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PubMed1988

Pulmonary valve insertion during reoperation for tetralogy of Fallot.

Our experience with pulmonary valve insertion during reoperation for residual lesions after initial open repair of tetralogy of Fallot in 15 patients is reported. Preoperatively, 14 patients were in moderate to severe congestive heart failure, and all 15 had decreased right ventricular (RV) function at cardiac catheterization. All 15 patients had pulmonary insufficiency but not as an isolated finding. The most common residual lesions encountered were ventricular septal defect in 9, tricuspid insufficiency in 11, and peripheral pulmonary arterial stenosis in 6. Tissue valves were inserted in all patients. Mean peak RV-left ventricular pressure ratio measured in the operating room decreased from 0.61 +/- 0.10 (+/- the standard deviation) to 0.47 +/- 0.17 (p less than 0.05). There were no operative deaths. At follow-up (mean, 33 months), all but 1 patient were in New York Heart Association Class I or II. Pulmonary valve insertion should be considered during reoperation for tetralogy of Fallot when pulmonary insufficiency and RV failure are present.

Adult↗
PubMed1997

Reoperative coronary artery bypass without cardiopulmonary bypass.

BACKGROUND: Conventional reoperative coronary artery bypass grafting using cardiopulmonary bypass carries relatively high mortality and morbidity. METHODS: Seventy-seven patients underwent coronary artery bypass grafting without cardiopulmonary bypass in two centers between 1988 and 1994. Mean age was 65 +/- 8 years (mean +/- SD). Twenty-three (30%) were operated on urgently and 7 (9%) emergently. Nine (12%) were referred for operation up to 2 weeks after acute myocardial infarction. Fifteen patients (19%) had an ejection fraction less than or equal to 0.35. The mean number of grafts per patient was 1.7 (range, 1 to 3), and the internal mammary artery was used in 66 patients (86%). Only 18 patients (23%) received at least one graft to the circumflex artery. Hospital stay was 7.4 +/- 6.5 days. RESULTS: Early events included operative death in 4 patients (5.2%), nonfatal myocardial infarction in 3 (3.9%), sternal infection in 2 (2.6%), and stroke in 0 (0%). Follow-up (30 +/- 15 months) showed 11 deaths (5 cardiac, 6 noncardiac), 2 (2.8%) nonfatal myocardial infarctions, and return of angina in 9 patients (12.8%). One- and 4-year actuarial survival rates were 90% and 69%, respectively. CONCLUSIONS: Reoperative coronary artery bypass grafting without cardiopulmonary bypass has acceptable early and midterm outcome, and should be considered a viable alternative for properly selected patients.

Aged↗
PubMed1997

Minimally invasive versus conventional reoperative coronary artery bypass.

BACKGROUND: Conventional reoperative (redo) coronary artery bypass grafting (CABG) is associated with significant morbidity. This retrospective study compared perioperative outcomes of conventional single-vessel redo CABG versus redo CABG done by a minimally invasive technique. METHODS: Group A consisted of 23 consecutive patients from September 1995 to July 1996 who underwent single vessel redo CABG of the left anterior descending artery with the left internal mammary artery using a limited anterior thoracotomy without cardiopulmonary bypass; group B consisted of 12 consecutive patients from November 1984 to July 1994 who underwent the same procedure using a median sternotomy with cardiopulmonary bypass. The two groups were similar with regard to age, sex, preoperative ejection fraction, and risk stratification. RESULTS: Mortality, cerebrovascular accidents, myocardial infarctions, and reoperations for bleeding were not significantly different between the groups. However, the patients in group A had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. With a mean of 12 +/- 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic. Actuarial survival rates for the patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively. CONCLUSIONS: Minimally invasive single-vessel redo CABG can be performed safely and may reduce the morbidity associated with conventional single-vessel redo CABG.

Actuarial Analysis↗
PubMed1997

Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations.

For more complex aorta, valvular, and coronary operations or reoperations where the new minimal-access operations are difficult to apply, a "J" or "j" sternal incision from the first interspace or sternal notch into the right fourth intercostal space is a useful alternative. The approach has been used for aortic and mitral valve procedures, coronary artery bypass with or without cardiopulmonary bypass, aortic root rupture, atrial septal defect repair, hemiarch repair, maze procedure, and composite valve grafts, including reoperations and transannular mitral valve replacements in 30 patients without complication related to it.

Aorta↗
PubMed1998

Hematologic and economic impact of aprotinin in reoperative pediatric cardiac operations.

BACKGROUND: Aprotinin consistently reduces blood loss and transfusion requirements in adults during and after cardiac surgical procedures, but its effectiveness in children is debated. We evaluated the hemostatic and economic effects of aprotinin in children undergoing reoperative cardiac procedures with cardiopulmonary bypass. METHODS: Control, low-dose aprotinin, and high-dose aprotinin groups were established with 15 children per group. Platelet counts, fibrinogen levels, and thromboelastographic values at baseline and after protamine sulfate administration, number of blood product transfusions, and 6-hour and 24-hour chest tube drainage were used to evaluate the effects of aprotinin on postbypass coagulopathies. Time needed for skin closure after protamine administration and lengths of stay in the intensive care unit and the hospital were recorded prospectively to determine the economic impact of aprotinin. RESULTS: Coagulation tests performed after protamine administration rarely demonstrated fibrinolysis but did show significant decreases in platelet and fibrinogen levels and function. The thromboelastographic variables indicated a preservation of platelet function by aprotinin. Decreased blood product transfusions, shortened skin closure times, and shortened durations of intensive care unit and hospital stays were found in the aprotinin groups, most significantly in the high-dose group with a subsequent average reduction of nearly $3,000 in patient charges. CONCLUSIONS: In children undergoing reoperative cardiac surgical procedures, aprotinin is effective in attenuating postbypass coagulopathies, decreasing blood product exposure, improving clinical outcome, and reducing patient charges.

Adolescent↗
PubMed1999

Recycling of arterial grafts during reoperative coronary artery operations.

BACKGROUND: To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts. METHODS: Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit. RESULTS: There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II. CONCLUSIONS: Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.

Adult↗
PubMed1997

Reoperation after pericardial patch tracheoplasty.

Between 1982 and 1995, 28 infants underwent pericardial tracheoplasty for long-segment tracheal stenosis. Seven of these infants required reoperation or stenting for residual or recurrent tracheal or bronchial stenosis. Revisions were performed 2 to 6 months after the original procedure with cardiopulmonary bypass and bronchoscopic guidance. Two patients underwent repeat pericardial patch tracheoplasty, and four patients underwent insertion of a rib cartilage graft. Two of these patients required Palmaz wire expandable stents and one other patient also underwent stent placement. There was one late death 1 year after cartilage graft insertion. The authors identified three risk factors for reoperation after tracheoplasty; younger age at initial surgery and associated pulmonary artery sling or tracheal right upper lobe bronchus. Good intermediate results are possible in this difficult group of children using a selective and inclusive strategy for tracheal enlargement that includes repeat pericardial tracheoplasty, autologous cartilage grafts, and expandable wire stents.

Age Factors↗
PubMed1998

The failed anoplasty: successful outcome after reoperative anoplasty and sigmoid resection.

BACKGROUND/PURPOSE: Children with anorectal malformations often have less than optimal results after repair. The authors report on five patients (ages 3 to 17 years) born with imperforate anus and treated with anoplasty as a newborn. At presentation, all patients were completely incontinent of stool. None had ever experienced voluntary bowel movements, and all wore diapers continuously. METHODS: Perineal examination with the nerve stimulator showed the muscle complex was largely intact with good contraction, but the neoanus was outside of the muscle complex. Contrast enema showed massive dilation of the rectosigmoid colon and fecal impaction. A tethered spinal cord was excluded by magnetic resonance imaging (MRI). We treated these patients with a combined reoperative anoplasty via the posterior sagittal approach and sigmoid resection. RESULTS: Within 6 months after the procedure, all patients had achieved complete continence. They had from one to three voluntary bowel movements per day without soiling. CONCLUSIONS: Children with severe constipation and fecal incontinence after anoplasty should undergo evaluation by a surgeon. If examination shows a reasonably intact muscle complex and correctable anatomic defects, an excellent result can be achieved with appropriate reoperation.

Adolescent↗
PubMed2006

Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations.

PURPOSE: Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations. MATERIALS AND METHODS: A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements. RESULTS: Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding. CONCLUSIONS: This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.

Adolescent↗
PubMed1997

Improved selection of patients for reoperation for medullary thyroid cancer by imaging with radiolabeled anticarcinoembryonic antigen antibodies.

BACKGROUND: This study examined the utility of using radiolabeled anticarcinoembryonic antigen (CEA) monoclonal antibodies (MAbs) as a noninvasive imaging method to aid in the selection of patients for reoperation after operation for medullary thyroid carcinoma (MTC). METHODS: Sixteen patients with persistent or recurrent hypercalcitoninemia since operation or MTC, but had negative or equivocal conventional imaging study results, were given 99mTc-, 123I-, or 131I-labeled NP-4 or MN-14 anti-CEA MAbs. Scintigraphic images were then performed to determine detection of tumor lesions. RESULTS: The MAb scans were positive in 13 (81%) of the 16 patients studied. However, in only three of 13 patients was disease confined to the cervical or mediastinal nodes. In 10 patients, disease was additionally or solely found in distant organs such as liver (five patients), bone (four patients), and periaortic nodes (one patient). On the basis of our studies, only three of the 13 patients with positive scans would benefit from repeat neck exploration, another three would possibly benefit from neck or mediastinal exploration and hepatic resection, and the remaining seven patients would not benefit from any reoperation with curative intent. CONCLUSIONS: MTC imaging with anti-CEA MAbs could be very useful in determining the ideal candidates for repeat neck exploration.

Adult↗
PubMed1997

The role of thyroid resection during reoperation for persistent or recurrent hyperparathyroidism.

BACKGROUND: The role of "blind" thyroid lobectomy in the surgical management of patients with persistent or recurrent primary hyperparathyroidism is not known. We reviewed our experience with reoperation for hyperparathyroidism to determine the utility of blind thyroid resection in this setting. METHODS: From 1982 to 1995, 269 patients underwent reoperation for hyperparathyroidism at our institution. All patients had biochemical confirmation of hyperparathyroidism and underwent noninvasive and if necessary invasive localization studies. Patients who underwent thyroid lobectomy in an attempt to extirpate the hyperfunctioning parathyroid gland form the basis of this report. RESULTS: Thirty-two of 269 patients (12%) underwent thyroid lobectomy to remove a parathyroid gland. Intrathyroidal parathyroids were confirmed in 19 of 32 patients (59%). In 18 of 19 patients (94%), preoperative or intraoperative ultrasonography correctly identified an intrathyroidal lesion suspicious or a parathyroid. Only 1 of 6 patients (17%) undergoing a blind thyroidectomy had an intrathyroidal gland identified. Ultrasonography had a sensitivity of 95% and a negative predictive value of 99.5% in detecting an intrathyroidal parathyroid gland. CONCLUSIONS: The prevalence of an intrathyroidal parathyroid gland in our series is low (19 of 269, 7%). Ultrasonography can be used reliably to select patients for thyroid resection, reducing the need to perform a blind thyroid lobectomy and avoiding the potential morbidity of thyroid resection in this clinical setting.

Adolescent↗
PubMed1991

Reoperation versus alternatives in retained biliary calculi.

Retained common bile duct stones can be treated by operation, dissolution, extraction, fragmentation, papillotomy, and reoperation. Each approach requires some expertise, and the likelihood of success of most depends on the composition and size of the stones. Good results often can be obtained nonoperatively, especially with a multidisciplinary team. Reoperation is rarely necessary.

Combined Modality Therapy↗
PubMed2001

Reoperation rates for acute graft extrusion and pseudarthrosis after one-level anterior corpectomy and fusion with and without plate instrumentation: etiology and corrective management.

BACKGROUND: Reoperation rates after one-level anterior cervical corpectomy with fusion (ACF) performed without and with plates need further evaluation. METHODS: Reoperation rates for graft extrusion and symptomatic pseudarthrosis were analyzed following 48 nonplated (1989-1996) and 35 plated (1997-2000) one-level ACF. Preoperatively, patients typically exhibited mild/moderate myelopathy attributed to spondylostenosis and ossification of the posterior longitudinal ligament (OPLL). Thirty-five ACF were performed with plates: 3 Orion, 12 Atlantis, and 20 ABC Aesculap plates. Fusion was documented on both dynamic X-rays and 2- or 3-dimensional CT studies 3 and 6 months postoperatively, or until fusion occurred. Follow-up averaged 82 months for the nonplated patients, and 21 months for the plated patients. RESULTS: Out of 48 nonplated patients, 3 developed immediate graft extrusions within 24 hours of surgery requiring graft replacement. Another 2 exhibited symptomatic pseudarthrosis 6 months postoperatively, and required secondary posterior wiring with fusion (PWF). In comparison, 1 of the 35 patients with plated one-level ACF developed plate displacement 6 weeks postoperatively, while 3 exhibited symptomatic pseudarthrosis 6 months after surgery, and required secondary posterior wiring and fusion (PWF). CONCLUSIONS: Comparison of one-level ACF performed with and without plates showed that plating did not appear to reduce pseudarthrosis or graft extrusion rates.

Adult↗
PubMedDate not supplied

The effect on costs of the use of half-dose aprotinin for first-time reoperative coronary artery bypass patients.

Half-dose aprotinin previously has been shown to reduce bleeding and the need for blood transfusions, but the results of cost-reduction studies have been variable. The purpose of the present retrospective study was to compare, from the perspective of the acute care hospital as health care provider, the costs associated with first-time reoperative coronary artery bypass graft (CABG) surgery in patients who received half-dose aprotinin with the costs in those who did not. Medical records from 46 historical controls (first-time reoperative CABG patients receiving no aprotinin) and 51 half-dose aprotinin-treated patients were reviewed. A total of 36 variables were abstracted from the medical records for analysis. It was found that more aprotinin-treated patients did not require transfusion compared with nontreated patients (47% vs 26%). Twenty-one percent fewer aprotinin-treated patients received red blood cell transfusions, 21% fewer received plateletpheresis packs, and 19% fewer received fresh frozen plasma. Cost savings per patient receiving half-dose aprotinin compared with no aprotinin were approximately $878 in blood products and $1088 in total length of stay (including critical care), for total savings of $1966. When the cost of aprotinin ($450) was subtracted, the approximate net mean savings per patient were $1516. This did not include additional cost savings with aprotinin resulting from a median 19.5-minute shorter pump time. The authors conclude that the use of half-dose aprotinin results in reductions in surgical and associated hospitalization costs because of decreases in the length of hospital stay, including length of stay in critical care, and in the use of blood products.

Adult↗
PubMed1996

Outcome of reoperation for carpal tunnel syndrome.

One hundred thirty-one patients with reoperation for carpal tunnel syndrome were followed for a mean of 11 years. Reoperation failed in 15 patients, necessitating a third operation. Satisfaction, symptom severity, and functional status scores were assessed with a standardized questionnaire in the other 116 patients. Patients with normal findings on preoperative nerve conduction studies, those who filed for compensation, and those who had pain in the distribution of the ulnar nerve had significantly worse results. Those with abnormal findings on nerve conduction studies who had not filed for compensation had the best symptom and function scores and satisfaction at latest follow-up examination; those with normal findings on nerve conduction studies who had filed for compensation had the poorest outcome. Although most patients were satisfied with the overall outcome, many reported residual symptoms; in addition to the 15 patients who required a third operation, 22 patients were dissatisfied with the final result.

Activities of Daily Living↗
PubMed2001

Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings.

OBJECTIVES: We sought to: 1) identify trends in the diagnostic testing of patients with prosthetic aortic valve (AVR) obstruction who undergo reoperation and 2) compare diagnostic test results with pathologic findings at surgery. BACKGROUND: It is unclear whether Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have reduced hemodynamic catheterization rates. METHODS: We reviewed 92 consecutive cases ofAVR reoperation at a single center from 1989 to 1998, comparing 49 cases of mechanical AVR obstruction (group A) to 43 cases of bioprosthetic obstruction (group B). Preoperative Doppler TTE was performed in all cases. RESULTS: In group A cases, there was a marginally significant trend towards lower catheterization rates for the Gorlin AVR area, from 36% in 1989 to 1990 to 10% in 1997 to 1998 (p = 0.07), but diagnostic TEE utilization (47% of cases) did not vary. The cause of mechanical AVR obstruction was pannus in 26 cases (53%), mismatch (P-PM) in 19 (39%) and thrombosis in 4 (8%). The mechanism (pannus/thrombus vs. mismatch) was identified in 10% by TTE and 49% by TEE (p < 0.001). In group B cases, hemodynamic catheterization rates (21%) and diagnostic TEE utilization (21%) did not vary with time. Obstruction was caused by structural degeneration in 37 cases (86%), thrombosis in 3 (7%), mismatch in 2 (5%) and pannus in 1 (2%). The mechanism was correctly identified in 63% by TTE and in 81% by TEE (p = 0.18). CONCLUSIONS: Doppler TTE is the primary means to diagnose AVR obstruction; hemodynamic catheterization is not routinely needed. In unselected patients with mechanical AVR obstruction, TEE differentiation of pannus or thrombus from mismatch is challenging.

Adult↗
PubMed1999

Redo carotid surgery: An analysis of materials and configurations used in carotid reoperations and their influence on perioperative stroke and subsequent recurrent stenosis.

OBJECTIVE: The ideal method of arterial reconstruction in operations for recurrent carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. METHODS: A retrospective review was conducted of 82 carotid reoperations performed on 74 patients at our institution. RESULTS: The patient population included 39 men (52.7%) and 35 women (47.3%), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, stroke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with saphenous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylene in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with saphenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylene in 16 (19.5%). The perioperative complications included three strokes (3.7%). There was a trend toward increased perioperative neurologic complications with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term clinical follow-up was obtained in all cases with a mean duration of 35 months, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with interposition grafting as opposed to patch angioplasty. However, the cases in which reconstruction was performed with a vein had a significantly higher rate of late failures (stroke, secondary recurrent stenosis, or occlusion) than those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P =.002 by Fisher exact test). CONCLUSION: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recurrent stenosis or total occlusion of the operated artery. The reason for this finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the perioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may be a more durable solution in long-term follow-up than redo endarterectomy and patch angioplasty. A longer follow-up period will be needed to confirm this conclusion.

Adult↗
PubMed1997

Surgical management of type A aortic dissection: evaluation of predisposing factors for postoperative neurologic complication and late reoperation.

The technique of cerebral protection during hypothermic circulatory arrest remains controversial. Forty-seven patients underwent operations for type A aortic dissection in the past 9 years. During hypothermic circulatory arrest, selective cerebral perfusion and retrograde cerebral perfusion was applied in 12 and seven patients, respectively. The mortality rate was 28.6% in patients without adjunctive cerebral perfusion, 25.0% in selective cerebral perfusion patients, and zero in the retrograde cerebral perfusion group (P > 0.05). However, there was no mortality by cerebral injury in cerebral perfusion groups (P = 0.03). Age (P = 0.001), hypothermic circulatory arrest time (P = 0.012), and acuity (P = 0.013) were predisposing factors for cerebral injury, but cerebral perfusion has not yet been found to be a protective factor (P = 0.56). Nine late reoperations and three deaths occurred during the follow-up period. Marfan syndrome was the only predisposing factor for late reoperation (P = 0.016). In summary, although further studies are still required, retrograde cerebral perfusion is a possible cerebral protective factor. In addition, periodic follow-up is mandatory, especially in patients with Marfan syndrome.

Adolescent↗