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PubMed1977

Experience with reoperation following coronary bypass grafting.

Thirty-four of 1152 patients who had undergone aortocoronary bypass grafting underwent reoperation. There were no early or late deaths among these 34 patients. The average time between operations was 14 months. At the initial operation, 88 grafts and 10 internal mammary implants were placed; at reoperation, 56 grafts and 8 internal mammary implants were placed and a left ventricular aneurysm was plicated. Twenty patients underwent reoperation for graft stenosis or occlusion, five because of progression of coronary artery disease, seven because of combined progression disease and graft occlusion and two to correct technical errors. Improvement in the class of angina was 1.1 classes at an average follow-up of 9 months. The authors believe that reoperation for coronary bypass grafting can be performed safely with symptomatic improvement for the patient.

Coronary Artery Bypass↗
PubMed1977

Reoperation following direct myocardial revascularization.

Among the 5507 patients who underwent aortocoronary bypass between October 1969 and June 1975, 41 patients (0.007%) developed recurrent angina and required reoperation. The factors necessitating reoperation were graft thrombosis in 10 patients (24%), progression of disease in 12 (29%), graft thrombosis and critical unbypassed lesions in one (2.4%), graft failure and progression of disease in in 12 (29%), graft failure and critical unbypassed lesions in four (10%), and all three factors in two patients (4.8%). Among 10 patients with 50% lesions present but not bypassed at the initial operation, nine of these lesions progressed to significant stenosis and in five patients this was the sole reason for reoperation. At the second operation, total revascularization was achieved in 32 patients (78%). One patient (2%) experienced a perioperative myocardial infarction and one patient (2%) died. This study emphasizes the importance of "complete" revascularization at initial operation, the concept that arteries with 50% obstruction should be routinely bypassed, and the conclusion that risks of reoperation are comparable with those of initial aortocoronary bypass, but that long-term relief of angina is less favorable.

Adult↗
PubMed1979

Carcinoembryonic antigen levels as an indicator for reoperation in patients with carcinoma of the colon and rectum.

The experience from the University of Minnesota with routine reoperations in cancers classified as Dukes' C suggests only a small minority of patients found to have asymptomatic recurrences will benefit from an additional operation. Also, morbidity and mortality will be significant. The presence of a rising carcinoembryonic antigen level following a potentially curative operation has been suggested as a more selective indicator for reoperation. Unfortunately, carcinoembryonic antigen levels are a far more sensitive indicator of hepatic metastases, the group usually not helped by operation. Patients with local-regional recurrent carcinoma of the colon and rectum--the group most likely to benefit from reoperation--often have normal carcinoembryonic antigen levels. The importance of patient selectivity for reoperation and the usefulness of the Astler-Coller staging system to define risk factors are stressed.

Carcinoembryonic Antigen↗
PubMed1978

Reoperation following failure of aortoiliofemoral arterial reconstruction.

Over a 19-year period, 729 primary arterial reconstructions for aneurysmal and occlusive disease of the aortoiliac arterial system were performed at the Health Sciences Centre, Winnipeg. During the same interval 49 of these reconstructions required reoperation and 6 additional cases were referred for secondary repair from other institutions. The authors reviewed these 55 cases to determine the reasons for reoperation and the cumulative results of secondary repair. Secondary arterial repair was performed in 11.5% of cases of occlusive disease and in 1.2% of cases of aneurysmal disease. The overall frequency of reoperation was 6.7%. The mean interval between primary and secondary operation was 31.5 months. Perioperative failure, false aneurysm, graft infection, progression of disease and late technical problems were the major reasons for reoperation. Of the secondary repairs the results in 83.6% were satisfactory at 30 days. At 5 years, 57% of secondary repairs at risk remained satisfactory. The operative mortality for secondary arterial repair was 5.4%. The authors believe that continued aggressive management of failed primary aortoiliac reconstructions is justified.

Adult↗
PubMed1981

Strategy and technique of reoperative parathyroid surgery.

Reoperative parathyroid surgery requires strategies and techniques different from those employed in initial surgery for primary hyperparathyroidism. Differentiation between single- and multiple-gland disease and between sporadic and familial disease helps determine the extent of surgery. Identification and removal of only enlarged glands with biopsy, if possible, of normal parathyroid tissue, is indicated in patients with sporadic disease. Patients with multiple-gland or familial disease undergoing reoperation for recurrence or persistence should have all identifiable parathyroid tissue removed from the neck, and portions should be cryopreserved. Immediate autotransplantation is not recommended even for patients undergoing total parathyroidectomy at reoperation. Such patients may become normocalcemic or remain hypercalcemic because of inaccurate assessment of previous surgery, supernumerary glands, or because an underlying stimulus promotes hyperplasia of residual parathyroid fragments. Since hypercalcemia in patients with functional tissue in the arm is difficult to manage, it is wiser to perform autograft with cryopreserved tissue only in those patients who exhibit prolonged hypoparathyroidism. A surgical approach with emphasis on operative techniques that has evolved from recent experience with over 90 reoperations is presented.

Biopsy↗
PubMed1980

Management of early and late thrombosis of expanded polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts: favorable prognosis with appropriate reoperation.

In a series of 175 polytetrafluorethylene (PTFE) femoropopliteal bypasses for limb salvage, nine thrombosed within the first montha after operation and 22 thrombosed from 1 to 23 months after operation. With reoperation (four simple thrombectomies and five graft extensions) all nine early closures are patent 3 to 27 months (mean 16 months) later. Four of the late thromboses did not jeopardize the limb, and viability has persisted 4 to 14 months. Eighteen of the late thromboses placed the limb in jeopardy. Appropriate reoperation after preoperative angiography restored graft patency for 2 to 27 months in 14 of 18 cases. Six grafts were patent more than 1 year after reoperation. The operations performed for late thrombosis were incision and patch angioplasty for intimal hyperplasia (25%), graft extension for distal disease (42%), and simple thrombectomy when no cause of thrombosis was identified (33%). These findings justify an aggressive approach with appropriate reoperations when PTFE femoropopliteal bypasses thrombose in the early or late postoperative period. Important additional limb salvage can thereby be obtained.

Blood Vessel Prosthesis↗
PubMed1977

[Reoperation on the bile ducts (author's transl)].

The total of 5560 operations on the gall bladder and bile ducts had been performed from 1951 to 1975, the mortality rate being 1.2% of all operated cases. There were 659 papillosphineterotomies, 82% of these were indicated for choledocholiathiasis associated with papillary changes, the remaining 18% for stenosis of the Vaterian system. 29 patients, i.e. 4.4% died following papillosphincterotomy. The total of 21 patients were reoperated on soon after the first intervention, 17 of them for inflammatory complications with four deaths, 4 for haemorrhage without any death. One of the patients died from a bleeding duodenal ulcer, 3 from postoperative pancreatitis. The last four patients were not reoperated. Later reoperations up to 7 years were performed in 24 cases. The other part of the paper presents an analysis of 35 patients reoperated on for iatrogenic postoperative strictures of the bile ducts mostly due to an injury induced during cholecystectomy or gastric resection.

Bile Ducts↗
PubMed1999

Reoperative parathyroid surgery in the era of sestamibi scanning and intraoperative parathyroid hormone monitoring.

HYPOTHESIS: Results of reoperative parathyroid surgery (RPS) have improved with the advent of sestamibi parathyroid subtraction scanning and intraoperative parathyroid hormone (IOPTH) monitoring. DESIGN: Retrospective review of patient histories, preoperative localization studies, operative data, including IOPTH monitoring, and outcomes for patients undergoing recent RPS at a single institution. Follow-up was complete (mean, 20 months). SETTING: Tertiary care referral center. PATIENTS: All patients undergoing RPS for benign persistent or recurrent primary hyperparathyroidism during the period 1989 to 1997. MAIN OUTCOME MEASURES: Overall cure rate and operative morbidity from RPS; sensitivity and accuracy of preoperative localization studies; and prediction of cure from IOPTH monitoring. RESULTS: The study group included 124 patients (87 women and 37 men). Hypercalcemia was corrected in 109 patients (88%). Permanent recurrent laryngeal nerve injury occurred in 0.8% and permanent hypoparathyroidism in 13% of patients. Test sensitivities and accuracies, respectively, were as follows: ultrasound with biopsy, 90% and 82%; sestamibi parathyroid subtraction scanning, 82% and 67%; and ultrasound alone, 75% and 65%. Level of IOPTH was predictive of cure in all patients with a 70% or greater fall from baseline at 20 minutes after excision. Persistent multigland disease was the major cause for reoperative failure (73%). CONCLUSIONS: Neither cure rates nor operative morbidity have changed appreciably over the past 2 decades, despite the introduction of sestamibi parathyroid subtraction scanning and IOPTH monitoring. Multigland disease continues to represent the principal cause of failure in RPS despite the routine use of preoperative localization studies. Thus far, increasing the stringency of IOPTH monitoring from a 50% to 70% decline from baseline levels has been predictive of cure, even in multigland disease. Most missed abnormal glands reside in normal anatomic locations, and the need for multiple operations, not just the reoperation, results in the increased morbidity seen with RPS.

Adolescent↗
PubMed1999

Failed antireflux surgery: what have we learned from reoperations?

HYPOTHESIS: Factors that lead to failures in antireflux procedures can be identified, and dealing with them at the initial operation may decrease the number of such failures. DESIGN: Analysis of symptoms, 24-hour esophageal pH monitoring, manometry, upper gastrointestinal tract radiographs, and correlation with operative anatomic findings. SETTING: University referral center. PATIENTS: Forty-eight patients who previously underwent antireflux surgery (Nissen fundoplication, 29; Hill fundoplication, 7; Angelchik prosthesis, 1; multiple, 5; unknown, 6) and had symptoms of foregut disease. MAIN OUTCOME MEASURES: Determination of the cause of failure of previous operations and identification of factors that may prevent recurrence. RESULTS: Fourteen patients (29%) presented with symptoms of an incompetent cardia (heartburn and regurgitation), 15 patients (31%) presented with symptoms of defective esophageal emptying (dysphagia), 13 (27%) had symptoms of both, and 6 (13%) had other symptoms. All patients were initially treated medically and/or with dilation. A reoperation was performed in 31 patients (65%) whose symptoms persisted. Reoperation was completed laparoscopically in 28 patients (90%). At reoperation we identified 3 main types of failure: type 1, patients in whom the gastroesophageal junction was herniated through the hiatus, either with the wrap (IA) or without it (IB). There were 13 patients (43%) classified as having type IA, and 5 patients (16%) classified as having type IB. Type II failure involved a paraesophageal component resulting from a redundant wrap in 5 patients (16%), and type III involved a malformation (defective position or construction) of the wrap in 2 patients (6%). The remainder had a failed Hill fundoplication (3 patients), a herniated Angelchik prosthesis (1 patient), and normal postoperative anatomy (2 patients). CONCLUSIONS: Failure of the crural closure and malformation of the wrap are the main reasons for failure of antireflux procedures. Use of proper surgical techniques including meticulous closure of the crura and appropriate construction and fixation of the wrap at the first operation will help prevent recurrence.

Female↗
PubMed2004

Parathyroid hormone venous sampling before reoperative surgery in renal hyperparathyroidism: comparison with noninvasive localization procedures and review of the literature.

OBJECTIVES: To analyze the predictive values of selective venous sampling (SVS) in our own experience and in a systematic meta-analysis of the international literature and to compare them with the results of noninvasive localization studies before reoperative parathyroid surgery. DATA SOURCES: Twenty-one consecutive patients with persistent or recurrent renal hyperparathyroidism underwent preoperative SVS and noninvasive imaging. These data were added to a systematic review of the literature on localization studies before reoperative surgery. The literature search included localization studies, recurrent hyperparathyroidism, and reoperation. STUDY SELECTION Prospective and retrospective studies that provided at least the true-positive rate of 1 procedure were included. Data from initial surgery, hyperfunctioning autografts, and case reports were excluded. DATA EXTRACTION: Thirty-one publications reported on SVS (n = 22), technetium Tc 99m sestamibi scintigraphy (n = 17), thallium-technetium scintigraphy (n = 11), ultrasonography (n = 18), magnetic resonance imaging (n = 12), and computed tomography (n = 13). The overall analysis was performed by dividing the overall number of true- and false-positive results by the total number of patients. DATA SYNTHESIS: Localization by SVS was correct in 20 of 21 patients. In 1 patient with 2 localizations, only 1 was predicted correctly. Therefore, the sensitivity of SVS was at least 90%, with no false-positive results. Overall true- and false-positive rates, respectively, in 31 studies were 71% and 9% for SVS, 69% and 7% for technetium Tc 99m sestamibi scintigraphy, 54% and 16% for magnetic resonance imaging, 55% and 15% for thallium-technetium scintigraphy, 50% and 18% for ultrasonography, and 45% and 14% for computed tomography. CONCLUSIONS: With its high sensitivity, SVS is the gold standard in patients with persistent or recurrent renal hyperparathyroidism and negative results of noninvasive localization procedures. The noninvasive procedure of choice is now technetium Tc 99m sestamibi scintigraphy, with high sensitivity and a low rate of false-positive results.

Adolescent↗
PubMed1989

Strategy in reoperative surgery for hyperparathyroidism.

Eighty-three patients undergoing reoperations for hyperparathyroidism were studied. Preoperative diagnosis was reviewed, and localization was employed in selected patients. Cervical reexploration was carried out in a systematic manner, and mediastinotomy was required in 11 patients. Sixty patients had had previous parathyroid exploration. Missed adenomas were found in 34, of which 28 were single and 6 were double adenomas. Fourteen single adenomas were in normal locations and 14 were in ectopic locations. Seventeen patients had hyperplasia; 6 were wrongly diagnosed as adenoma, 3 had inadequate excision, 2 had supernumerary glands, and 6 had remnant hypertrophy. Three patients had recurrent carcinoma. Two had wrong diagnoses and 4 had uncertain diagnoses. Reoperation eliminated hypercalcemia in 71 patients (85.5%). Eight patients developed permanent hypoparathyroidism, and 1 had a permanent recurrent nerve palsy. Reoperative parathyroid surgery can be minimized with thorough initial cervical exploration, correct pathologic interpretation, and adequate parathyroid resection.

Adenoma↗
PubMed1990

Reoperative surgery for the morbidly obese. A university experience.

Patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications. To evaluate outcome following revisional procedures, we reviewed the records of 32 such patients treated at UCLA between April 1986 and May 1989. Twenty-five women (78%) and 7 men (22%) with a mean age of 44 years underwent 76 reoperations (2.4 per patient) for complications of prior obesity surgery. Indications for initial surgical revision consisted primarily of metabolic derangements (12 patients) and weight-related problems (11 patients). In contrast, indications for the patients' final surgical procedure were commonly for bowel obstruction (41%), intra-abdominal sepsis (12%), and gastrointestinal bleeding (6%). Following initial revision, 23 patients (71.8%) required further surgery for major complications and four patients died (12.5%). While initial revisions are frequently indicated for metabolic problems, final reoperations are more frequently undertaken for urgent, life-threatening complications. Revisional procedures for morbid obesity should be carefully considered, and the potential for major complications and/or death should be weighted heavily against proposed benefits.

Adult↗
PubMed1993

Reoperation for suspected primary hyperparathyroidism.

A retrospective analysis of 93 patients undergoing 128 re-explorations for persistent or recurrent hypercalcaemia is presented. Seventy-six patients (82 per cent) became normocalcaemic after between one and five reoperations. Nine patients had hypercalcaemia caused by sarcoidosis, familial hypocalciuric hypercalcaemia or metastatic disease, and two had parathyroid carcinoma. Fifteen patients (16 per cent) developed permanent hypoparathyroidism requiring vitamin D and/or calcium therapy and nine had permanent recurrent laryngeal nerve paralysis. Undetected adenomas (41 cases) and inadequate resection in hyperplastic disease (28) were the predominant causes of initial failure. Reoperation for persistent or recurrent hyperparathyroidism restored normocalcaemia in the majority of patients. This 'cure' was achieved at the cost of considerable morbidity and a careful risk-benefit analysis of each patient is recommended before performing reoperative parathyroid surgery.

Adenoma↗
PubMed1994

Reoperation after failed antireflux surgery.

Between 1978 and 1992, 61 patients were operated on for new or recurrent problems after antireflux surgery. Indications for reoperation were recurrent reflux in 50 patients (associated with dysphagia in 14), dysphagia alone in six and postprandial pain in five. At reoperation the cause of the problem was apparent as anatomical breakdown of the repair in 19 patients, gastric pull-through (slipped Nissen procedure) in 14 and paraoesophageal hernia in six. In 18 patients the cause of the symptoms was not readily apparent. Reoperation consisted of fundoplication alone in 27 patients, fundoplication with pyloroplasty in eight, fundoplication with proximal gastric vagotomy in four, a Collis-Nissen procedure in 11 (four also had pyloroplasty), a Roux-en-Y procedure in four, total gastrectomy in one and reduction of a paraoesophageal hernia in six. Of the 20 patients with some form of destruction of the gastric outlet six experienced troublesome dumping symptoms and in two this was severe. Two patients died from cardiac causes after surgery. Of the remaining 59 patients, 51 rated the procedure as successful. Repeat antireflux procedures can give results almost as good as those of primary antireflux surgery. However, pyloroplasty and gastric resection should be avoided if at all possible.

Adult↗
PubMed1986

A new microsurgical reoperation for failed lumbar disc surgery.

This paper reports a consecutive series of 103 patients operated upon over a 4.2-year period (from November 1978 through January 1983). These patients were initially operated upon by other orthopedic and neurologic surgeons without relief of their sciatic pain. The average duration of symptoms prior to microsurgical reoperation was 35.9 months. The average number of reoperations per patient was 1.4. The median follow-up time was 27 months (range 1-50 months). Preoperative evaluation included examination, CAT scan, myelogram, and electromyogram. Average postoperative hospital stay without spinal fusion was 5.1 days. Two techniques were used: a unilateral decompression and a bilateral intersegmental decompression. Results are compared. A classification of operative findings is given. Eight patients in the series received spinal fusion as part of their procedure. Microsurgical reoperation benefited 80.6% of the 103 patients.

Adult↗
PubMed1996

Posterior exposure of the popliteal artery in reoperative vascular surgery.

Reoperative vascular surgical procedures play an important role in the successful salvage of ischemic limbs. Such secondary procedures frequently involve difficult situation where the surgical incisions and the vascular anatomy have been compromised by infection of prior surgery. In such instances an alternative surgical approach may provide a significant advantage and aid in successful revascularization. Use of the posterior approach in reoperative vascular surgery is unusual. The application of this exposure may facilitate selected secondary surgical procedures. We review the use of the posterior approach to the popliteal vessels in three patients who required reoperative vascular reconstruction. These cases illustrate the judicious application of this technique and the resultant benefit of this unusual surgical approach.

Aged↗
PubMed1996

Curative reoperations for locally recurrent rectal cancer.

PURPOSE: Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer. METHODS: Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure, i.e., no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy. RESULTS: None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three-year, five-year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection (P < 0.001). Survival tended to be greater in females (P < 0.075) and in patients without pain (P < 0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively. CONCLUSIONS: Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long-term survival and can be accomplished safely in select patients.

Antimetabolites, Antineoplastic↗
PubMed2001

Early reoperation for perirectal abscess: a preventable complication.

PURPOSE: The aim of this study was to analyze failures in the operative management of perirectal abscesses resulting in early reoperation. METHODS: This was a retrospective case study of 500 consecutive patients who underwent 627 drainage procedures for a perirectal abscess. RESULTS: Forty-eight patients (7.6 percent of all drainage procedures) required reoperation within ten days of the original procedure. The main factors leading to reoperation were incomplete drainage (23 patients), missed loculations within a drained abscess (15 patients), missed abscesses (4 patients), and postoperative bleeding (3 patients). Incomplete drainage was more common with simple perirectal abscesses, whereas most overlooked collections were located posteriorly. Horseshoe abscesses were associated with a particularly high rate (50 percent) of operative failures. Neither preexisting perianal pathology nor systemic immunosuppressive disease contributed to early failures. CONCLUSION: Surgical errors are the leading cause of early failures in the surgical treatment of perianal abscesses. These errors occur in a limited number of typical patterns and can therefore be identified and taught with an aim to decrease their occurrence.

Abscess↗