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Biomedical subjects

T Carrel

Publications and source records attributed to T Carrel.

At least 181 records · Page 10Linked to original sources
PubMed1992

[Retroperitoneal approach in selective surgery of the infrarenal aorta].

In recent years, there has been a resurgence of interest in the retroperitoneal approach to the aorta; however, there has been only few prospective studies in the literature and the results are controversial. For this reason, we assessed peri- and postoperative problems associated with both procedures and compared the results of each one in a prospective study. Between 1989 and 1990, 163 patients underwent operative procedure because of an aortic or aorto-iliac lesion. 121 were operated on through the "classical" transperitoneal method (87 had aortic aneurysm, 34 aorto-iliac occlusive disease) whereas in 42 patients, retroperitoneal approach of the aorto-iliac bifurcation was performed (28 because of aortic aneurysm and 14 because of occlusive disease). Early mortality was 0 in the group with retroperitoneal approach, despite the fact that 66% of these patients were classified as high-risk patients (American Society of Anesthesia risk classification III or IV); it was 0.8% in the group with classical approach. Retroperitoneal group demonstrated significant decrease in blood (630 vs 1300 ml) and crystalloids (1700 vs 3250 ml) requirement, shorter nasogastric intubation time (1.6 vs 4.4 d) and quicker peroral intake. Significant pulmonary and cardiac complications were less often observed in the group of patients after retroperitoneal approach to the abdominal aorta. Mean postoperative hospital stay was significant shorter when compared with the transperitoneal group (8.5 vs 13.9 d). Our results confirm that retroperitoneal approach is an excellent alternative to the transperitoneal method for elective reconstructive surgery of the abdominal aorta. It is associated with better tolerated incisional pain, decrease in cardiac and pulmonary complications and thereby decreased hospitalization time.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorta, Abdominal↗
PubMed1992

[Intestinal ischemia following replacement of the infrarenal aorta and aorto-iliac bifurcation].

Intestinal ischemia following abdominal aortic surgery is a rare but dreaded complication and is associated with a high postoperative morbidity and mortality. Based on a review of the literature the incidence was noted between 2% to 10% of patients undergoing reconstruction of the abdominal aorta. From January 1980 to March 1991, 1017 patients were operated on the abdominal aorta or aorto-iliac bifurcation; the diagnosis was either abdominal aortic aneurysm (AAA) or chronic occlusive disease (COD). There were 819 patients with AAA (80.5%, mean age 67.9 years), and 198 patients with COD (19.5%, mean age 62.2 years). In 134 cases (122 for AAA, 12 for COD) the inferior mesenteric artery (IMA) was reimplantated into the graft. The incidence of postoperative intestinal ischemia after AAA repair was 2.8% (23/819 patients) after AAA repair and 0.5% (1/198 patient) with COD. 66% of the patients who have developed intestinal ischemia were operated emergently. However 2/134 (1.5%) patients presented intestinal ischemia despite reimplantation of IMA. Early explorative laparotomy or early postoperative colonoscopy could demonstrate ischemia in the majority of cases, whereas diagnosis of intestinal ischemia was confirmed at autopsy in 2 patients. In our experience with more than 1000 patients operated on the infrarenal aorta during a 10-year period suggests that a postoperative intestinal ischemia is caused mainly by a misbalance of the blood supply of the left hemicolon and rectosigmoid and may be prevent by reimplantation of IMA. Our actual policy consider reimplantation in presence of patent and large IMA with weak backflow, especially in patients with previous colonic disease or by missing collaterals at preoperative angiogram.

Aged↗
PubMed1992

[Blood substitution in aorto-iliac surgery].

To determine the amount of blood substitution required we evaluated in a retrospective analysis 68 consecutive patients that were operated on the infrarenal abdominal aorta 1990, 60 men with a mean age of 66 years (40-87) and 8 women, aged 73 years (62-85). Indications for treatment were: aneurysm (55) and occlusive disease (13). 21 aneurysms (45%) were ruptured and had to be operated as an emergency. Early lethality (less than 30 days) in this group was 19% (n = 4). In the other 47 patients there was no early mortality. Mean blood products transfusion requirements in patients with ruptured abdominal aortic aneurysm was: 18 (9-34) units of concentrated red cells, 16 (3-43) units of fresh frozen plasma (FFP) and 5 (0-19) units of concentrated red cells, 2 (0-7) units of FFP in the elective group. Main determinants of blood loss in the elective group were: the number of anastomoses and the preoperative status of the coagulant system. We conclude that in elective surgery of the infrarenal aorta homologous transfusion can be virtually eliminated if an entire autologous transfusion concepts is applied (predonation, intraoperative salvage, hemodilution and plasmapheresis).

Aged↗
PubMed1992

[Mycotic aneurysm of the infrarenal aorta: surgical possibilities and results].

Between 1973 and 1990 eleven patients with mycotic aneurysm of the abdominal aorta underwent surgery. Extra-anatomic axillobifemoral bypass with aortic ligation and aneurysm excision was performed in 5 patients, and in situ reconstruction in 6. There were 3 early and 3 late deaths. Regardless of the type of operation, surgery of mycotic aneurysm is followed by severe postoperative complications with high the early and the late mortality rates.

Aged↗
PubMed1992

[Surgery of the suprarenal subdiaphragmatic aorta: early and long-term results].

Surgery of the suprarenal segment of abdominal aorta is characterized by specific problems of operative techniques and of circulatory support during operative procedure. Ischaemic time of kidneys and other viscera has to be limited and use of femoro-femoral bypass allows perfusion of distal aortic branches during performance of the proximal anastomose. Replacement of the suprarenal abdominal aortic segment was performed in 57 consecutive patients (45 with aneurysm and 12 with para- or suprarenal atherosclerosis). Emergent operation was performed in 10 patients (9 with aortic rupture and 1 with acute renal failure by occlusion of the pararenal aortic segment) with early mortality of 50%. Elective operation was much safer with early mortality of 4.3% (2/47 patients). Following procedures were performed to revascularize the kidney and the other visceral arteries: direct replantation with or without endarterectomy (80%), bypass with prosthetic material or saphenous vein (15%), other procedures (5%). Nephrectomy was done in 3 patients. Overall 6-year survival was 64% in patients with aneurysm and 48% in patients with aortic atherosclerosis. 6-year survival was significant (p less than 0.01) higher in patients with normal renal function postoperatively than patients with persisting creatinine value over 200 micromol/l 3 months after operation (68% vs 15%).

Aged↗
PubMed1991

[Aortocoronary bypass surgery in patients older than 70 years].

From January 1981 to December 1990, 204 patients aged between 70 and 81 years underwent aortocoronary bypass surgery. Operative mortality (30-day mortality) was 6.8%. Actuarial survival rate at 1 and 5 years was 92% and 86% respectively. A higher incidence of postoperative complications was observed (arrhythmias in 19%, reoperation for bleeding in 5.4%, respiratory and neurological complications in 13% and 3% respectively, perioperative infarction in 4.4%). The mean follow-up was 25 months. Preoperatively most patients (71%) were in New York Heart Association (NYHA) functional class III and IV, and at the end of following-up in NYHA functional class I and II (95%) (p less than 0.001). A rapid rise in coronary artery surgery in the elderly is evident. It is associated with an increased but acceptable operative risk. Long-term results and postoperative improvement of functional status are very satisfactory.

Age Factors↗
PubMed1991

[Successful resection of a hypernephroma extending continuously into the right ventricle: utilization of extracorporeal circulation in general surgery].

We report the case of a 53-year-old woman with renal cell carcinoma extending into the inferior vena cava and through the tricuspid valve into the right ventricle. Successful total removal was performed with the aid of cardiopulmonary bypass. The rarity of this case prompted a review of the literature in which only the involvement of right atrium in this type of tumor was found. Review of our own experience with extracorporal circulation in non-cardiac procedures demonstrates that an aggressive therapeutic approach, requiring operations of escalating magnitude and multidisciplinary surgical treatment, can salvage patients who otherwise might not be considered for operation.

Carcinoma, Renal Cell↗
PubMed1991

[Vascular complications associated with aortic dissection].

Aortic branch occlusion may constitute the mode of presentation or become an important focus of treatment in patients sustaining acute aortic dissection. The optimal therapeutic approach in patients with acute aortic dissection complicated by cerebral, visceral and peripheral vascular problems, and the implications of such complications, are not well established. We review the outcome in 187 consecutive patients (149 males and 38 females, mean age 58 years) with acute dissection of the thoracic aorta who were admitted and operated on in our department over a 13-year period. We assess the incidence, consequences and specific management of significant stenotic and obstructive lesions of the aorta and its branches. Noncardiac vascular complications occurred in 59 patients (32%); of these complications, 38 were associated with type A dissection (incidence 28%) and 21 with type B dissection (incidence 48%). A trend towards decreasing overall surgical mortality was observed in the second part of the study (1983-1989) compared with the first part (1977-1982) i.e. 28% versus 12%. Although aortic rupture and cardiac tamponade were the strongest correlate of morbidity and mortality, death specifically related to vascular complication was more common when such malperfusion occurred in the carotid, celio-mesenteric and renal circulation. Proximal aortic repair at the site of the intimal tear with obliteration of the false lumen may have restored adequate distal circulation in 27 patients in whom improvement of the visceral or peripheral ischemia was observed after the thoracic aortic repair. Additional procedures (immediately after the thoracic repair or later) were necessary in 15 patients to restore adequate perfusion in the compromised area.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

[Early results following surgical treatment of heart tumors].

Between December 1968 and March 1990 a total of 51 patients (24 male, 27 female) with a mean age of 49 years (7 months to 76 years) underwent surgery for primary or secondary cardiac tumor. In 46/51 cases (90%) the tumor was benign and in 5/51 (10%) malignant; 41/51 (80%) were myxomas. In 40 patients complete resection of myxoma was possible, whereas in one patient only biopsy was performed. In 6 patients an additional procedure was necessary (CABG 4 times, double valve replacement once, mitral valve reconstruction once). In 17/41 patients (41%) rhythm disturbances were observed postoperatively. No patient died after operation. In one patient surgery of a recurrent myxoma was necessary 18 months after primary operation. In 5/51 patients (10%) surgery of benign non-myxomatous tumor was performed (lipoma twice, cavernous hemangioma once, fibroma once fibrous leiomyoma once). Radical excision of tumor was not possible in 2 cases; both died soon after operation. Surgery of malignant heart tumors was performed in 5/51 patients (10%) (synovialoma once, lymphoma twice, metastasis twice). In 3 patients tumor excision was radical; there was nevertheless recurrence in all patients despite adjuvant therapy. Only 1 patient is still alive 6 months after surgery. Prognosis after surgery for heart tumors is dependent on histology and resectability. Mortality after resection of myxoma is very low, but postoperative rhythm disturbances are frequent. Survival after excision of benign non-myxomatous tumors is dependent on resectability. Malignant cardiac tumors have a very bad prognosis despite chemotherapy and radiotherapy.

Adult↗
PubMed1991

Simultaneous revascularization for critical coronary and peripheral vascular ischemia.

Patients with coronary artery disease can exhibit substantial vascular involvement, and patients with vascular disease have a high incidence of coronary disease. Simultaneous coronary artery bypass grafting and treatment of vascular disease was performed in 32 patients with strong indications for surgical treatment of coronary artery disease and critical peripheral vascular ischemia operated on from 1980 until 1990. Overall hospital mortality was 3.1%; 1 patient died of myocardial infarction 2 days after urgent combined revascularization because of unstable angina pectoris and subacute occlusion of the aortoiliac bifurcation. Early mortality was 0% in patients undergoing elective operations. Eight-year actuarial survival was 87.5%. Combined procedures can be performed with acceptable risk and with encouraging long-term results in this special group of patients; they may improve prognosis in patients with diffuse atherosclerosis.

Adult↗
PubMed1991

Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach.

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.

Actuarial Analysis↗
PubMed1991

Preoperative assessment of the likelihood of infection of the lower respiratory tract after cardiac surgery.

Lower-respiratory-tract infections are among the most frequent complications observed in the intensive care unit, leading to delayed postoperative recovery time and increased costs and mortality. We have tried to evaluate the prognostic value of perioperative bacteriology of tracheal aspirates in assessing the risk of such complications. In a prospective study aspirates of 100 patients undergoing cardiac surgery were taken immediately after intubation and were analysed for microorganisms by Gram-stain and microbiological cultures using standard procedures. All patients received perioperative antibiotic prophylaxis with a single dose of 2 g ceftriaxone intravenously. From 26 patients with bacteriologically positive tracheal secretion, 8 (30.7%) developed lower respiratory tract infection whereas only 1 of 72 patients (1.4%) with negative bacteriological results developed this complication. Smoking (p less than 0.01) and abnormal preoperative lung function (p less than 0.01) were significantly more frequent in patients developing postoperative pneumonia. Regarding the results of this study, the risk of developing pulmonary infection in the early postoperative course after cardiac surgery can be estimated from the tracheal aspirates.

Adult↗
PubMed1991

Early and late results after surgery for massive pulmonary embolism.

Between 1978 and 1990 emergency pulmonary embolectomy with the aid of extracorporeal circulation (ECC) was performed for massive pulmonary embolism (PE) in 44 patients (19-73 yrs; 49 +/- 15 yrs). Cardiopulmonary circulation was stable in 16/44 patients but unstable in 28/44; of the latter, 15 had undergone previous cardiopulmonary resuscitation due to cardiac arrest. Diagnosis of PE was obtained clinically in 15/44 patients, by angiography in 13/44, by echocardiography in 10/44, and by perfusion scintigraphy of the lung in 6/44 patients. There were 9/44 (20%) postoperative deaths. Early mortality was significantly higher in previously resuscitated patients (p less than 0.05). There were 2/36 (6%) late deaths. Actuarial survival was 75% after 4 yrs and 71% after 8 yrs. 77% or 35 survivors were in NYHA-class I and 23% in NYHA-class II after a mean follow-up of 4.6 yrs. Pulmonary embolectomy is indicated in patients with central PE and shock; it is advisable in patients with embolism of the main pulmonary artery or its major branches or in patients with contraindication to thrombolysis. Intraoperative insertion of a vena cava filter is recommended for prevention of recurrent embolism. Preoperative resuscitation and duration of ECC are predictors for early death.

Actuarial Analysis↗
PubMed1991

Hepatic abscess following biliary tract surgery. Etiology, treatment and results.

Experience of seven consecutive cases of liver abscess following biliary tract surgery is presented. The age range was 41-83 years, and six of the patients were women. The interval from operation to appearance of abscess was 10 days to 14 months. Primary surgical drainage was used in two patients, who remained clinically well 6 months and 2 years later. Four of five patients with initially percutaneous drainage subsequently underwent operative drainage, but one refused further surgery and died 8 days later of sepsis. Multiple factors may predispose to both cholangitis and hepatic abscess following biliary tract surgery. Radiologic investigation of abscess must also focus on identifying underlying biliary pathology. Bactericholia and obstructed bile flow are two of the most important etiologic factors in hepatic abscess after biliary surgery. Experience with these cases suggests that a surgical approach may be preferable to percutaneous techniques in management also of the associated biliary pathology.

Adult↗
PubMed1991

[Early and late results after surgical treatment of pulmonary atresia with intact ventricular septum].

Between 1970 und 1989 30 children were admitted with the diagnosis of pulmonary atresia with intact ventricular septum (PA/IVS). Before palliation 4 children died. According to the grade of right heart hypoplasia the patients were divided into 3 groups of mild, moderate or severe hypoplasia. Palliative operations were performed in 25 children (17 m, 9 f) with a mean age of 10 days: 13 valvotomies (V), 5 aortopulmonary shunts (S), 7 V plus S. One patient had total correction as primary procedure. A total of 17 reoperations was necessary in 12 of 26 patients (10 palliations, 7 total corrections). Total corrections were: 2 conduits and 5 patches of the right ventricular outflow tract (RVOT). Total mortality was 14/30 (54%) children: early 10/26 (38%), late 4/16 (25%) children. After total correction mortality was 3/7 (43%) children. Actuarial survival after palliation was 46% after 5 and 10 years. For patients with PA/IVS we recommend the following surgical strategy: 1. mild hypoplasia: V plus S for palliation; 2. moderate hypoplasia: S plus patch of RVOT; 3. severe hypoplasia: after initial ballon septostomy S and antegrade decompression of the right ventricle (RV). For total correction in a well developed RV we prefer ASD-closure and patch of RVOT if possible with homograft monocusp. In moderate or severe hypoplasia a Fontan operation is done with closure of the ASD and tricuspid orifice with a single patch.

Cause of Death↗
PubMed1991

[Reduction of postoperative blood loss and donor blood use in heart surgery with aprotinin: experience with various dosages].

The effect of high dose aprotinin was evaluated in a prospective study on 100 patients undergoing cardiopulmonary bypass. Special attention was made on postoperative blood loss and transfusions of bank blood postoperatively. In the first part of the study, after induction of anesthesia, a loading dose of 2,000,000 kallikrein-inhibiting-unit (KIU) = 280 mg aprotinin was given intravenously over a 30-min period. Immediately afterward, a continuous infusion of 500,000 KIU/h was started and maintained until skin closure. Another 2,000,000 KIU was added to the priming volume of the heart-lung machine. A control group of 50 patients was randomized with similar indication for surgery and past cardiac history. The total loss from the thoracic drains was significantly reduced in the aprotinin group as compared with the loss in the control group (490 +/- 265 ml versus 1045 +/- 380 ml). In a separate group of risk patients (redo-operations, infective endocarditis) the total blood loss was even more significant reduced in the aprotinin group (690 +/- 195 ml versus 1585 +/- 290 ml). Patients of the aprotinin group received markedly less bank blood postoperatively (350 +/- 100 ml versus 900 +/- 240 ml without aprotinin). Part II of the study (36 patients) consisted of lower dosage (2,000,000 KIU intravenously during induction of anesthesia only or 2,000,000 KIU in the priming volume of the heart-lung machine only). Patients who received aprotinin in the heart-lung machine only showed no significant difference regarding blood loss and blood requirement to patients with high dose aprotinin. It appears possible that aprotinin reduces the activation of the coagulation during cardiopulmonary bypass and preserves platelet function without affecting platelet consumption during the extracorporeal circulation. The results of our study demonstrate that high dose aprotinin markedly reduces blood loss as well as homologous blood requirement in the early postoperative course of cardiosurgical patients. Similar effects due to reduced aprotinin dose have been observed in patients receiving aprotinin in the extracorporeal circulation only.

Aged↗