Free internal mammary artery graft reimplantation on the same vessel in repeat coronary revascularization

We describe the case of a 62-year-old man who needed a 3-vessel coronary artery bypass reoperation and mitral valve replacement. The patient's existing free left internal mammary artery graft was not functioning because of a critical stenosis in the native vessel just after the distal anastomosis. The free graft itself was in perfect condition, and we decided to reuse it. Because the course of the graft was so tortuous, we concluded that skeletonization would yield the extra length needed for reimplantation. After reimplanting the graft, we performed venous grafting and mitral valve replacement. The patient was well and had no signs of ischemia at 29 months postoperatively. There have been few reports on recycling internal mammary artery grafts in repeat coronary artery bypass grafting. To our knowledge, ours is the first report of the reimplantation of a free internal mammary artery graft on the same vessel. We describe the procedure and our decision-making process.

Transumbilical laparoendoscopic single-site ureteral reimplantation

OBJECTIVE

To analyze the outcomes of umbilical laparoendoscopic single-site (LESS) ureteral reimplantation using a reusable single-port platform.

MATERIAL AND METHOD

The casuistic of LESS ureteral reimplantation in 5 patients is presented. The surgical technique using KeyPort system (reusable umbilical single-site platform) is described. Dissection, suctioning and suturing by minilaparoscopy through 3.5mm accessory port in the iliac fossa are performed. Operative and postoperative outcomes are presented. The median follow-up at time of analysis was 11 ± 14 months.

RESULTS

The median age of patients was a 49 ± 34 year; male-female ratio was 1:1.15. Left surgery was carried out in all cases. In 4 patients, the etiology was secondary to stenosis (3 iatrogenic and 1 pelvic endometriosis). In the remaining case, the procedure was performed after excision of a symptomatic adult ureterocele. In all cases, bladder catheter and double-J ureteral catheter were inserted for 7 ± 3 and 30 ± 15 days and then removed. No conversion to convectional laparoscopic or open surgery occurred. The surgery time was 145 ± 60 min, and intraoperative bleeding was 100 ± 75 cc. Neither transfusion nor high analgesia was necessary. No postoperative complications, minor or major, have been reported. Hospital stay was 2 ± 0.5 days. In any patient, restenosis or worsening of renal function occurred.

CONCLUSIONS

In experimented centers, transumbilical laparoendoscopic single-site ureteroneocystostomy is a safe alternative with comparable results to conventional laparoscopy and an excellent cosmetic result at low cost thanks to device reuse.

[Aortic Root Reimplantation for Extra-cardiac Unruptured Sinus of Valsalva Aneurysm]

Aneurysms of the sinus of Valsalva are rare. We report a case of extra-cardiac unruptured aneurysm of the sinus of Valsalva with moderate aortic regurgitation (AR). A 57-year-old woman was referred to our institution because of AR. Echocardiography showed moderate AR and computed tomographic scanning demonstrated an extra-cardiac aneurysm of the unruptured sinus of Valsalva, which extended from the right sinus of Valsalva to the non-coronary sinus of Valsalva. She underwent aortic root reimplantation procedure with a Valsalva graft. Although mild AR was observed postoperatively, her postoperative course was uneventful.

Should simultaneous ureteral reimplantation be performed during sigmoid bladder augmentation to reduce vesicoureteral reflux in neurogenic bladder cases?

PURPOSE

To assess the necessity of performing simultaneous collateral reimplantation during sigmoid bladder augmentation (SBA) to reduce vesicoureteral reflux (VUR) in low-compliance neuropathic bladder with associated VUR.

METHODS

We retrospectively identified 31 patients who underwent SBA alone or with simultaneous ureteral reimplantation at our hospital. The video urodynamics data, VUR status, renal function, and clinical symptoms were studied during follow-up.

RESULTS

The mean follow-up time was 57 months (range 12-117). All patients displayed significantly increased safe cystometric capacity (P < 0.001) and bladder compliance (P < 0.001) and decreased creatinine (P < 0.01) and urea nitrogen (P < 0.05) compared with preoperative levels. High-grade VUR was resolved in only 7 of 15 patients (47%) in Group A (simultaneous ureteral reimplantation), whereas low-grade VUR was resolved in 13 of 16 patients (81%) in Group B (SBA alone). The other 11 patients still displaying VUR after SBA had larger safe bladder volumes due to augmentation. The patients' improving renal function benefited most from the enlarged bladder and partly from increased antireflux resistance of vesico-ureter anastomosis. Twelve (38.7%) had recurrent febrile urinary tract infection after SBA, and one (3.2%) suffered from vesico-ureter anastomosis contracture after ureteral reimplantation.

CONCLUSIONS

A preoperative intravesical VUR pressure of 20 cmH2O is not an effective cutoff point for whether ureteral reimplantation should be simultaneously performed during SBA. Augmentation appears to be more important than reimplantation for protecting kidney from damage due to febrile urinary tract infection after SBA. Simultaneous reimplantation may be not necessary during SBA in neurogenic bladder.

Operation for preservation of lung parenchyma in central lung cancer--in vivo and ex situ reimplantation techniques

BACKGROUND/AIM

Lobar reimplantation techniques enable the safe resection of lung cancer when pneumonectomy is not desirable or not feasible. We report our experience with this procedure.

PATIENTS AND METHODS

Patients with difficult to resect upper/middle lobe non-small cell lung cancer were included. In situ reimplantation technique requires the reanastomosis of the pulmonary vein of the healthy lower lobe to the upper lobe stump; bench surgery reimplantation involves the ex vivo surgical treatment of the whole excised lung and subsequent reimplantation of the healthy remnant.

RESULTS

Nine patients with upper-middle lobe lung cancer underwent in situ reimplantation, mean age=70.7±4.2 years; 6 patients underwent ex situ resection, mean age=64.3±18.4 years. One obese patient succumbed due to thrombosis of the anastomosed pulmonary vein. One patient developed a stroke.

CONCLUSION

The procedure was in general well-tolerated and enables for curative resection of otherwise unresectable lung cancer.

[DEVELOPMENT AND CLINICAL APPLICATION OF MEDICAL HEAT PRESERVATION DEVICE USED IN HAND SURGERY]

OBJECTIVE

To introduce a new medical heat preservation device, and to explore the application value and effectiveness in replantation of severed fingers.

METHODS

The medical heat preservation device was design, water was used as the heating medium, and temperature was set and controlled by microcomputer. Between November 2010 and January 2014, 421 cases undergoing replantation of severed fingers were divided into 2 groups. Within 9 days after operation, the medical heat preservation device was used in 210 cases (experimental group), and the conventional heat lamp was used in 211 cases (control group). There was no significant difference in gender, age, injury cause, the interval between injury and admission, injury finger side, and operation time between 2 groups (P > 0.05). The vascular crisis rate, success rate of replantation of severed fingers, comfort, sleep quality, and the influence on roommates were compared.

RESULTS

The comfort and the influence on roommates were good in 188 cases (89.52%) and 201 cases (95.71%) in the experimental group, which were significantly higher than those in the control group (25/211, 11.85%; 145/211, 68.72%). According to Pittsburgh sleep quality index (PSQI) for sleep quality, the results were good in 105 cases, fair in 85 cases, and poor in 20 cases in the experimental group; the results were good in 45 cases, fair in 95 cases, and poor in 71 cases in the control group. Blood vessel crisis occurred in 35 cases (16.67%) of the experimental group, which was significantly lower than that in the control group (76/211, 36.02%) (P < 0.05). The survival rate of replantation in the experimental group (196/210, 93.3%) was significantly higher than that in the control group (181/211, 85.78%) (P < 0.05). Significant differences were found between 2 groups (P < 0.05) in above indexs.

CONCLUSION

Medical heat preservation device for replantation of severed fingers can improve the comfortable degree of patients and the quality of sleep, increase the survival rate of finger replantation, and reduce the occurrence of vascular crisis after operation.

Vesicoureteric reflux in children

Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.

[Experience in treatment of combined osteovascular limb injuries in children]

The article is dedicated to one of the currently important problems of present-day traumatology and angiosurgery, i. e. possibility of performing primary reconstructive operations in children with complete and incomplete amputations, open and closed bone fractures in the conditions of circulatory impairment. The authors share their experience in treatment of 92 patients presenting with such injuries, describing the main indications for carrying out repair operations, and drawing appropriate conclusions. The main stages of reconstructions are demonstrated by a series of clinical examples.

[Peculiarities of diagnosis and surgical policy in elderly patients with pathological tortuosity of the internal carotid artery]

The study was aimed at optimizing surgical treatment management of elderly patients presenting with pathological tortuosity of the internal carotid artery (ICA). We examined a total of 94 patients with unilateral haemodynamically significant tortuosity of the ICA. Depending on the age, the patients were subdivided into two groups: Group One comprising forty-six (49%) 50-to-60-year-old patients and Group Two consisting of 48 (51%) patients above 60 years (from 61 to 84 years). 37% of patients had were found to have pathological tortuosity combined with haemodynamically significant ICA stenosis. In these patients linear blood velocity in the zone of the largest deformation was by 15% less than in patients with isolated tortuosity (p<0.05). All patients underwent reconstructive operations of carotid arteries with a good clinical effect. A combination of stenosis and pathological tortuosity of the ICA was treated by eversion carotid endarterectomy with lowering down and reimplantation of the artery into the previous ostium; microaneurysms present in the ICA wall were managed by resection of the artery's portion with autovenous prosthetic repair or bringing down the artery into the previous ostium. In 77% of patients above 60 years the operation was carried out under regional anaesthesia. According to the findings of duplex scanning, rectilinearity of the ICA after surgery was restored in 100% of cases, blood flow was of major type, with no turbulence registered. It was demonstrated that surgical management of elderly patients with pathological tortuosity is an effective method of prevention of ischaemic stroke. The complications rate in patients presenting with combined atherosclerotic lesions of the ICA and its pathological tortuosity, should adequate surgical policy be employed, falls within the framework of the accepted standards and does not depend on the type of ICA lesion.

Carbon dioxide laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant

OBJECTIVE

Demonstrate and report initial results using a carbon dioxide (CO2) laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant (RALUR).

METHODS

Retrospective chart review was performed for cases of RALUR from 2011 to 2014. Patients undergoing complex reconstruction (ureteral tailoring, dismembered reimplant, concomitant ureteroureterostomy), and those who had incomplete follow-up were excluded. Variables, including use of the CO2 laser, were collected and correlated with outcomes.

RESULTS

23 patients representing 40 ureteral units were included for analysis. A CO2 laser was used in 9/23 (39%) patients and 16/40 (40%) ureteral units. Intraoperative mucosotomy was reported in 3/14 (21%) patients for the electrocautery group and 1/9 (11%) patients for the CO2 laser group. Resolution of VUR was observed in 11/14 (79%), and 9/9 (100%) of patients for the electrocautery group and the CO2 laser group, respectively. Two complications were identified in the electrocautery group of patients: ileus (Clavien 2), and transient bilateral ureteral obstruction requiring placement of ureteral stents (Clavien 3B). There were no complications in the CO2 laser group.

CONCLUSIONS

Creation of the detrusor tunnel with a CO2 laser is safe and effective, and is associated with a lower rate of failure and complication in this cohort.

[Experimental study on effect of power-assisted intravascular shunt in replantation of amputated limbs in rabbits]

OBJECTIVE

To investigate the effect of power-assisted intravascular shunt in replantation of amputated limbs of rabbits.

METHODS

Eighty rabbits weighing 1.8-2.5 kg (male or female) were selected to establish the model of circular amputation at the hind groin, only femoral arteries and veins were completely preserved. After the femoral artery was clamped in 60 rabbits, the rabbits underwent power-assisted intravascular shunt with high-flow rate (group A, n=20), power-assisted intravascular shunt with low-flow rate (group B, n=20), and no power-assisted intravascular shunt (group C, n=20) to reconstruct blood supply; the femoral artery was not clamped in another 20 rabbits of sham group (group D). Before and after intravascular shunt (1, 3, 6, and 12 hours), the malondialdehyde (MDA), lactate dehydrogenase (LDH), and creatine kinase (CK) of the serum were determined. The myeloperoxidase (MPO), MDA, and wet to dry weight ratio (W/D ratio) of the gastrocnemius muscle were measured, and the thrombogenesis and survival rate of limb were observed.

RESULTS

Before intravascular shunt, MDA, LDH, and CK of the serum and MPO, MDA, and W/D ratio of the muscle showed no significant difference among 4 groups (P > 0.05). At each time point after intravascular shunt, no significant difference was found in all indexes between groups A and D (P > 0.05); the indexes of groups B and C were significantly higher than those of groups A and D (P < 0.05); the values were the highest in group C (P < 0.05), and reached the peak at 12 hours. All limbs of group A survived with low thrombosis rate, and less limbs could survive with high thrombosis rate in group C.

CONCLUSION

The power-assisted intravascular shunt with high-flow rate can effective ensure the blood supply of the amputated limbs of rabbits with lower limb injury and higher survival rate of amputated limbs after replantation.

Anatomic relationships of psoas muscle: clinical applications to psoas hitch ureteral reimplantation

OBJECTIVE

The objective of the study was to examine the anatomic relationship of the genitofemoral and femoral nerves to the psoas major muscle.

STUDY DESIGN

Dissections were performed in 17 unembalmed female cadavers. Point A was used as the approximate location for placement of psoas hitch sutures and as the reference point from which all measurements were taken. Measurements included the width of the psoas major muscle, psoas minor tendon, genitofemoral nerve branches, and femoral nerve. The relative location of the genitofemoral and femoral nerves to point A and the presence or absence of a psoas minor tendon were documented.

RESULTS

The psoas minor tendon was absent on at least 1 side in 11 specimens (64.7%). The median width of the psoas minor tendon was 7 mm (range, 3-11.5 mm). The median width and depth of the psoas major muscle was 21.5 mm (range, 10-35 mm) and 20.0 mm (range, 11.5-32 mm), respectively. The median width of the genitofemoral nerve was 2 mm (range, 1-4.5 mm) and that of the femoral nerve was 6.3 mm (range, 5-10.5 mm). Overall, 54 genitofemoral nerve branches were identified in 17 cadavers, 30 medial (55.5%), 22 lateral (40.7%), and 2 directly overlying point A (3.7%).

CONCLUSION

The exact location for the placement of the psoas hitch sutures will vary, depending on the location of the ureteral injury and the anatomy of the psoas muscle and surrounding structures. A thorough understanding of this regional anatomy should optimize the placement of psoas hitch sutures during ureteral reimplantation procedures and help avoid nerve and vessel injury.

Cross-finger dermal pocketing to augment venous outflow for distal fingertip replantation

Venous anastomosis in distal fingertip replantations is not always possible, and venous congestion is recognized as a potential cause of failure. Methods previously described to address this problem include amputate deepithelization and dermal pocketing postarterial anastomosis to augment venous outflow. However, attachment of the digit to the palm or abdomen resulted in finger stiffness. We describe a modification of the previous methods by utilizing dermal flaps raised from the adjacent digit in the form of a cross-finger flap. The key differences are the partial deepithelization of the replanted fingertip and subsequent replacement of the dermal flap to the donor digit to minimize donor site morbidity. During the period where the 2 digits are attached, interphalangeal joint mobilization is permitted to maintain joint mobility.

[Transperitoneal laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy for adult obstructive megaureter]

This paper focuses on a novel modified technique about the treatment of adult obstructed megaureter by the transperitoneal laparoscopic procedure. With the improvement of the laparoscopic surgery, many urological surgeries can be safely and effectually performed by laparoscopic approach. The previously reported laparoscopic methods for treatment of adult obstructed megaureter were complex and time-consuming. To simplify the method, we modified the laparoscopic approach based on the previous methods. The innovative points of our novel technique are the extracorporeal tailoring of ureter and nipple ureteroneocystostomy. By this modified procedure, the time of operation can be obviously reduced while the procedure is effective. We hope this modified procedure will be accepted by more urologists.

Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter

OBJECTIVE

To demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter.

METHODS

A 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO2) laser.

RESULTS

The patient's vesicoureteral reflux was successfully corrected, and he is now asymptomatic.

CONCLUSION

Specific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO2 laser is advantageous for detrusorotomy.

[Application of venous flow-through flap in finger replantation with circularity soft tissue defect]

OBJECTIVE

To investigate the treatment outcome of applying venous Flow-through flap in the replantation of severed finger with circularity soft tissue defect and vascular defect.

METHODS

Between January 2010 and December 2012, 11 cases (11 fingers) of severed finger with circularity soft tissue defect and vascular defect underwent replantation with venous Flow-through flaps. There were 8 males and 3 females, aged 18-42 years (mean, 24.6 years). The cause of injury was squeeze injury in 6 cases, crush injury in 3 cases, and strangulation in 2 cases. Combined injuries included nerve defect in 3 cases (1.0, 2.0, and 3.5 cm in length), and tendon defect in 2 cases (2.0 and 6.5 cm in length); cyclic skin and soft tissue defect was 3.0-4.5 cm in width, was 1/2-1 finger circumference in length, and was 2.0 cm x 1.0 cm to 7.0 cm x 4.5 cm in size. Six cases had complete circular defect (both finger artery and vein defects), and 5 cases had incomplete circular defect (only finger artery defect), and vascular defect was 1.0-4.5 cm in length. The time from injury to operation was 1.5-4.5 hours.

RESULTS

Venous crisis occurred in 1 case at 2 days after operation, was cured after vein graft; flap edge necrosis was observed in 2 cases and was cured after dressing change and skin grafting respectively; flap edema and blister occurred in 2 cases and relieved spontaneously. The other 6 flaps and replanted fingers survived completely, with primary healing of incision. Ten cases were followed up 12-18 months (mean, 15.5 months). Only a linear scar was seen at the donor sites, with no functional limitation. The flaps had similar color and texture to adjacent skin. The two-point discrimination was 6.5-13.0 mm (mean, 8.6 mm). According to replanted finger function scoring system of Society of Hand Surgery of Chinese Medical Association, the results were excellent in 6 cases, good in 3 cases, and poor in 1 case at last follow-up, and the excellent and good rate was 90%.

CONCLUSION

Venous Flow-through flap can repair both vascular defect and soft tissue defect, so it has good outcome in increasing the survival rate of replanted finger for severed finger replantation with circularity soft tissue defect and vascular defect.

[Effectiveness comparison between two kinds of procedures for treatment of totally degloved hand]

OBJECTIVE

To compare the effectiveness between toe transfer combined with an abdominal flap and bag-shaped abdominal flap for treatment of totally degloved hand.

METHODS

Between January 2005 and January 2012, 18 patients with totally degloved hand were treated by two kinds of techniques. Those patients were divided into 2 groups according to the technique. The bag-shaped abdominal flap was used in 8 cases (group A), and toe transfer with a dorsal is pedis skin flap combined with abdominal S-shaped tile-joint subdermal vascular network flaps was performed in 10 cases (group B). There was no significant difference in gender, age, injury cause, injury degree, and interval between injury and operation between 2 groups (P > 0.05). The static two-point discrimination (s2PD), grip power of the reconstructed hand, time of returning to work, and active total range of motion (ROM) of the operated finger were compared between 2 groups to assess the effectiveness.

RESULTS

All flaps and skin grafts survived in 2 groups. One flap suffered vascular crisis at 2 days after operation and survived after surgical exploration in group B. All patients were followed up 12-24 months (mean, 16 months). At last follow-up, group B showed a better recovery of s2PD of the thumb and ROM, and shorter time of returning to work than group A (P < 0.05), but no significant difference was found in grip power of the reconstructed hand and s2PD of the other fingers between 2 groups (P > 0.05).

CONCLUSION

The technique of toe transfer combined with an abdominal flap is better than traditional bag-shaped abdominal flap with the advantages of easy dissection, less time of operation, and satisfactory functional recovery.

Proposed modification for valve-sparing aortic root replacement

Valve-sparing aortic root replacement (ARR) is the procedure of choice in young patients with aortic root aneurysm and preserved aortic valve leaflets; however, coronary ostial anastomoses remain an issue. Troublesome bleeding sometimes occurs during surgery, and in the long term, there is a risk of aneurysmal formation in the residual aortic wall of the ostial "button." We describe a technique of valve-sparing ARR wherein each coronary button along with its flange of aortic tissue is implanted within the prosthetic graft used for ARR, thereby eliminating the risk of both immediate surgical bleeding and late coronary button aneurysms.

The Bentall procedure with a biological valved conduit: substitute options and techniques

As originally described by Bentall and De Bono, aortic root replacement with reimplantation of the coronary arteries using a composite valved conduit represents the gold standard intervention in patients with aneurysmal disease or dissection involving the aortic root. Over the last decade, the number of Bentall procedures performed using biological valved conduit has dramatically expanded mainly due to the increased incidence of aortic disease in the aging population. Here, we sought to describe the commercially available biological composite grafts and the techniques that, to the best of our knowledge, are most frequently used in this setting.

Cryopreservation and replantation of amputated rat hind limbs

BACKGROUND

In spite of the relatively high success rate of limb replantation, many patients cannot undergo replantation surgery because the preservation time of an amputated limb is only about six hours. In addition, although allotransplantation of composite tissues is being performed more commonly with increasingly greater success rates, the shortage of donors limits the number of patients that can be treated. So the purpose of this study is to examine the feasibility of cryopreservation and replantation of limbs in a rat model.

METHODS

Twelve five-month-old Sprague-Dawley rats were divided evenly into group A (above-knee amputation) and group B (Syme's amputation). One hind limb was amputated from each rat. The limbs were irrigated with cryoprotectant, cooled in a controlled manner to -140°C, and placed in liquid nitrogen. Thawing and replantation were performed 14 days later.

RESULTS

In group A, the limbs became swollen after restoration of blood flow resulting in blood vessel compression and all replantations failed. In group B, restoration of blood flow was noted in all limbs after replantation. In one case, the rat chewed the replanted limb and replantation failed. The other five rats were followed for three months with no abnormalities noted in the replanted limbs.

CONCLUSIONS

Limbs with a minimal amount of muscle tissue can be successfully cryopreserved and replanted.