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At least 793 records · Page 44Linked to original sources
PubMed1998

Minimally invasive radioguided parathyroidectomy in the reoperative neck.

BACKGROUND: Operations for hyperparathyroidism (HPT) in a previously operated neck present a significant challenge and carry much higher morbidity rates than first-time operations. Our extensive experience with minimally invasive radioguided parathyroidectomy (MIRP) for first-time surgery for HPT has shown this method to be a directed approach to the offending adenoma, suggesting that the technique could be used to minimize reoperative neck surgery as well. METHODS: Over an 11-month period 24 consecutive patients with primary HPT who had undergone at least one previous neck operation were referred for re-exploration. All patients underwent preoperative sestamibi scanning; 21 localized sufficiently to undergo MIRP. RESULTS: All patients were cured after reoperation. Eighteen patients underwent MIRP under local anesthesia as outpatients; 3 MIRPs were done under general anesthesia. Average total operative time was 44 minutes, average incision length was 3.0 cm +/- 0.2 cm. Nineteen of the procedures were completed without any frozen sections. There were no complications. CONCLUSION: MIRP is extremely effective in patients with HPT who have undergone previous neck exploration for parathyroid or thyroid disease. The technique allows for such a directed dissection that smaller incisions and local anesthesia in an outpatient setting are routine.

Adenoma↗
PubMed1994

Clinical outcome and reoperation after low-weight transurethral resection of the prostate.

The clinical outcome and reoperation rate after low-weight transurethral prostatectomies are not well documented. Seventy-four consecutive patients who underwent a transurethral resection of the prostate weighing 10 g or less over a 24-month period were evaluated with a preoperative and postoperative comparative symptom score analysis. The overall clinical outcome in these patients was: improvement in 44%, no change in 39% and unfavorable in 17%. Irritative and obstructive voiding symptoms resolved in 32% and 43% of patients, respectively. Reoperations were performed in 23% of the patients. These results are compared with reports of resections of larger glands, revealing a dissimilarity in clinical outcome and resolution of symptoms.

Aged↗
PubMed1998

Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation.

Complete thyroidectomy was recommended for patients with well-differentiated thyroid carcinoma to remove any potential residual contralateral cancer tissue and to facilitate detection of metastatic lesions by radioactive iodide (131I). Unfortunately, 8-32% incidence of severe complications were noted after reoperation. At present, there are still not enough data about the ablative effect of 131I for such conservative surgical treatment of well-differentiated thyroid cancers. The major goal of the present study was to examine the effects of 311I for ablation of thyroid remnants in order to obviate the severe complications associated with reoperation. From January 1977 to December 1995, 210 papillary or follicular thyroid carcinoma patients received subtotal thyroidectomy or lobectomy. After the operation, 46 of the 210 patients received 131I for remnant ablation. At doses of > or = 30 mCi 131I, 38 thyroid remnants were successfully ablated; 25 of 38 (65.8%) patients successfully ablated patients received 30 mCi 131I one-four times. Five patients expired during the follow-up period, including two follicular carcinoma patients who were misinterpreted as having benign lesions in the first operation. Patients in the overall failure versus success group for thyroid remnant ablation revealed increased age, histopathology of follicular carcinoma, higher postoperative 131I uptake in the neck bed, higher postoperative thyroglobulin levels, bigger tumor size, and higher mortality. In conclusion, repeated 30 mCi 131I treatments were adequate for most thyroid remnant ablations following subtotal thyroidectomy or lobectomy in well-differentiated thyroid cancer patients. Misinterpretation of follicular cancer as benign lesions and unresectable tumor comprised the main reasons for mortality.

Adenocarcinoma, Follicular↗
PubMed1999

Reoperation in recurrent high-grade gliomas: literature review of prognostic factors and outcome.

Two percent of cancer deaths are caused by malignant primary brain tumors, and most of these are high-grade gliomas. Despite the treatment given, malignant gliomas recur early. Mean survival is less than 12 months, and only 20% of patients survive for more than 2 years. This rapid course induces some physicians to resort to all the therapeutic options available and, at recurrence, to reevaluate the patient for a second intervention. Others consider reoperation to be an overtreatment. The debate is ongoing, and an answer likely will be found only through better identification of the prognostic factors that will identify patients who will benefit from reoperation.

Brain Neoplasms↗
PubMed1996

The efficacy and cost of aprotinin in children undergoing reoperative open heart surgery.

We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the efficacy of aprotinin in 61 children (median age 3.7 yr) undergoing reoperative open heart surgery (OHS). Three demographically similar groups were studied: large-dose aprotinin (ALD), small-dose aprotinin (ASD), and placebo (P). Over the first 24 postoperative hours fewer patients in the aprotinin groups received packed red cells (ALD, 53%; ASD, 89%; and P, 95%; P = 0.001), platelets (ALD, 32%; ASD, 50%; and P, 65%; P = 0.04), and fresh frozen plasma (ALD, 16%; ASD, 17%; and P, 60%; P = 0.003) than placebo patients. Most importantly, aprotinin patients had fewer exposures to banked blood components (ALD, median 1 U; and ASD, median 2 U) than P (median 6 U; P = 0.001), with no difference in overall complication rate. Use of aprotinin was associated with a savings in the patient charges for blood components, operating room time, and duration of hospitalization. In conclusion, aprotinin decreased the number of units of banked blood components used during the first 24 postoperative hours in reoperative pediatric OHS. Aprotinin thus decreases the risks associated with exposure to banked blood components and reduces hospital charges.

Aprotinin↗
PubMed1998

Vascularized muscle flaps and reoperative approach for complicated, dehisced sternal wounds in children.

Vascularized muscle flaps for treatment of mediastinitis and sternal wound dehiscence have become standard treatment practice, but triple-muscle flap reconstruction is reserved for the more complex wounds. The incisional approach for reoperation in such patients is controversial. We report an extremely ill infant, born at 38 weeks gestational age, who underwent an arterial switch procedure for transposition of the great arteries at 12 days of age. Sternal wound infection, dehiscence, mediastinitis, and extensive wound necrosis complicated the postoperative course. The cultured organism Enterobacter is a relatively rare cause for median sternotomy wound infection and was associated with massive postoperative hemorrhage. The infant underwent multiple debridements and at 2 months of age had reconstructive surgery with bilateral pectoralis major muscle advancement flaps combined with a rectus abdominis muscle flap. Three months postreconstruction the infant required reoperation to correct a stenosis at the site of the pulmonary artery anastomosis. This surgery was carried out through the previous median sternotomy scar because it was the safest, most direct approach and would also limit additional scarring. Long-term follow-up at 2 years of age shows a well-developed young boy with no limitations in growth and activity.

Anti-Bacterial Agents↗
PubMed1984

Intraoperative urinary cyclic adenosine monophosphate as a guide to successful reoperative parathyroidectomy.

Sixty patients with persistent or recurrent primary hyperparathyroidism underwent reexploration during which urinary cyclic adenosine monophosphate (UcAMP) levels were determined at half-hour intervals by radioimmunoassay. Retrospective analysis of the data allowed us to develop UcAMP criteria for surgical success. Following removal of parathyroid tissue, if an individual UcAMP level dropped 50% from the median baseline level, or if elevated levels dropped to less than 4.0 nmol/dl glomerular filtrate, surgery was predicted to be successful. Eight unsuccessful procedures in seven patients produced no decline in UcAMP, and the intraoperative results accurately predicted surgical failure. Fifty-three patients underwent successful procedures and in every case UcAMP fell. Ninety-eight per cent of these successful procedures were predicted by our criteria. Levels of UcAMP fell 1.5 +/- 0.5 hours (means +/- SD) following abnormal parathyroidectomy. In 19 of 36 successful cases diagnosed before surgery as adenoma, the operative procedure was terminated before a significant drop in UcAMP. In 16 of 17 successful cases diagnosed before surgery as hyperplasia or uncertain histology, UcAMP fell during the operation. Intraoperative determination of UcAMP is helpful in reoperative parathyroid surgery. The criteria established allow intraoperative prediction of success with remarkable accuracy. Urinary cyclic AMP is especially helpful in reoperation for multigland disease; when enough pathologic tissue has been removed, the criteria will be met and the procedure may be terminated with confidence.

Cyclic AMP↗
PubMed1985

Reoperations for esophagitis following failed antireflux procedures.

During the last 20 years, several procedures have been introduced that effectively control gastroesophageal reflux. Nevertheless, little has been written regarding surgical management of patients with recurrent esophagitis following a failed antireflux procedure. The purpose of this study was to review the results of all operations for recurrent esophagitis. Fifty-five patients had undergone a total of 61 previous operations for reflux (initial operation: Hill, nine; Nissen, 30; Allison, eight; Thal, patch three; Belsey, 10; other, one). Eleven patients underwent a Hill procedure (indications: intractable "gas-bloat" syndrome, 4 patients, esophagitis, 7 patients). Two developed recurrent esophagitis (18%). Seventy-eight per cent had satisfactory results (mean follow-up 24 months), and there were no deaths. Three individuals had a transabdominal fundoplication. One patient was lost to follow-up while the other two had satisfactory results (follow-up, 1 and 6 years). Twenty-nine patients were subjected to a transthoracic fundoplication, with two deaths (seven per cent). One patient (four per cent) was lost to follow-up at 9 months; mean follow-up was 44 months). Eighty-six per cent had satisfactory results. The sole poor result occurred in a scleroderma patient who ultimately required colon interposition. Twelve patients underwent a Thal-Nissen procedure. One patient was lost to follow-up (eight per cent), while another with scleroderma had an unsatisfactory result (eight per cent); 83% had satisfactory results. The mean follow-up was 70 months. There were no deaths. Overall, 80% of patients subjected to reoperation had satisfactory results. Mortality was four per cent. Reoperations for gastroesophageal reflux constitute an effective means of controlling recurrent esophagitis and compare favorably with primary operations in both mortality and success rate.

Esophagitis, Peptic↗
PubMed1985

Recurrent carotid stenosis. A five-year series of 65 reoperations.

From 1979 to 1983, 1726 carotid endarterectomies were performed at the Cleveland Clinic. During this period, 39 men (mean age, 60 years) and 22 women (mean age, 63 years) required 65 reoperations (3.8%) for correction of recurrent carotid stenosis occurring 3 to 194 months (mean, 42 months) after previous endarterectomy at this center (N = 43) or elsewhere (N = 22). Remedial procedures were necessary because of restenosis demonstrated by routine noninvasive testing in 32 asymptomatic lesions and because of neurologic symptoms in 33 others. The mean recurrence interval was 57 postoperative months for atherosclerosis (N = 37) in comparison to 21 months (p = 0.0007) for myointimal hyperplasia (N = 28), and was 48 months for men in comparison to 31 months for women (p = NS). Hypercholesterolemia appeared to be associated with late atherosclerotic recurrence (p = 0.05), but was not a feature of myointimal hyperplasia. Patch angioplasty (N = 59) or graft replacement (N = 3) was employed during 62 of the 65 reoperations, with a total of two operative deaths (3.1%), one nonfatal stroke (1.5%), and six transient cranial nerve injuries (9.2%). Three unrelated late deaths have occurred within a mean follow-up period of 23 months, but only three patients have experienced subsequent neurologic symptoms.

Adult↗
PubMed1986

Vocal cord paralysis and reoperative parathyroidectomy. A prospective study.

One hundred sixty-three patients undergoing reoperative parathyroidectomy were evaluated before and after operation to determine the incidence of, risk factors for, and morbidity of vocal cord paralysis. These patients were compared to 77 patients undergoing initial parathyroid operation, only one of whom had vocal cord paralysis on postoperative indirect laryngoscopy (1.3%). Preoperative examination of the reoperative patients revealed vocal cord paralysis from initial exploration in 11 patients who were excluded from this study. After re-exploration, 10 patients (6.6%) had vocal cord paralysis, eight unilateral and two bilateral. Right vocal cords were paralyzed twice as often as left. In 90%, vocal cord paralysis was associated with removal or biopsy of an ipsilateral gland. Vocal cord paralysis occurred despite intraoperative visualization of the recurrent laryngeal nerves. Preoperative localization, parathyroid gland pathology, and concomitant thyroidectomy were not associated with increased risk of vocal cord paralysis. Hoarseness was the major symptom. Tracheostomy was required for two patients, one was permanent. One patient was treated for aspiration with a temporary gastrostomy. Nine of 10 patients had return of normal voice quality in an average of 4 months time. On examination 4 years or more after surgery, two of five patients had normal vocal cord motion. The oblique anatomic course of the right recurrent laryngeal nerve may account for the greater frequency of right vocal cord paralysis.

Follow-Up Studies↗
PubMed1988

Reoperation for congenital choledochal cyst.

A reoperation after excisional procedure was carried out in seven cases due to early or late postoperative complications. Of the 12 patients with early complications, four underwent relaparotomy due to anastomotic leakage and bleeding. Late complications were seen in nine patients with recurrent cholangitis caused by an anastomotic stricture, and three patients with intrahepatic involvement required a reoperation several years after the initial surgery. Recurrent cholangitis after biliary reconstruction mainly occurs due to an anastomotic stricture of the hepaticoenterostomy. There was no significant difference in the results between hepaticoduodenostomy and hepaticojejunostomy over a long follow-up period. A wide anastomotic stoma that permits free drainage of bile into the intestine is imperative to the prevention of cholangitis, and can be created by an incision extending along the lateral wall of both the hepatic ducts with a hepaticoenterostomy at the hilum. This procedure is obviously necessary in all patients with or without intrahepatic involvement. Carcinoma of the intrahepatic ducts and the retained distal choledochus have rarely developed in patients undergoing cyst excision followed by biliary reconstruction. Complete excision of the whole extrahepatic bile duct could prevent carcinoma arising in the distal choledochus, although it could not prevent carcinoma arising from the intrahepatic ducts. However, patients with carcinoma of the intrahepatic duct were reported to have had symptoms of biliary stricture for a long time since the cyst excision. Bile stagnation in the intrahepatic ducts is possibly responsible for the development of carcinoma. A wide anastomosis resulting in free drainage of bile appears to be essential to the prevention of carcinoma arising in the intrahepatic ducts after cyst excision.

Adenocarcinoma↗
PubMed1992

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

Acidosis↗
PubMed1997

Improved results of cervical reoperation for medullary thyroid carcinoma.

OBJECTIVE: The purpose of the study is to determine whether reoperation for medullary thyroid carcinoma (MTC), performed with low morbidity in carefully selected patients, consistently results in improvement as determined by lowering of stimulated calcitonin levels. BACKGROUND: Persistent or recurrent elevation of stimulated plasma calcitonin levels occurs in > 50% of patients after primary operation for MTC. Success of reoperation with clearance of metastatic cervical nodal disease has been hampered by failure to identify patients with distant metastases and by inadequate removal of involved nodal groups. METHODS: Since 1992, the authors have evaluated 115 patients with recurrent or residual MTC. Fifty-three patients have not undergone operation because of extent of disease, previous extensive treatment, medical condition, or patient choice. Sixty-two patients underwent surgery. Ten patients had laparoscopic or open examination of the liver, the results of which showed liver metastases. Seven patients had palliative debulking of cervical tumor. In 45 patients without evidence of distant metastases, cervical operation was carried out with curative intent. Removal of central, upper mediastinal, and lateral nodes (levels II, III, IV, VI, and VII) was done. RESULTS: Seven of eight patients who had palliative resections are alive without symptoms. In patients who underwent curative resections, postoperative stimulated calcitonin levels were in the normal range in 17 patients (38%) and were not significantly lowered in 6 patients (13%). There were no deaths, and no transfusions were used. CONCLUSIONS: These results are a significant improvement over the authors' previous series and reflect better preoperative identification of patients with disease confined to the neck and improved operative strategy based on knowledge of the pattern of nodal spread of MTC.

Adolescent↗
PubMed1997

Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients.

OBJECTIVE: The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%. METHODS: Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed. RESULTS: One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy. CONCLUSION: Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.

Adolescent↗
PubMed1999

Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay.

OBJECTIVE: The clinical usefulness of preoperative localization and intraoperative PTH assay (QPTH) in primary hyperparathyroidism have been established. However, without the use of QPTH, the parathyroidectomy failure rate remains 5% to 10% in large reported series and is probably much higher in the hands of less experienced parathyroid surgeons. Persistent hypercalcemia requires another surgical procedure. The authors compared the outcomes in 50 consecutive patients undergoing more difficult secondary parathyroidectomy with and without the adjunctive support of QPTH. METHODS: Two groups of similar patients underwent reoperative parathyroidectomy for failed surgery or recurrent disease. The successful return to normocalcemia in group I, with QPTH used to localize and confirm complete excision of all hyperfunctioning glands, was compared with group II, who did not have this intraoperative adjunct. RESULTS: In 31/33 patients in group I, calcium levels returned to normal. With good preoperative localization studies, 17 patients underwent successful straightforward parathyroidectomies as predicted by QPTH. In the other 14 patients, QPTH assay proved extremely beneficial by facilitating localization with differential venous sampling; measuring the increase in hormone secretion after massage of specific areas; recognizing suspicious nonparathyroid tissue excised without a decrease in hormone levels, avoiding frozen-section delay; and correctly identifying the excision of abnormal tissue despite false-positive/false-negative sestamibi scans. In group II, who underwent surgery before QPTH was available, 4 of 17 patients (24%) remained hypercalcemic after extensive reexploration. CONCLUSION: With the intraoperative hormone assay used to facilitate localization and confirm excision of all hyperfunctioning tissue, the success rate of reoperative parathyroidectomy has improved from 76% to 94%.

Adult↗
PubMed1994

Reoperative coronary artery bypass grafting.

In recent years reoperative coronary artery bypass surgery has become increasingly more commonplace. This article reviews the current status of this procedure with regard to patient population, risk factors, and long-term follow-up. Important aspects of the specific technical considerations involved in reoperative surgery are also reviewed and evaluated.

Coronary Artery Bypass↗
PubMed1998

Reoperation in patients after anterior cervical plate stabilization in degenerative disease.

STUDY DESIGN: Consecutive case retrospective chart review. OBJECTIVES: First, to assess whether the number of' patients requiring a second cervical surgical intervention was changed as a result of using anterior cervical plate stabilization, and second, to determine the additional risks and/or benefits associated with the hardware implantation. SUMMARY OF BACKGROUND DATA: The optimal technique of performing stabilization, arthrodesis, and alignment of a cervical segment after discectomy with neural decompression in degenerative disease has yet to be determined. METHODS: The charts of 402 patients who had undergone an anterior cervical discectomy and arthrodesis for degenerative disease performed both with and without anterior cervical plate stabilization were reviewed, and reoperation data were compiled. The average follow-up time was 3.8 years (range, 1.5-9.4 years). RESULTS: Of 365 patients with 1- or 2-level cervical arthrodesis, 22 required a second surgical intervention (20 bone alone, 2 with anterior cervical plate stabilization). The Log-Rank test, which uses all patients and their total follow-up periods, was statistically significant favoring anterior cervical plate stabilization at one and two levels (P = 0.015). CONCLUSIONS: The addition of anterior cervical plate stabilization in one- and two-level cervical degenerative disease supplements the internal stabilization initially provided by the bone graft, and yields a lower reoperation rate.

Adult↗
PubMed2004

Tube-onlay-tube tunica vaginalis flap for proximal primary and reoperative adult hypospadias.

PURPOSE: We describe the surgical technique of and report the results in the first 20 patients who underwent combined onlay-tube construction of a tunica vaginalis flap. MATERIALS AND METHODS: We repaired 20 cases of proximal primary (8) and repeat (12), adult hypospadias using a tube-onlay in 4, an onlay-tube in 3, a tube-onlay-tube in 9 and an onlay-tube-onlay in 4. In 15 patients contralateral tunica vaginalis was used as a blanket wrap. Three to 6 months postoperatively after obtaining informed consent retrograde urethrography, cystourethroscopy, uroflowmetry and urethral biopsy were done in 20, 17, 10 and 13 patients, respectively. RESULTS: No fistula or diverticulum developed. Complications occurred in 3 patients (15%), including urethral stricture, meatal stenosis and urethral stricture, and meatal regression and urethral stricture in 1 each. All strictures occurred in the distal urethra in reoperative cases. At long-term followup there was no recurrent stricture or meatal stenosis after internal urethrotomy and dilation. Urethral biopsy in all 13 patients showed a stratified epithelium indistinguishable from native urethra. The reasons for delayed presentation include perceiving hypospadias as a normal variation (paribor or cut by angels), losing hope for a cure after multiple failed repairs, being told by urologists that repair is futile and pressure by wives for cosmetic or fertility reasons. CONCLUSIONS: The place of tunica vaginalis in hypospadias surgery is more than coverage for urethroplasty. It can be successfully used for substitution urethroplasty. As an extension to the principles of the onlay flap and the concept of urethral plate preservation, combined onlay-tube constructions of tunica vaginalis, including a tube-onlay-tube flap, are successfully applicable to proximal hypospadias, especially in reoperative cases. Urothelialization of the tunica vaginalis occurs within months of surgery.

Adult↗