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PubMed2005

Clinical review: the strategy of immediate reoperation for transsphenoidal surgery for Cushing's disease.

CONTEXT: Transsphenoidal surgery is currently the primary therapeutic option for Cushing's disease. Despite considerable initial success, 10-30% of patients fail to achieve lasting remission. EVIDENCE ACQUISITION: We evaluated a strategy of immediate reoperation in surgical failures judged by plasma cortisol levels that did not fall to 2 microg/dl or less within 72 h of surgery. Of 215 patients with presumed ACTH microadenomas, treated between 1993 and 2004, 12 met inclusion criteria and had prompt (within 15 d) reoperation for residual or missed ACTH microadenoma. These 12 patients represent 28% of those who did not have evidence of postoperative adrenal insufficiency. EVIDENCE SYNTHESIS: Based on an outcome measure of sustained subnormal or normal plasma cortisol levels, eight of 12 patients (67%) achieved remission from the two operations. Adjunctive therapies (radiotherapy, gamma knife radiosurgery, and adrenalectomy) led to remission in another three patients. It is recognized that this outcome required either total hypophysectomy (one patient) or postoperative hypopituitarism (all patients in remission). CONCLUSION: Magnetic resonance imaging was not usually helpful in determining therapeutic strategies; however, inferior petrosal sinus sampling was critical in providing confidence that the disease was of pituitary origin. A treatment algorithm is recommended, based on this study.

Adult↗
PubMed2005

Use of ultrasonic aspiration for dural opening in cranial reoperations: technical note.

OBJECTIVE: Dural detachment from the brain in cranial reoperations has been accomplished previously by selective coagulation and the cutting of brain-dural adhesions. The results of ultrasonic aspiration during tumor surgery or brain cutting procedures led the authors to speculate that the detachment of the dura mater from brain tumors by applying the Cavitron ultrasonic surgical aspirator (Valleylab, Boulder, CO [formerly Cavitron, Inc., Stamford, CT]) to the brain-dura mater interface could be used to reduce bleeding and facilitate dural opening during cranial reoperations. METHODS: Ten patients underwent a second craniotomy for epilepsy surgery (five cases of extended temporal lobectomy and five cases of extended extratemporal lesionectomy). The use of ultrasonic aspiration and its effects on brain separation from the dura mater were examined. RESULTS: Intraoperative use of the Cavitron ultrasonic surgical aspirator during dural opening produced immediate blanching of the dura mater and enhanced visualization of the cortical surface without distortion of the brain anatomy. CONCLUSION: Incremental dural opening and brain visualization is achieved by careful application of ultrasonic aspiration directly into the brain-dura limit, producing immediate regional dural devascularization. Use of this technique reduces cortical and dural bleeding and enhances the ease and effectiveness of brain visualization.

Dura Mater↗
PubMed1986

Actuarial analysis of reoperation in patients undergoing open mitral commissurotomy for mitral stenosis.

Reoperation is one of the most seriously problematical events in postoperative follow-up of patients undergoing open mitral commissurotomy (OMC) for mitral stenosis. In 217 patients with pure mitral stenosis, even when associated with severe subvalvular changes, the actuarial rate of freedom from reoperation was 94% 12 years after OMC. In contrast, in 85 patients with MS combined with regurgitation, the rate was 66%. In postoperative management of patients undergoing OMC, it is mandatory to know preoperative anatomical findings of the stenosed mitral valve.

Actuarial Analysis↗
PubMed2001

Complications after gastroplasty and gastric bypass as a primary operation and as a reoperation.

BACKGROUND: Since 1991 we performed vertical banded gastroplasty (VBG) as our surgical treatment of choice for morbid obesity in 680 patients, and since 1996 we also performed Roux-en-Y gastric bypass (RYGB) in 36 patients. For revisional surgery, the surgeons chose procedures based on their experience. METHODS: We recorded early complications (0.6%) and late complications (8.5%) after the primary operations. When staple-line disruption or stenosis of the banded stoma occurred after VBG, revisional surgery was performed with re-VBG or conversion to RYGBP. Some early complications needed emergency operation for bleeding or gastric perforation. RESULTS: Mortality was zero. Reoperation with re-VBG and RYGBP was effective in all patients, but for many, a long stay in hospital was necessary because reoperation had a high rate of early and late complications, 33.8% and 21.8% respectively. CONCLUSION: The treatment of complications after VBG with re-VBG and RYGBP had danger. We believe that when VBG failure occurs, to avoid dangerous complications again, we should perform a biliopancreatic diversion, which does not involve a gastric restriction.

Anastomosis, Roux-en-Y↗
PubMed2004

Doubled mortality rate in irradiated patients reoperated for regrowth of a macroadenoma of the pituitary gland.

BACKGROUND: Reduced life expectancy has been shown in patients with hypopituitarism, mainly caused by cardiovascular diseases. A major cause of hypopituitarism is pituitary adenomas, and radiotherapy may be employed as a treatment modality to reduce the post-operative regrowth rate of these tumours. Recently, we showed that in patients with craniopharyngiomas, tumour regrowth foreshadowed a fourfold risk increase for death. For patients with pituitary adenomas, the impact of regrowth on life expectancy is, however, not known. OBJECTIVE: To assess the impact of a reoperation due to a regrowth of a pituitary macroadenoma on mortality, taking into account other candidate prognostic factors. DESIGN AND PATIENTS: In 281 patients with operated and irradiated macroadenomas, excluding acromegaly and Cushing's disease, 35 patients had a regrowth (median follow-up 16.6 years). Possible risk factors for tumour regrowth were investigated by Cox regression models. RESULTS: For tumour regrowth, age, calendar time at primary surgery, gender and extension of tumour growth had no statistically significant impact. For younger patients, the proportion of regrowths was higher, but after age-stratified Cox regression analysis only regrowth was shown to have a significant impact on mortality, with a more than doubled mortality risk for patients with tumour regrowth as compared with the non-regrowing tumour patients (hazard ratio=2.24, P<0.001). This finding was corroborated by cohort analyses using the general population as an external comparison group. CONCLUSION: Among patients with irradiated pituitary macroadenomas, excluding acromegaly and Cushing's disease, a doubled mortality rate was observed for those reoperated for tumour regrowth as compared with patients with non-regrowing tumours.

Adenoma↗
PubMed2004

Robot-assisted off-pump minimally invasive reoperative coronary artery bypass grafting: case report.

BACKGROUND: Resternotomy for reoperative coronary artery bypass grafting (CABG) has become increasingly common with an aging patient population. Minimally invasive and robotic techniques permit us to perform these surgeries with reduced morbidity and mortality. CASE REPORT: A 67-year-old woman was taken to the operating room for repeat CABG. A free right internal mammary graft was endoscopically harvested using the da Vinci robotic operating system. A small left thoracotomy was then used to perform an off-pump bypass from the descending aorta to the hood of a diseased saphenous vein graft. CONCLUSION: Robotic and minimally invasive cardiac surgery undergoes continuous refinement. As the incidence of reoperative surgery in patients with multiple previous interventions rises, surgeons will have to become increasingly creative with their choice of conduits, incisions, and the use of hybrid open and endoscopic techniques.

Aged↗
PubMed2005

Cardiaplasty and Roux-en-Y partial gastrectomy (Serra-Dória procedure) for reoperation of achalasia.

BACKGROUND: After cardiomyotomy for the treatment of megaesophagus, recurrence of symptoms occur in up to 15% of the patients, but only some require a reoperation. AIM: To evaluate the results of reoperation -- cardioplasty with Roux-en-Y partial gastrectomy, a technique proposed by Serra-Dória. CASUISTIC AND METHODS: Twenty patients with achalasia previously treated by cardiomyotomy, were retrospectively studied. The etiology of symptoms recurrence was reflux esophagitis in nine (45.0%) patients, healing of the myotomy in five (25.0%), end staging megaesophagus in five (25.0%) and incomplete myotomy in one (5%). Intra and postoperative complications were analyzed. The patients were studied by clinical (dysphagia, regurgitation, heartburn and weight gain), radiological and endoscopic evaluation, in the pre- and postoperative period. RESULTS: Five (25.0%) patients had complications in the immediate postoperative period. No deaths were observed. Dysphagia improved in all the patients. Regurgitation and heartburn almost disappeared in the whole group. Weight was maintained or increased in 64.7% of the patients. Radiological studies showed a decrease in the caliber of the esophagus in 53.0%, while the remaining patients maintained the pre-operative diameter. Endoscopy, performed during the late postoperative period in 17 patients, showed that 6 among the 9 with reflux esophagitis improved; 2 among the 8 with a normal esophagus during the preoperative period, developed esophagitis. CONCLUSIONS: The Serra-Dória procedure for the treatment of megaesophagus in patients who had already undergone cardiomyotomy and whose symptoms recurred, presented a low morbidity and no mortality. It offered a significant relief of symptoms with a decrease of the caliber of the esophagus in several patients. The patients also improved with regards to reflux esophagitis. In some cases reflux was still present after surgery. Others with normal esophagus in the preoperative period developed esophagitis.

Adolescent↗
PubMed1990

Indications for and risks in reoperation for coronary artery disease.

Seventy-one coronary artery bypass grafting (CABG) reoperations were performed during a 17-year period, comprising 2.7% of all CABG operations. The main indication (in 87%) was vein graft failure alone or combined with other causes. Progression of disease in native coronary arteries was the sole indication in only 4 of the 71 cases. There were seven perioperative deaths, mainly due to myocardial infarction. Significant perioperative complications arose in 36 cases, including intraoperative lesion of a previous left internal mammary graft (16.2%) or of the right ventricle or anterior descending branch of the left coronary artery (2.8%). Postoperative low output syndrome appeared in 13 patients (18.3%), in seven of whom myocardial infarction was verified. Postoperative bleeding required resternotomy in six cases (9.1%). Because of the heightened operative mortality and morbidity risks, indications for redo CABG should be individualized. A well functioning internal mammary artery graft may be a relative contraindication. Accurate knowledge of the previous operation is essential and, especially in young patients, the possibility of reoperation should be taken into consideration at initial CABG.

Adult↗
PubMed1994

Gamma nail vs compression screw for trochanteric femoral fractures. 15 reoperations in a prospective, randomized study of 378 patients.

A total of 378 trochanteric and subtrochanteric femoral fractures were randomized to treatment with Gamma nail (177) or Hip Compression Screw (HCS) (201). After a median follow-up time of 17 (10-27) months, 15 patients needed reoperations; 13 had been treated with Gamma nail and 2 with HCS. 10 patients, all treated with Gamma nail, were reoperated because of a femoral shaft fracture. 5 of these fractures occurred 8 (4-10) days postoperatively and were related to intraoperative complications. The other 5 shaft fractures occurred a median of 2 (1-3) months postoperatively after falls, and may be related to stress concentration at the tip of the solid nail. The lag screw cut out or penetrated the femoral head in 5 patients, 3 of them treated with Gamma nail and 2 with HCS.

Aged↗
PubMed1984

Failed aneurysm surgery. Reoperation in 115 cases.

Failure to obliterate intracranial aneurysms completely during initial surgery still occurs in spite of recent technical advances. Of the 115 reoperations reported in this series, 89% of the aneurysms were obliterated, and 84% of the patients had a satisfactory outcome. Twelve patients had poor results, three (2.6%) of whom were in poor condition before reoperation.

Cerebral Angiography↗
PubMed1989

Results of reoperation for failed epilepsy surgery.

A total of 37 patients who failed epilepsy surgery were evaluated with magnetic resonance imaging and long-term scalp electroencephalographic monitoring before reoperation. Repeat surgery involved focal resections after initial focal resections (30 cases) or stereotactic lesions (one case), or focal resections following anterior corpus callosotomy (six cases). Patients with initial focal resections followed by enlargement of the original operative site had the most successful outcome, especially those with complex partial seizures of temporal lobe origin. The most common cause for poor outcome of the original operation in patients with temporal lobe epilepsy was insufficient hippocampal resection. Patients who were most likely to benefit from reoperation were: 1) those with initially incompletely resected structural lesions; 2) those who were initially evaluated with invasive ictal monitoring; and 3) those who underwent further resection of the initial operative site rather than resection of a different cortical region.

Adolescent↗
PubMed1999

[Comparison between intermittent antegrade warm blood cardioplegia and cold crystalloid cardioplegia in patients performed reoperation for valvular heart disease].

The purpose of this study was to compare the postoperative cardiac function and systemic effects between intermittent antegrade warm blood cardioplegia and cold crystalloid cardioplegia in patients performed reoperation for chronic acquired valvular heart disease. Group I consisted of 4 patients who underwent intermittent antegrade warm blood cardioplegia (MVR in 1, MVR + TAP in 2, DVR + TAP in 1), and Group II consisted of 5 patients who underwent intermittent antegrade cold crystalloid cardioplegia (MVR + TAP in 3, TVR in 2). There were no significant differences found between the two groups in operation time, perfusion time, aortic cross clamp time, spontaneous beating rate after declamping and reperfusion time. Also doses of inotropes required during weaning was almost the same for the both groups. But 24 hours after surgery, smaller doses of inotropes (4.4 +/- 2.1 gamma/kg/min) were required for Group 1, while larger doses (7.8 +/- 2.8 gamma/kg/min) were required for Group 2 (p < 0.05). As for the postoperative complications, none was noted in Group 1, while multiple organ failure in 2, hyperbilirubinemia in 2 and complete atrioventricular block in 1 patient was noted in Group 2. The above results suggest that, for reoperations of valvular heart disease, intermittent antegrade warm blood cardioplegia is a useful and reliable method with optimum myocardial protection as well as favorable systemic effects.

Adult↗
PubMed1999

Reoperation as treatment of relapse after subtotal thyroidectomy in Graves' disease.

BACKGROUND AND METHODS: In Graves' disease radioiodine is the recommended treatment for relapses after subtotal thyroidectomy. If patients reject radioiodine, hyperthyroidism is managed with antithyroid drugs; surgery is generally not considered as an alternative. Here we retrospectively analyzed 30 consecutive patients with Graves' disease who had recurrent hyperthyroidism after subtotal thyroidectomy. RESULTS: On relapse after the first operation, the patients were initially treated by medication; 25 opted for definitive treatment (19 for reoperation and 6 for radioiodine). Operations consisted of 10 unilateral and 8 bilateral resections (total or near-total with capsular remnants of < 1 g) and 1 transsternal approach (because of dystopic intrathoracic thyroid tissue). The decision between a unilateral and a bilateral reintervention was based on the ultrasonographic determination of remnant volumes. These size estimates were valid because they were significantly correlated to the weight of the resected remnants (r = 0.92, slope = 0.95). Eighteen of the 19 patients were adequately treated by this approach. Unilateral resection was performed in 1 patient with a remaining contralateral remnant of 5.4 mL; this patient had a second relapse. The complication rate was low (2 cases of transient recurrent nerve injury and 1 of transient hypocalcemia). CONCLUSION: Provided that no contraindication is present, reoperation is safe, effective, and expeditious in recurrent hyperthyroidism. Because the likelihood of a recurrence depends on the total remnant size, the goal is to keep it below 2 g. Preoperative ultrasonography can effectively guide the decision between a unilateral and a bilateral resection.

Adult↗
PubMed2000

[Disbiotic conditions in patients operated and reoperated for heart defects and ischemic heart disease].

Bacteriological examination of angiocardiac system, biocenosis of the intestine and upper respiratory tracts was made in 3473 patients who were to be operated or reoperated for congenital or acquired valvular defects in the presence of chroniosepsis and chronic septic endocarditis, complicated IHD. 375 patients with other diseases served control. 74 of them have undergone surgery for varicose veins of the legs. Preoperative contamination with opportunistic microflora was found in the heart, major vessels, veins of the majority of the patients. There was also dysbiosis of natural biotops. Patients with valvular defects to be reoperated 2-20 years after the initial operation on the heart had infection in the angiocardiac structures, severe dysbiosis of natural biotops, i.e. advanced dysbiosis--severe persistent condition with permanent source of endogenic infection complicated the underlying disease and bringing postoperative septic complications.

Adult↗
PubMed1999

[Upper thoracic thoracoscopic sympathectomy as the method of choice for reoperation of the thoracic sympathetic nerve].

The authors present in their paper the possibility of thoracoscopic thoracic sympathectomy as the method of choice for reoperation of the thoracic sympathetic nerve 14 years after classical surgical upper chest sympathectomy, as the original effect had receded. They mention the possibility of reoperation of the sympathetic nerve with a subsequent favourable effect by the endoscopic method which reduces the risk of complications to a minimum.

Female↗
PubMed2000

[Use of porous polytetrafluoroethylene prostheses in reconstructive reoperations in patients with occlusive lesions of the aorta and arteries of the lower limbs].

The use of a new domestic vascular prosthesis "Vitaflon" in reconstructive reoperations on 21 patients was clinically estimated. The positive properties of the prosthesis such as high biological inertia, good plastic properties, strength and reliability allow this prosthesis to be recommended for using in reconstructive reoperations on the vessels.

Adult↗
PubMed2001

[Efficacy of modified ultrafiltration in reoperation for valvular disease].

We evaluated the efficacy of modified ultrafiltration (MUF) in reoperation for valvular disease. Fourteen patients were divide into two groups consisting of a control group (n = 6) and a MUF group (n = 8). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 31% in the MUF group (p < 0.05). The percentage of the increase in body weight after the operation in the MUF group was significantly less than that in the control group (3.3 +/- 3.1% vs 8.3 +/- 4.3%, p < 0.05). The PaO2/FIO2 after the operation in the MUF group was significantly higher than that in the control group (376 +/- 125 mmHg vs 242 +/- 79 mmHg, p < 0.05). The duration of mechanical ventilation in the MUF group was significantly less than that in the control group (1.1 +/- 1.1 days vs 5.3 +/- 3.3 days, p < 0.05). In conclusion, MUF is useful to hemoconcentrate, reduce postoperative body weight gain and promote early recovery of pulmonary function in reoperation for valvular disease.

Aged↗
PubMed2000

[Arterial reoperation of the aorto-femoral segment].

Late rethromboses of aortofemoral prostheses following arterial reconstructions for aortoiliac occlusive disease (AIOD) are among the serious challenges faced by vascular surgeons. Hyperplasia of the intima, progressive atherosclerotic process, as well as regional hemodynamics impairment are taken to be the major factors promoting late rethrombosis development after arterial bypass for AIOD. It is the purpose of the study to assay the underlying causes and terms of rethrombosis in aortofemoral bypasses for AIOD, and analyze the results of the arterial reoperation procedures used. Over the period 1990-1997, 408 aortofemoral bypass procedures are performed in the University Hospital "St Catherine", with rethrombosis of the prostheses occurring in 19.45 per cent of the branches within 5 years of the initial intervention. Five methods of reoperation are used, with optimal results--100 per cent patency of prostheses--attained in aortobifemoral re-bypasses. Nevertheless, this particular operative procedure is considered as practicable in isolated, properly selected, relatively young patients free of associated diseases. In adults or patients with health problems preference is given to rather simple procedures, if possible performed under regional anesthesia, such as thrombectomy of the prosthesis (TE) using a deep femoral artery patch and/or sequence distal bypass towards arteria poplitea. The latter method accounts for limb salvage in 97.14 per cent of cases. A satisfactory outcome (88.58% preserved limbs) is likewise secured by resection of the failing distal anastomosis, and its substitution for neobifurcation towards the unobstructed AFS and APF. In elder and/or poor health patients the application of cross-over and axillofemoral bypasses are also advisable.

Adult↗