Should octogenarians be denied access to surgery for acute type A aortic dissection?

AIM

Outcomes after surgery for acute type A aortic dissection in the octogenarian are controversial. To analyze this issue further, the authors reviewed their experience in the hope of finding ways to improve results in these high-risk patients.

METHODS

Between April 1990 and November 2006, 319 consecutive patients underwent emergency surgery for acute type A aortic dissection at the San Martino University Hospital of Genoa (Italy). Among them, 23 (7%) patients were aged 80 years or older (mean age 82 years, range 80 to 86 years) and represent the study population. On admission 7 patients (30%) had preoperative shock, 1 needed cardiopulmonary resuscitation, 7 (30%) had a neurological deficit, 2 (9%) had acute renal failure. Deep hypothermic circulatory arrest was performed in 19 patients (83%). Surgical procedures included isolated replacement of the ascending aorta in all patients associated with root replacement in 2 (9%) and total aortic arch replacement in 5 (22%). Median follow up was 4.1 years (range 3 to 83 months).

RESULTS

Hospital mortality was 61% (14 of 23 patients). Late mortality was 11% (1 of 9 survivors). Stepwise logistic regression identified the extension of surgery to the arch as independent risk factors for hospital death. Fourteen patients (61%) had 1 or more postoperative complications. Overall survival was 39+/-10% and 33+/-10% after 1 and 5 years respectively.

CONCLUSIONS

Surgery for acute type A aortic dissection in the octogenarian shows high hospital mortality but satisfactory long-term survival among discharged patients. A less aggressive approach should increase the outcomes of surgically managed patients.

Ross and Ross-Konno procedures in infants, children and adolescents: a 13-year experience

BACKGROUND AND AIM OF THE STUDY

Due to hemodynamic performance and potential for growth of the pulmonary autograft, the Ross operation is considered to be the surgery of choice for irreparable aortic valve disease in pediatric patients. The study aim was to analyze the long-term clinical and echocardiographic results of the Ross operation.

METHODS

Between February 1993 and July 2006, 55 consecutive patients (mean age 10.0 +/- 6.2 years; range: 3 months to 18 years) underwent eithera Ross operation (n=46) or a Ross-Konno procedure (n=9). The underlying left ventricular outflow tract pathology was mainly congenital (n=47). Among patients, 23 (42%) had undergone a previous aortic valve procedure. Concomitant procedures were performed in 16 patients (29%). The Ross operation was performed as a root replacement in all cases; the mean cross-clamp time was 132 min (range: 100-188 min). The autograft diameter was indexed to the body surface area and compared to normal values. The mean follow up was 5.5 +/- 3.8 years, and was 100% complete.

RESULTS

There was one early death (2%) and two late deaths (4%). The actuarial patient survival was 93% at 10 years. None of the patients developed moderate or severe autograft regurgitation. All measured maximal root diameters were above the 90th percentile of normal aortic diameter, without correlation to autograft regurgitation. Five patients (9%) had a mean homograft gradient > or = 40 mmHg, and two (4%) were reoperated on. The freedom from reoperation for homograft degeneration was 91% at 10 years.

CONCLUSION

Autograft regurgitation after the Ross and Ross-Konno procedures is uncommon, and the risk of homograft degeneration appears low. Autograft dilatation is common but does not correlate with autograft regurgitation. When considering long-term freedom from autograft and homograft degeneration, the results of the present study confirm the Ross operation as the surgery of choice for irreparable aortic valve disease in infants, children and young adults.

The need of appropriate brain SPECT templates for SPM comparisons

AIM

Statistical parametric mapping (SPM) is used worldwide to compare brain perfusion single photon emission computed tomography (SPECT) data. The default template within the SPM package used for SPECT image normalization includes images of a group of healthy subjects studied with [(99m)Tc]HMPAO. Since [(99m)Tc]HMPAO and [(99m)Tc]ECD have shown to distribute differently in SPECT studies, we formulated the hypothesis that comparing set of [(99m)Tc]ECD data normalized by means of a [(99m)Tc]HMPAO template may lead to incorrect results.

METHODS

A customized [(99m)Tc]ECD template was built with SPECT and magnetic resonance imaging (MRI) images of 22 neurologically healthy women. Then, two sets of subjects, i.e. a group of patients with very early Alzheimer's disease (eAD) and a matched control group, studied by means of [(99m)Tc]ECD SPECT, were chosen for comparisons. The same statistical approach (t-test between eAD patients and controls and correlation analysis between brain SPECT and a cognitive score) was applied twice, i.e. after normalization with either the default [(99m)Tc]HMPAO template or the customized [(99m)Tc]ECD template.

RESULTS

In the comparison between eAD and controls, a cluster of difference in the posterior cingulate gyrus of both hemispheres was only highlighted when using the customized [(99m)Tc]ECD template, but was missed when using the default [(99m)Tc]HMPAO template. In the correlation between brain perfusion and a cognitive score, the significant cluster was more significant and far more extended, also including the right superior temporal gyrus, using the customized [(99m)Tc]ECD template than using the default [(99m)Tc]HMPAO template.

CONCLUSION

These data suggest the need of customized, radiopharmaceutical-matched SPECT templates to be used within the SPM package. The present customized [(99m)Tc]ECD template is now freely available on the web.

[Endoscopic vein harvesting. Impact of learning curve on results and rehabilitation]

BACKGROUND

The tendency of modern surgery is towards the reduction of invasiveness. The aim of this study is to evaluate the impact of the learning curve, the reliability, the short term results and the advantages in terms of rapid rehabilitation of endoscopic vein harvesting (EVH) in a consecutive series of 20 patients operated on of aorto-coronary bypass surgery.

METHODS

Between February and June 2005, 20 patients between 61 e 82 years of age underwent EVH with the use of Vasoview 5 (Guidant Corporation, Indianapolis, USA). To evaluate the impact of learning curve on the total operative time, patients were divided in 4 chronologically consecutive groups (G1, G2, G3, G4). Intraoperative characteristics and short term results were evaluated.

RESULTS

The mean velocity and the mean time of harvesting in G4 were 0,68 cm/min and 45 min. respectively, similar to the time required for a scheletonized left internal mammary artery harvesting. In the first 5 patients 2 conversions were required, one of them related to the EVH technique. No bleeding, functional impairment or infective complications are reported. Active mobilization was possible in every case in the first post-operative day.

CONCLUSIONS

EVH is a reliable technique and the learning curve can be limited to the first 5 cases. The foreseeble reduction of infectious complications, the absence of pain and the immediate mobilization of the leg allow a rapid and effective rehabilitation.

Staging and therapy monitoring of multiple myeloma by 99mTc-sestamibi scintigraphy: a five year single center experience

The aim of the present study was the evaluation of the diagnostic value of 99mTc-sestamibi (MIBI) in the detection of bone marrow involvement in patients suffering from multiple myeloma (MM) and its possible role in the follow-up. Between 1998 and 2003, 68 patients with MM and 42 pts with monoclonal gammopathy of undetermined significance (MGUS) were consecutively enrolled in this study. 51/68 MM patients had active disease (AD), 11/62 were in complete remission (CR) and 6/68 in partial remission (PR) after chemotherapy. 18 patients with MM repeated a 99mTc-MIBI scintigraphic study at least 2 months after high-dose chemotherapy. All the scans were scored semi quantitatively according to extension and intensity of tracer uptake. All MGUS pts had a negative 99mTc-MIBI. As far as the MM pts are concerned, 54/68 (49%) pts (48 with AD, 5 with PR and 1 with CR) had a positive 99mTc-MIBI scan, while the 99mTc-MIBI scan was negative in 14/68 pts (10 with CR, 1 with PR and 3 with AD). The overall sensitivity of the 99mTc-MIBI scintigraphy was 92%; specificity was 96%. In the follow up of the pts treated with chemotherapy 99mTc-MIBI closely paralleled the activity of myeloma bone disease. In conclusion, these results indicate that 99mTc-MIBI scintigraphy closely reflects myeloma disease activity in the bone marrow, and that a negative 99mTc-MIBI scan in patients with suspected MM clearly, though not absolutely, indicates absence of disease or clinical remission. The results of this study suggest a clear diagnostic value of 99mTc-MIBI scintigraphy in patients with MM and its potential role during the follow-up for the monitoring of MM bone disease.

Global cognitive impairment should be taken into account in SPECT-neuropsychology correlations: the example of verbal memory in very mild Alzheimer's disease

PURPOSE

To examine the impact of severity of global cognitive impairment on SPECT-neuropsychology correlations, we correlated a verbal memory test with brain perfusion in patients with very mild Alzheimer's disease (AD), taking into account the Mini-Mental State Examination (MMSE) score as an index of global cognitive impairment.

METHODS

Twenty-nine outpatients (mean age 78.2+/-5.5 years) affected by very mild, probable AD underwent brain SPECT with 99mTc-ethylcysteinate dimer and a word list learning test. SPM99 was used for voxel-based correlation analysis after normalisation to mean cerebellar counts (height threshold: p<0.01). In a first analysis, only age and years of education were inserted as nuisance covariates, while in a second analysis the MMSE score was inserted as well.

RESULTS

In the first analysis, two clusters of significant correlation were found in both hemispheres, mainly including regions of the right hemisphere, such as the inferior parietal lobule, the middle temporal gyrus and the posterior cingulate. Significant correlation in the left hemisphere was observed in the lingual lobule, the parietal precuneus and the posterior cingulate. After taking into consideration the MMSE, the largest cluster of correlation was found in the left hemisphere, including the parietal gyrus angularis, the posterior cingulate and the middle temporal gyrus.

CONCLUSION

The wide differences observed between the correlations achieved with and without taking into account the MMSE score indicate that severity of global cognitive impairment should be considered when searching for brain perfusion-neuropsychology correlations. In the present case, this strategy resulted in correlations that more closely matched neuropsychological models of verbal memory deficit.

[Videolaparoscopic oncologic surgery of the right colon: our experience]

The authors present their experience in videolaparoscopic surgery for right colon cancer after two years of videolaparoscopic surgery for approach to colorectal cancer. In the period between March 2002 and March 2003 they have practiced 11 right emicolectomy by videolaparoscopic technique for neoplasms: 7 were males and 4 were females with age of about 70 years old. These case included: 7 right colon's cancers, 2 cecal cancers and two hepatic flexure cancers. One postoperative complications has been observed (9%) for bowel's occlusion for early adhesion syndrome. On the base of their experience the authors perform usually videolaparoscopic surgery (M.I.S.) for the approach to right colon cancer.

[Videolaparoscopic oncologic surgery of the left and right colon: our experience]

The authors present their experience in videolaparoscopic surgery for colorectal cancer. In the period between November 2000 and march 2003 they have treated 31 patients by videolaparoscopic surgery for colorectal cancer: 17 were males and 14 were females with age included between 41 and 93 y.o. These case included: 15 rectal cancers, 12 sigmoid cancer, 3 cases of lineal flexura's cancers and I case of transverse cancer. Postoperative complications has been observed in three cases (9.6%) in the first 14 operations practiced, then confirming the learning curve. The authors perform usually mini-invasive surgery (MIS) for the approach to colorectal cancer surgery.

[A splenic autograft in posttraumatic splenectomies]

BACKGROUND AND AIMS

The authors report their experience regarding the use of autologous splenic transplantation in post-traumatic splenectomy unable to be treated using conservative surgery. After reviewing the international literature on the subject, they report a retrospective survey of cases treated from January 1992 to December 1996.

METHODS

Owing to the particular logistic location of the hospital in an area with a high density of industry and at the crossroad of major road and rail routes, a total of 56 patients were admitted to the Emergency Ward suffering from abdominal trauma in 4 years. The patients included in this study could not be treated using conservative surgery: the study group included 15 patients aged between 14 and 76 years old. The surgical technique consisted of the graft of sections of splenic pulp in omental pockets, subsequently marked using metal clips. In order to evaluate splenic immunological function a complete hemochromocytometric examination was performed in each patient at the same time as emergency preoperative tests consisting of peripheral blood strip and pitted cells (PC) assay. This was followed by postoperative evaluations at weekly intervals, including platelet count, Howell-Jolly bodies assay (HJb), immunoglobulin M assay and hepatosplenic scintigraphy using erythrocytes marked with 99m-Technetium pertechnetate (99mTc).

RESULTS

An adequate functional recovery of splenic tissue was achieved in all patients with partial recovery of hemocatheretic and immunological function.

CONCLUSIONS

The authors' clinical experience confirmed the data inferred from animal experiments: the simplicity of the preparation technique and the autologous transplantation of splenic pulp in the absence of major complications confirms the possibility of applying this method in all splenectomies performed under emergency conditions.

[Plasma levels of beta-endorphins and ACTH in labor with continuous peridural analgesia]

In order to investigate whether continuous lumbar epidural analgesia is associated with alterations of plasma levels of beta-endorphins and ACTH, we have studied a group (A) of patients under epidural analgesia and a matched group of control (B) at different stages of labour. Plasma levels of beta-endorphins and ACTH in group A did not significantly change during the labour, while in group B beta-endorphins and ACTH increased in the second stage of labour and decreased thereafter one hour after delivery. The levels of beta-endorphins and ACTH in umbilical cord mix blood were elevated in both groups.

[Medium- and long-term use of central venous catheters in pediatrics. Personal experience]

From January 1992 to October 1994, 74 central venous catheters were inserted, in the University Hospital of Rome: Polyclinic Umberto I - "La Sapienza", in 62 paediatric patients (15.17 +/- 1.64 years old), admitted to the paediatric surgery division. The authors used a large amount of CVC: totally implanted devices (34 Groshong, 7 Broviac, 2 Hickman, 3 Port) and percutaneous catheters (28 Arrow). The choice of the infusional devices has been influenced by the length of the treatment, the primitive disease, the age and the size of the patient. The authors used totally implanted devices in paediatric patients undergoing chemotherapeutic and nutritional therapies. External central venous access devices were used in patients undergoing central catheterization lasting less than two months. The subclavian vein has been used as venous access in patients weighing > 5 kg, the internal jugular vein in < 5, kg patients. This work reports the early (PNX, hematomas, arterial access) and the long term complications (infections, accidental unthreading, occlusions and dislocations). We can say that the medium and long last term CVC is well tolerated and accepted in paediatric patients too, for antineoplastic, nutritional and infusion therapies.

Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

[Endoscopic and pharmacologic treatment with omeprazole of upper digestive hemorrhage]

Upper gastrointestinal bleeding is still a subject much discussed as much for the diagnostic approach and as by the therapeutic decisions read. The authors present their experience of the treatment of upper gastrointestinal bleeding not caused by portal hypertension or by neoplasm. The patients undergo emergency endoscopy by haemostatic treatment if necessary and pharmacological therapy by omeprazole. The evaluation criteria are: stopped bleeding, the need of blood transfusion, the healing of the bleeding site. Stopped bleeding has been watched at first endoscopic check in 85% of patients; only 26 blood units has been necessary; the complete healing of bleeding injury happened not later than 30 days.

[The use of a total parenteral nutrition solution in major gastrointestinal surgery]

This study evaluates the efficacy and tolerance of a complete preparation for TPN, "Trive 1000" consisting of an emulsion of lipids, amino acids and sorbitol, balanced in the substratum with a caloric water ratio of 1 cal/1 ml. The preparation offers sterility and simplicities of use guarantee. 20 patients, subjected to major digestive surgery, were treated. The valuation of the product has been effected through nourishing index of common use and by checking of side effects. The results confirm the handling and the tolerance of "Trive 1000" although in hepatic and nephropathic patients the solution must be used with caution.

[Acute enterorrhagia. A diagnostic-therapeutic approach]

The Authors report their experience in cases of severe lower intestinal bleeding. On the basis of personal data and previously reported results, endoscopy is shown to be the primary and sometimes essential method, especially in the case of colo-rectal bleeding, both in terms of its diagnostic precision and possible therapeutic uses. This technique was used to treat all emergency cases, obtaining a diagnostic resolution in 85.6% and hemostasis and/or the concomitant removal of the lesion in 52.3% of cases.

Prophylaxis of infection with intravenous immunoglobulins plus antibiotic for patients at risk for sepsis undergoing surgery for colorectal cancer: results of a randomized, multicenter clinical trial

BACKGROUND

The results of a randomized, multicenter clinical trial with perioperative short-term antibiotic plus intravenous immunoglobulins (IVIG + A) versus antibiotic alone (A) for prevention of postoperative infections in patients at risk for sepsis undergoing surgery for colorectal cancer are presented.

METHODS

The patients at risk for sepsis were selected by an original multiparametric test based on delayed-hypersensitivity skin testing and serum protein electrophoretic subfractions. This screening had shown 76% positive predictability in a previous validation assessment. Eighty patients at risk for sepsis were selected prospectively from 210 patients undergoing surgery for colorectal cancer; 43 patients were randomly assigned to the IVIG + A group and 37 to the A group. IVIG was administered on the day before operation, on the first and fifth postoperative days.

RESULTS

There was a clear-cut reduction of postoperative infections in the IVIG + A group: 21 infections in 20 patients versus 37 infections in 29 patients in the A group (p less than 0.004). With regard to serum immunoglobulin (Ig) G monitoring, basal IgG levels were significantly lower in patients given IVIG + A who had postsurgical infections (p less than 0.005) compared with patients with a regular outcome, whereas the same was not true in the A group of patients.

CONCLUSIONS

A significant decrease (p less than 0.001) of postoperative IgG was evidenced in the A group of patients who had infections as opposed to a significant increase (p less than 0.001) of postoperative IgG in IVIG + A patients with a normal outcome.

Anatomopathological study of dementia syndrome linked with an abnormal cerebrospinal fluid flow. Report of literature and personal observations

The authors have analysed the data of the literature to identify the cases of normotensive hydrocephalus that underwent surgery and then died after the operation; some of these patients died over varying periods of time after the operation and the death was due to accidents. It seems that the anatomopathological lesions are less important in cases that benefited from the operation compared with cases that did not present perceptable clinical variations. The authors report the anatomopathological data of four personal cases which, from the clinical point of view, presented the dementia symptom associated in varying degrees to other neurological symptoms such as disturbances of the gait and of the sphincters functions (Adams' triad). All four subjects presented dilatation of the cerebral ventricles without cortical atrophy. From the histological point of view, there was: exfoliation of the ependyma, subependymal gliosis, demyelination of the white periventricular matter and spongiosis; there were no lesions of the meninges, of the cerebral cortex, no vascular alterations, except for those due to age, or stenosis of the aqueduct. The cause of the ventricular dilatation that was responsible for the clinical symptoms was not clear from the histological examination; the value and the significance of the histopathological data obtained and from the data available from the review of the literature are discussed and they point out the fact that many of the lesions encountered seem to be the consequence rather than the cause of the hydrocephalus.(ABSTRACT TRUNCATED AT 250 WORDS)

Scinticisternography in presenile and senile degenerative disease

86 patients suffering from various senile and presenile degenerative diseases were studied using scinticisternography with In111-DTPA. Flow reversal and delayed clearance were observed in 62 of these patients. These alterations, possibly related to the cerebrospinal fluid dynamics, show the aspecificity of the SC picture. The SC picture does not seem to be correlated to the clinical signs.

Spinal cord softenings of identifiable cause: anatomical and clinical features

To complete our bibliographic review of spinal cord softenings, we now discuss the clinical and pathological findings in the cases of known or probable cause. Comparison of the diagnostic groups yields some differences in respect of sex, age and mode of onset, survival and extent of the anatomical lesion. Further differences, especially in age at onset, clinical pattern and lesion site, emerge from a comparison of these cases of known or probable cause with those whose cause is not apparent.