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Aortico-left ventricular tunnel is a rare congenital anomaly that presents as aortic regurgitation in infancy or childhood. Information on late results of surgery, especially with reoperations for progressive aortic regurgitation and recurrences are limited. The case histories of two patients with reoperations following correction of aortico-left ventricular tunnel are reported.
OBJECTIVE: To identify predictors of early and late outcomes of common arterial trunk (CAT) after primary surgical correction, such as clinical state prior to surgery, age and weight at presentation, implications of truncal valve abnormalities and associated anomalies of this complex congenital malformation. METHODS: A consecutive series of 106 patients, operated between 1976 and 1998, were reviewed retrospectively. Using the 'Van Praagh' classification, 59 patients presented as A1, 33 as A2, six as A3, and eight as A4. The mean age at operation was 8.6 months (range, 14 days-8.9 years; median, 4.4 months), and the mean weight was 5.2 kg (range, 2.5-30.8 kg; median, 4.4 kg). At the time of operation, 32 patients had congestive heart failure, five were on ventilator support for less than 1 week, and 21 for more than 1 week. RESULTS: Between 1976 and 1989, the early mortality was 21%, and between 1990 and 1998, it dropped to 13%. After 1, 10 and 15 years, the overall survival was 66, 61 and 59%. The 1, 5, 10 and 15 year freedom from reoperation was 82, 60, 22 and 10%, respectively. Clinical condition prior to intervention, truncal valvar dysfunction, and coronary anomalies were significantly associated with poor surgical outcome, whereas weight and age at presentation in our series were not. CONCLUSIONS: In the current era of paediatric cardiac surgery, primary surgical repair of CAT can be carried out with reasonable early and late mortality. However, our data suggest that a high incidence of reoperation, mainly due to the outgrowth and failure of the conduit, has to be expected. The patient's clinical state after diagnosis is decisive for the timing of intervention.
OBJECTIVES: Truncus arteriosus (TA) continues to be associated with significant morbidity and mortality, but there have been clinically significant improvements with early repair. METHODS: Sixty patients underwent physiological correction of TA between November 1978 and January 2000. The average age was 76 days (range, 3 days--20 months). Associated cardiac anomalies were frequently encountered, the most common being severe truncal valve regurgitation (n=7), interrupted aortic arch (n=6), coronary artery anomalies (n=6), non-confluent pulmonary arteries (n=4), and total anomalous pulmonary venous return (n=1). Truncal valve replacement was performed initially or subsequently in seven patients with severe regurgitation (mechanical prostheses in six patients and a cryopreserved aortic homograft in one patient). Right ventricle--pulmonary artery continuity was established with an aortic (n=16) or pulmonary homograft (n=32) in 48 patients, a Dacron polyester porcine valved conduit in five, a non-valved polytetrafluoroethylene (PTFE) tube in three, direct anastomosis to the right ventricle with anterior patch arterioplasty in three, and a bovine jugular venous valve conduit in one patient. RESULTS: There were ten hospital deaths (17%; 70% confidence limit, 7--25%). Multivariate and univariate analyses demonstrated a relationship between hospital mortality and associated cardiac anomalies. In the 43 patients without these associated cardiac anomalies, the early survival was 91% (group I). In the 17 patients with one or more of these risk factors, the survival was 71% (group II, P=0.002). There was one late death. Twenty-three patients (46%) required reoperation for right ventricular outflow tract (RVOT) obstruction at a mean follow-up time of 59.1 months. In 23 patients, the RVOT reconstruction was performed with a PTFE monocusp, and six patients had of a variety of replacement conduits inserted. Postoperatively, there were 34 (68%) patients in New York Heart Association functional class I and 16 (32%) in class II. Twenty-eight surviving patients are reported as doing well without any medication. The freedom of reoperation in the 39 hospital survivors (group I) without risk factors was 64% at 7 years; and 36% at 10 years in the 11 patients (group II) surviving with risk factors. CONCLUSIONS: Associated cardiac anomalies were risk factors for death after the repair of TA. In the absence of these associated lesions, TA can be repaired with an excellent surgical outcome in the neonatal and early infancy period.
OBJECTIVE: To compare three different techniques of distal aortic repair in acute type A (de Bakey type I) aortic dissection and to evaluate their impact on the late morphology of the aortic arch and descending aorta and on the incidence of reoperation. METHODS: From 65 patients operated on due to an acute type A aortic dissection between 1989 and 1993, 54 long-term survivors underwent clinical and radiologic follow-up examination after a mean postoperative interval of 62+/-16 months. The surgical techniques of distal aortic reconstruction included closed repair using Teflon felt reinforcement under moderate hypothermic cardiopulmonary bypass (n = 20) and open repair in deep hypothermic circulatory arrest using either Teflon felt reinforcement (n = 16) or gelatin-resorcin-formaldehyde (GRF) glue (n = 18) to readapt the dissected aortic layers. In all patients, MR imaging was performed on a 1.5-T whole body imaging system for the evaluation of the morphology and function of the heart, aorta and supraaortic branches. RESULTS: Overall hospital mortality following surgical repair of type A aortic dissection was 15.4% during this time period. The highest rate of persistent false lumen perfusion (17/20, 85%) and presence of an intimal flap in the aortic arch (13/20, 65%) was observed in patients following closed repair of acute ascending aortic dissection, whereas the lowest rate of such findings was demonstrated in patients who had undergone open distal aortic repair using biological glue (false lumen perfusion 10/18, 55% and intimal flap in the arch 2/18, 11%). Redo-surgery was significantly reduced in the open repair group using GRF glue (1/18, 5.5%) as compared with the Teflon felt repair group (3/16, 18%) and the closed repair group (6/20, 30%). CONCLUSIONS: In patients with acute type A dissection, open distal aortic repair using GRF-glue favourably influences both (1) the severity of late morphologic alterations in the downstream aorta and (2) the incidence of reoperation.
Tracheal resection and reconstruction for postintubation stenosis is successful in more than 95% of initial repair attempts. The most likely causes of anastomotic failure are anastomotic tension, local devascularization, and granulomatous foreign body reaction. Incomplete resection of areas of stenosis or malacia might also lead to postoperative airway compromise. A variety of systemic factors might contribute to poor anastomotic healing. Postoperative respiratory difficulty requires immediate evaluation. In a patient with recurrent tracheal stenosis, the airway can be managed with dilation, or a tracheostomy or T-tube can be inserted through the failed anastomosis. Patients who are candidates for reoperative tracheal resection and reconstruction can expect good or satisfactory results in 91.9% of cases. Preoperatively addressing the patient's risk factors for failing, and liberally employing release procedures to reduce tension on the anastomosis contribute to the success of a reoperative procedure.
Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.
The purpose of this study was to evaluate the reoperation rate of elbow synovectomy in patients with rheumatoid arthritis. A total of 103 synovectomies were performed in 88 patients (61 women) with rheumatoid factor-positive rheumatoid arthritis with a mean follow-up of 5.2 years (range, 1-8 years). The survival rate after elbow synovectomy (free from reoperation) was 77% (95% confidence interval, 66%-85%) at 5 years. Eight resynovectomies and fourteen total elbow replacements were performed during the follow-up. No significant improvement in range of motion was detected after synovectomy, but pain relief and patient satisfaction were favorable. Elbows were classified preoperatively (before primary synovectomy) with the Larsen system. All resynovectomies were performed for elbows of grade 0-2 destruction. A significant difference was found between early (Larsen grade 0-2) and late (Larsen grade 3) synovectomies in relation to elbow replacement (P =.002) during the follow-up. Late synovectomy yielded more temporary pain relief with a high rate of elbow arthroplasties.
The purpose of this study was to determine prospectively the safety and efficacy of an adjustable silicone gastric band and reservoir system for the treatment of morbid obesity. Between 1992 and 1995, forty primary procedures were performed. Twenty-six females and 14 males entered the study. The mean age of the subjects was 34 years (range 19 to 51 years). Mean body mass index was 50 kg/m2 (range 39 to 75 kg/m2). There were no deaths. Mean body mass index (in kg/m2) at follow-up visits was 38.4 at 1 year, 38.0 at 2 years, 40.2 at 3 years, and 40.4 at 4 years. These decreases were significant at P <0. 001. Thirty-two reoperations (12 intra-abdominal procedures and 20 abdominal wall procedures) have been necessary to maintain efficacy or correct complications. At the four-year interval, the reoperation rate of 80% was unsatisfactory. The excess weight loss has been 41% for those subjects who have an intact gastric band system and continue in the study. Improvements to the implantable band and/or operative technique must be implemented and studied long term if this procedure is to become an accepted surgical treatment for severe obesity.
BACKGROUND CONTEXT: Pedicle screw fixation in osteoporotic bone and in revision of previous pedicle screw fixation cases presents a significant challenge to spine surgeons. Biomechanical tests have shown that a pedicle screw that expands within the vertebrae body can substantially improve fixation in the presence of compromised bone. PURPOSE: To review the clinical and radiographic results with the use of expandable pedicle screws. STUDY DESIGN: One hundred forty-five patients received one or more expandable pedicle screws from the Omega21 spinal fixation system (EBI, L.P., Parsippany, NJ) to obtain thorocolumbar or lumbosacral stabilization. PATIENT SAMPLE: The indications for use of the expandable screws were osteoporosis (21 cases), reoperation of previous pedicle instrumentation (27 cases), intraoperative screw relocation (17 cases), construct reinforcement (23 cases), and sacral anchoring to avoid the necessity of anterior penetration of the sacral cortex (57 cases). OUTCOME MEASURES: The presence of radiographic fusion and complications arising from the instrumentation were reviewed at a mean follow-up period of 35 months (range, 24-72 months). METHODS: A retrospective clinical and radiographic review was performed. Fusion was evaluated based on anterior-posterior and lateral radiographs as well as dynamic radiographs in flexion and extension. RESULTS: Radiographic evidence of fusion was obtained in 125 of the 145 cases (86%). Eighty-six percent of patients with osteoporosis and 89% of reoperations fused. There were no instances of screw loosening or pullout of the expandable screws. Screw breakage occurred in four patients (2.8%), including three patients where fusion was not obtained. In six patients the expandable screws were removed without difficulty after fusion because of local discomfort. CONCLUSION: The results of this study have shown that expandable pedicle screws can be efficacious in cases in which pedicle screw fixation is difficult and adds a valuable tool to the growing armamentarium of spinal instrumentation.
BACKGROUND: The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations. METHODS: The outcome was determined for 27 patients (14 men, 13 women) who had undergone attempted laparoscopic revision between 3 months and 25 years after a previous antireflux operation. Median follow-up was 12 (range 3-48) months. RESULTS: Thirteen patients had previously had an open antireflux procedure (Nissen fundoplication, seven; transthoracic anatomical repair, five; Belsey procedure, one) and 14 a laparoscopic procedure (Nissen, 12; anterior partial fundoplication, two). The indications for revision were: recurrent reflux, 15; paraoesophageal hiatus hernia, six; troublesome dysphagia, six. Fifteen procedures comprised construction of a new Nissen fundoplication, six conversion from a Nissen to a partial wrap, three repair of a paraoesophageal hernia and three widening of the oesophageal hiatus. Revision was successfully completed laparoscopically in 12 patients following a previous laparoscopic procedure and in nine following a previous open operation. Median operating time was 105 min after previous open surgery and 80 min after laparoscopic surgery. No perioperative complications occurred in either group and a good outcome was achieved in 25 of the 27 patients. CONCLUSION: Laparoscopic reoperative antireflux surgery is feasible. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.
BACKGROUND: A small number of patients develop acute severe dysphagia for which reoperation is necessary within 10 days of laparoscopic fundoplication. The aim of this study was to identify clinical variables that might predict the likelihood of this condition occurring, such that it could be avoided in the future. METHODS: This was a prospective cohort study from three tertiary referral centres, using reoperation for acute dysphagia as the main outcome variable. Gastrointestinal symptom rating scale, and psychological well-being index questionnaires were undertaken before laparoscopic fundoplication, and dysphagia scores were determined before operation and 1 year later. Standard preoperative assessment included gastroscopy, oesophageal manometry and pH studies. RESULTS: Twelve (1.9 per cent) of the 617 patients suffered acute dysphagia, which was predicted by older age and female sex, and resulted in a longer duration of hospital stay. This condition was not predicted by any other demographic, clinical, investigative or operative variables. CONCLUSION: The study did not identify useful criteria by which severe acute dysphagia could be anticipated and thereby avoided following laparoscopic fundoplication.
OBJECTIVE: The goal was to report the treatment results after a second operation on patients with recurrent glioblastoma multiforme (GBM) and to investigate if patient's quality of life is improved and survival is lengthened. - METHODS: Thirty-eight patients (17%) out of 224 patients with glioblastoma multiforme, treated at our department from 1/93 to 12/98, underwent re-operation due to clinical and neuroradiological significant recurrence of GBM. Not included were patients who had a lower malignant tumor at first operation and GBM on second operation. All 38 patients had completed radiation therapy. - RESULTS: Overall median survival of re-operated patients was 57 weeks. Interval between 1(st) and 2(nd) operation was 42 weeks and median survival after 2(nd) operation was 23 weeks. Total survival was significantly longer in patients under 50 years at time of re-operation, a time interval longer than 26 weeks between 1(st) and 2(nd) operation, complete resection and a Karnofsky Performance Scale (KPS) >/= 90 at the time of re-operation. Only in the subgroup Karnofsky Performance Scale more or equal 90 had a significant longer survival time after reoperation (29 weeks versus 18 weeks). Based on a KPS change of at least 10 points clinical status was improved in 22 patients, unchanged in 16 patients and no patient deteriorated. No perioperative mortality has occurred. - CONCLUSIONS: Prolongation of survival time after reoperation was statistically significant only in the Karnofsky Performance subgroup. In all other groups prolongation of survival was a relative constant measure of 23%%weeks. The well known favorable prognostic indicators, such as younger age, longer event-free period, had also in our investigation the longest survival times.
BACKGROUND: Long-term results after composite graft replacement of the aortic root may depend on the insertion technique. METHODS: 181 consecutive patients (mean age 53 years; 153 men) operated on between 1983 and 1993 were studied. Indications for surgery were annuloaortic ectasia (n=98), acute aortic dissection (n = 46), other indications (n = 12), and various indications after previous aortic valve replacement (n = 25). Mean follow-up was 28 months. The open-button technique was performed in 74 patients (41 %) and the Bentall inclusion technique in 107 patients (59%), with a Cabrol shunt to the right atrium in 16 patients. RESULTS: Overall survival was 75% after 7 years, significantly decreased in acute aortic dissection (p = 0.0019) and without difference between the two surgical techniques (p = 0.3166). Reoperation-free survival was 69% at 7 years and significantly decreased after acute dissection (p = 0.0421 ). Pseudoaneurysm formation only occurred in 3 patients operated with the Bentall technique not including a Cabrol shunt. CONCLUSIONS: Long-term results are satisfactory. In acute aortic dissection survival is decreased and late reoperations more frequent. The open technique is safe in non-dissection and in acute dissection and avoids pseudoaneurysm formation. The Bentall technique combined with Cabrol shunt is indicated if there is a high risk of hemorrhage. Long-term monitoring of the aorta is mandatory in patients with acute dissection and/or Marfan disease.
In a retrospective analysis of 115 patients who underwent a coronary reoperation between 1984 and 1989, we studied the influence of age and other risk factors on the perioperative morbidity and mortality and on the long-term results. The mean age of the population was 59.4 years, 55 patients were below 60, 52 between 60 and 70 and 8 patients over 70 years, respectively. The distribution of risk factors was similar to other populations suffering from coronary heart disease. The mean time between first and second coronary operation was 7.1 years. Complete revascularisation at the reoperation could be achieved in only 20.9% (n = 24) of the patients. A mean of 1.9 vein grafts were implanted. The perioperative mortality (within 30 days) was 5.2% (n = 6) for the whole group, whereas the highest mortality rate could be observed in the patients aged over 70 with 25% (n = 2). The incidence of perioperative complications was also higher in the elderly patients, comparing them to the whole group. Mean follow-up time was 39 months. During follow up 14 patients (12.4%) died, most of the deaths were cardiac related. The cumulative survival rate was 91% after one, 90% after three, and 88% after five years. We found no statistically significant differences in the survival rates and the myocardial infarction rates regarding the different age groups. The exercise capacity and functional status at the time of follow up were quite acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)
In 149 patients, scheduled for cardiac reoperations, repair of cyanotic heart disease or resection of aneurysms of the ascending or descending aorta, the effect of intraoperative hemoseparation was studied. The amount of autologous blood which was collected before, during, and after systemic heparinisation and processed to washed packed red cells was registered. Mean packed cell quantities gained intraoperatively were: 1275 (1006-2067) ml (descending aortic aneurysm), 1800 (1186-2500) ml (ascending aortic aneurysm), 1524 (1030-1801) ml (single valve rereplacement), 1896 (1398-2368) ml (double valve rereplacement), 946 (800-1050) ml (coronary artery reoperation), 1362 (922-1455) ml (cyanotic heart disease) and 1519 (1194-2066) ml (miscellaneous cardiac operations). In 35 patients more than 2000 ml and in 14 patients more than 3000 ml packed cells were harvested. Based on body weight, relatively more packed cells could be gained in patients with cyanotic heart disease (41 ml/kg) than in the other groups (21 ml/kg). In these young patients the application of a smaller centrifuge bowl (125 ml) can be helpful. These results demonstrate that cell saving by means of a cell separator with a special suction line and collecting system can help to reduce the donor blood requirement in cardiac operations, in which large intraoperative blood loss is anticipated.
Following the increasing number of patients with heart valve replacement and an extended indication (older age groups, acute infective endocarditis, multivalvular procedures) the indicence of malfunction of valve prostheses is continuously growing. The prognosis of patients with a malfunctioning prosthesis mainly depends on early diagnosis and adequate therapy. In a retrospective study (1970 to 1984) 3,533 implanted heart valve prostheses were followed up and the cases with malfunction (n = 150; 4.2%) were analyzed. During the follow-up period after 1963 mitral valve replacements (MVR) there were 78 cases of malfunction (4.6%), after 1806 aortic valve replacements (AVR) 73 (4.1%), and after 34 tricuspid valve replacements (TVR) 4 malfunctions (11.8%). These malfunctions concerned periprosthetic leakages (n = 65), prosthetic endocarditis (n = 42), prosthetic valve thrombosis (n = 13), mechanical dysfunction including bioprosthetic degeneration (n = 17), valve related hemolysis (n = 3), and unsatisfactory hemodynamics (n = 10). Special attention was turned to the problem of prosthetic endocarditis (1963-1984) found in a total of 71 patients following 3,878 prosthetic valve replacements (1.9%). In 42 reoperated cases (1970-1984) the causing microorganisms were analyzed, demonstrating staphylococci in a leading position. Secondary complications and additional risk factors are discussed. There has been no change concerning the basis and the strategy of management for prosthetic endocarditis for many years: After a short time of conservative management with tested antibiotics, early reoperation and exchange of the prosthesis seems to be the optimal therapy, despite a distinctly high postoperative mortality (17%).(ABSTRACT TRUNCATED AT 250 WORDS)
Reoperations after cardiac valve replacement are unavoidable: their frequency depends on surgical technique, type of valve used, and the anatomical situation. Erlangen, almost 300 such procedures were required among 3500 valve replacements, while 19 out of 700 bioprostheses had to be exchanged. Statistically relevant complications occurring with variable frequency are paravalvular leakage, thrombosis and degeneration of the bioprostheses which have to be corrected for hemodynamic reasons. Other indications are thromboembolism and endocarditis. Rare complications are: rupture of the posterior wall of the ventricle or aortic root with subsequent development of aneurysm, entrapment of the occluder due to long sutures, pannus, muscle chordae, strut fracture (Björk) or wear of the occluder (Wada, Starr, Edwards, Beall). Some complications as dehiscence, entrapment, rupture and aneurysm of the posterior wall of the ventricle and aortic root can largely be avoided by good surgical techniques. Reoperative mortality rate is slightly higher due to greater possibilities of injury and bleeding. Emergency procedures in grade IV NYHA have the highest rate (50%), elective procedures for leakage, calcified or regurgitant bioprostheses the lowest. The most frequent indication for re-operation is perivalvular leakage. Dehiscence requires surgery to deal with hemolysis or for hemodynamic reasons. Dehiscence is more common in aortic than in mitral position; the latter can be closed by felt-padded stitches in 80%. This technique is the most reliable in preventing leakage, although thrombosis is more likely. Causes of dehiscence are endocarditis, suture-line tearing, calcium in the annulus. The incidence of valve thrombosis is related to valve type, usually associated with inadequate or abruptly terminated anticoagulation therapy (rebound). Disc valve are at particular risk.(ABSTRACT TRUNCATED AT 250 WORDS)
PURPOSE: The purpose of this study was to investigate the incidence of reoperation after temporomandibular joint arthroscopic surgery in 315 consecutive patients (488 joints). STUDY DESIGN: The clinical data and operative reports of all patients who underwent arthroscopic procedures from 1995 to 2000 were reviewed retrospectively. Patients had a preoperative clinical and panoramic radiographic evaluation. Most of the patients had disk displacement without reduction. In the remaining patients, the intra-articular pathologic conditions ranged from disk displacement with reduction to degenerative joint disease. The outcome assessment was based on reduction in pain, improvement in vertical dimension of mouth opening, and mandibular excursions. The same surgical team performed all arthroscopic procedures. Before surgery, all patients received at least 3 to 6 months of nonsurgical therapy consisting of anti-inflammatory medications, muscle relaxants, splint therapy, physiotherapy, exercise, moist heat, cold laser, ultrasound, and soft diet or a combination thereof. Patients were monitored postoperatively for as long as 5 years. RESULTS: Results showed that approximately 20% of those patients who had temporomandibular joint arthroscopic surgery underwent further temporomandibular joint procedures ranging from repeat arthroscopic surgery to open-joint arthrotomy. CONCLUSION: Temporomandibular joint surgical arthroscopy is an appropriate therapeutic modality for patients with temporomandibular joint internal derangements, with reoperation required for only 20% of patients.