); extent V, 23 (3.5%); and descending thoracic, 147 (22%). The adjuncts cerebrospinal fluid drainage and distal aortic perfusion were used in 428 cases (65%). RESULTS: Thirty-day mortality was 14% (94 of 654). The in-hospital mortality was 16% (106 of 654). Early neurologic deficits occurred in 33 patients (5.0%). Overall, 14 of 428 (3.3%) neurologic deficits were observed in the adjunct group, and 19 of 226 (8.4%) in the nonadjunct group (p = 0.004). When the adjuncts were used during extent II repair, the incidence was 10 of 129 (7.8%) compared with 11 of 36 (30.6%) in the nonadjunct group (p < 0.001). Multivariate analysis demonstrated that risk factors for neurologic deficit were cerebrovascular disease and extent of TAAA (II and III) (p < 0.05). CONCLUSIONS: The combined adjuncts of distal aortic perfusion and cerebrospinal fluid drainage demonstrated improved neurologic outcome with repair of thoracic and TAAAs. In extent II aneurysms, adjuncts continue to make a considerable difference in the outcome and to provide significant protection against spinal cord morbidity. Future research should focus on spinal cord protection in patients with high-risk extent II aneurysms.
Esophagectomy after pneumonectomy: a surgical challenge.
Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.
Transjugular intrahepatic portosystemic shunt for recurrent hepatic hydrothorax.
For many years, pleural effusions have been recognized as a complication of cirrhosis, occurring in approximately 5.5% of patients. Recent studies have confirmed that small defects in the diaphragm allow for passage of ascitic fluid into the pleural space. Successful management of these patients is challenging, as many of the treatment options can be associated with increased morbidity. The initial treatment should focus on eliminating and preventing the recurrence of ascites with diuretics and water and salt restriction. For those patients who do not respond medically, more invasive techniques have been used including serial thoracentesis, chest tube placement, chemical pleurodesis, and peritoneovenous shunts. We present a patient with recurrent pleural effusions secondary to hepatic cirrhosis who was unsuccessfully treated medically, and subsequently treated with thoracentesis, chest tube drainage and pleurodesis, with ultimate resolution after transjugular intrahepatic portosystemic shunt placement.
Current approaches to minimally invasive aortic valve surgery.
Minimally invasive as it applies to aortic valve surgery refers to the exposure required to perform the aortic procedure, because total cardiopulmonary bypass is still required. Initial experience used the anterior thoracotomy, but recent series report the ministernotomy or "J" incision as the preferred technique for exposure. Though pain, blood loss, and length of stay may not be significantly different when compared with the conventional technique, lower costs and earlier recovery may be achieved. Minimally invasive aortic valve surgery is a technique that is still evolving.
Hydroblast injuries to the small bowel and inferior vena cava.
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Technical aspects of implanting the St. Jude Toronto stentless porcine valve.
Stentless xenograft aortic valves were designed to provide superior hemodynamic characteristics and durability, in comparison with stented tissue valves. The senior author (MJR) has implanted 46 St. Jude Toronto stentless porcine valves--with excellent hemodynamic results and no aortic insufficiency--since this valve was released by the Food and Drug Administration in November 1997. Because the implantation technique is significantly different from that of implanting a stented valve, and because proper implantation is critical for proper valve function and avoidance of aortic insufficiency, we discuss our technique in some detail.
Thoracic aortic aneurysms.
Remarkable progress has been made in the surgical treatment of thoracoabdominal aortic aneurysms. The decline in mortality and complication rates can be attributed to improvements in perioperative care and in surgical technique, particularly the adoption of adjunct distal aortic perfusion and cerebrospinal fluid drainage. Neurologic deficit is no longer a major threat to patients, as the use of adjuncts has brought the incidence down to 2.4% for all thoracoabdominal aortic aneurysms. However, we continue to pursue research to improve organ preservation, particularly for the most troublesome extent II thoracoabdominal aortic aneurysm.