Extrusion of Teflon aortic pledgets from a sternal wound six years after cardiac surgery

A novel suture technique for distal aorta-graft anastomosis in aortic aneurysm repair surgery: diagonal basting stitch

We describe a novel suture technique of distal anastomosis between the graft and the aorta in ascending aortic aneurysm repair surgery. In this technique, the aortic graft is positioned inside the distal aortic lumen with an overlapping segment and circumferential or back wall part only diagonal basting stitches are performed without use of Teflon pledgets, strips, or bioadhesives. This new technique establishes a secure anastomosis line, shortens anastomosis time, and avoids the use of foreign materials.

A stitch in time saves nine: closing the hole after removal of the aortic root cannula

BACKGROUND

On completion of the surgical procedure the hole in the ascending aorta has to be closed after withdrawal of the aortic root cannula. The aorta is usually pinched by a double transversal stitch or it is crumpled by a purse string suture. Nevertheless, hemostasis is difficult to obtain because closure is done under recovered pressure. Additional stitches buttressed with teflon-felt pledgets are often required. Unfortunately, sensitivity to bacterial implantation and the proximity to the sternotomy line could make the foreign material of the pledgets responsible for chronic infections and fistulas.

METHODS

Two simple square stitches orthogonal to each other could be a very useful suture combining simplicity with effectiveness. To do this, two 4-0 polypropylene half-threads are put obliquely through the full thickness of the aortic wall, to and fro with inverse obliquities. Each of them draws a cross inside the aortic wall and two sides of a square outside. As a result a little square is drawn by the threads around the hole.

RESULTS

For years we have never needed to reinforce the closure by supplemental stitches with hundreds of patients.

CONCLUSION

This type of closure has some advantages. In contrast to common stitches the aortic wall is not bent, crumpled or deformed, bites pass all aortic layers and the crossing of the threads covers the hole from inside rather than outside. Moreover, each thread can be tied with half of the tension required by other sutures because the two stitches act together but in the opposite direction. Finally, the technique is speedy and it requires only two half-threads. Most importantly, there is no need for teflon-felt pledgets. As a result, we have no longer seen any type of chronic infection or fistula.

Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration

BACKGROUND

Nissen fundoplication has become the standard operative procedure for the treatment of severe gastroesophageal reflux disease. The use of Teflon pledgets in Nissen fundoplications by our unit has been associated with a number of complications that has led to a change of technique in performing these operations.

METHODS

We reviewed our database of all patients who had fundoplications that involved the use of pledgets and identified those who had represented with postoperative complications related to pledget erosion/migration.

RESULTS

We identified 11 patients to date from a total of 1,175 fundoplications who had symptomatic pledget erosion occurring between 2 and 85 months after surgery (mean time 33.3 months). Symptoms included dysphagia, recurrent symptomatic gastroesophageal reflux, chest pain, and melaena, and in some cases significant morbidity was associated with the erosion. No common factor predisposing these patients to pledget erosion was identified. In the majority of cases removal of the pledget was associated with resolution of the symptoms. A review of the literature does not reveal any similar studies but problems associated with the erosion and migration of Teflon prostheses are described.

CONCLUSIONS

The use of Teflon pledgets in fundoplication is associated with a small but significant risk of complications that has led to our unit abandoning this technique.

Removal of an infected ventricular septal defect patch after tetralogy repair

An infected Dacron ventricular septal defect (VSD) patch was removed 15 years after repair of tetralogy of Fallot. Cardiopulmonary bypass was not utilized, and no significant hemorrhage was encountered. The patient recovered uneventfully and continues to do well 7 years after surgery without infection or residual VSD.