Artificial intelligence for phase recognition in complex laparoscopic cholecystectomy

BACKGROUND

The potential role and benefits of AI in surgery has yet to be determined. This study is a first step in developing an AI system for minimizing adverse events and improving patient's safety. We developed an Artificial Intelligence (AI) algorithm and evaluated its performance in recognizing surgical phases of laparoscopic cholecystectomy (LC) videos spanning a range of complexities.

METHODS

A set of 371 LC videos with various complexity levels and containing adverse events was collected from five hospitals. Two expert surgeons segmented each video into 10 phases including Calot's triangle dissection and clipping and cutting. For each video, adverse events were also annotated when present (major bleeding; gallbladder perforation; major bile leakage; and incidental finding) and complexity level (on a scale of 1-5) was also recorded. The dataset was then split in an 80:20 ratio (294 and 77 videos), stratified by complexity, hospital, and adverse events to train and test the AI model, respectively. The AI-surgeon agreement was then compared to the agreement between surgeons.

RESULTS

The mean accuracy of the AI model for surgical phase recognition was 89% [95% CI 87.1%, 90.6%], comparable to the mean inter-annotator agreement of 90% [95% CI 89.4%, 90.5%]. The model's accuracy was inversely associated with procedure complexity, decreasing from 92% (complexity level 1) to 88% (complexity level 3) to 81% (complexity level 5).

CONCLUSION

The AI model successfully identified surgical phases in both simple and complex LC procedures. Further validation and system training is warranted to evaluate its potential applications such as to increase patient safety during surgery.

[PANCREATIC NEUROENDOCRINE TUMORS (PNET): THE DILEMMA OF SURGERY VS. WATCHFUL WAITING APPROACH]

INTRODUCTION

Neuroendocrine tumors (NEN) originate from hormone producing cells located in various organs and tissues. NEN are unique tumors in terms of their diverse and particular clinical presentations, growth pattern, location and relatively good prognosis. NEN can be either secreting or non-secreting tumors. The clinical presentation and symptoms are according to the specific hormone produced by the tumor. A non-secreting tumor will eventually cause symptoms that relate to a mass-effect or a metastatic disease. There are various familial and genetic syndromes that are related to NEN. The most common neuroendocrine genetic syndrome is Multiple Endocrine Neoplasia syndrome type 1 (MEN 1). The clinical approach and treatment of NEN are unlike any other cancer. The gold standard management is surgery but unlike other cancerous diseases, surgical intervention is also indicated in cases of metastatic disease. There are several surgical approaches, and they all depend on tumor size, location, grade, stage, lymph node involvement, remote metastases and patients' age and comorbidities. Besides surgery, some cases are also treated with systemic therapies such as Somatostatin analogues, chemotherapy, immunotherapies, targeted therapies and occasionally radiation therapy is used. In the last decade there is a significant increase in the number of patients diagnosed with small non-secreting pancreatic tumors (PNET) due to advanced imaging techniques and diagnostic tools. This incidental increase is the reason for the emerging dilemma of whether to operate or merely conduct a watchful waiting policy. Small non-secreting tumors are commonly not considered malignant and thus the question is if surgery is always the right approach. The benefits of surgery must be carefully considered against the potential damage that may occur during these complex and radical procedures. Moreover, new and progressive systemic pharmacological therapies are now available to efficiently suppress tumor hormonal secretion. Recent studies have challenged surgery as the only treatment of choice, and in some cases suggest conservative treatment and follow up. The aim of this present literature review is to describe PNET diagnostic tools and evaluation, and to examine the different approaches of PNET treatment.

Transanal endoscopic microsurgery under spinal anaesthesia

Background

Transanal endoscopic microsurgery (TEM) is considered the procedure of choice for rectal adenomas non-amendable for endoscopic excision and for early rectal cancer. TEM may gain more importance in patients who are considered unfit for major surgery. The option of spinal anaesthesia may offer many advantages for patients undergoing TEM while maintaining the principles of complete tumour excision. The aim of this study is to report the outcome of patients undergoing TEM under spinal anaesthesia.

Methods

Demographic and clinical data pertaining patients undergoing TEM under spinal anaesthesia between 2004 and 2015 were retrospectively collected.

Results

A total of 158 TEM procedures were recorded in the study period. Twenty-three patients (15%) underwent the procedure under spinal anaesthesia and were included in the study; 13 of them were male and ten were female. The mean age of the patients was 69.1 ± 10.6 years. Seventeen (74%) rectal lesions were adenomas, two (9%) were adenocarcinoma and four (17%) had involved margins after polypectomy. The mean tumour size was 2.1 cm (range, 0.5-3). Distance from the anal verge was 7.7 ± 2.2 cm. Seventeen (74%) lesions were in the posterior wall. The operative time was 73 min (range, 46-108) No adverse anaesthesia-related events were recorded, and the post-operative pain was reduced. The median time of hospitalisation was 2 days (range, 1-4). No major complications were noted, and the minor complications were treated conservatively. The surgical margins were free of tumour in all cases.

Conclusion

TEM under spinal anaesthesia had short duration of surgery, no increase in operative and post-operative complications or hospital length of stay. Avoiding the use of general anaesthesia, in such challenging procedure, may open new opportunities for patients determined to be unfit for general anaesthesia.

The outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with high-risk T1 rectal cancer

Introduction:

Transanal endoscopic microsurgery (TEM) is considered the technique of choice for adenoma and low-risk T1 rectal cancer. The adequacy of such treatment for high-risk T1 tumours, however, is still controversial. The aim of the study is to evaluate our results with local excision of high-risk T1 cancers.

Materials and Methods:

Demographic, clinical data pertaining to patients undergoing TEM for T1 rectal cancer between 1999 and 2015 was retrospectively collected. Long-term outcomes were assessed for the entire cohort. Patients were classified into two groups: favourable and high-risk cancer features.

Results:

Three hundred and fifty-five TEM procedures were recorded in the study period. Forty-three patients were included in the present study. There were 20 females and 23 males, the median age was 69 ± 9. The median tumour distance from the anal verge was 6 cm (range 1–13 cm). Post-operative histopathology showed well/moderately differentiated T1 adenocarcinoma in 30 patients and poorly differentiated in 13. The overall survival for patients with favourable and high-risk features groups were 93.5% and 77%, respectively, while the local recurrence (LR) was 3.5% and 23.1%, respectively. Nine patients with high-risk features received adjuvant radiotherapy; one (11.1%) of them experienced LR.

Conclusions:

Local excision by TEM augmented by adjuvant radiotherapy may be a feasible alternative for selected patients with high-risk T1 rectal cancer. The addition of radiotherapy seems to decrease the rates of LR.

A necktie fashion vascular loop seton tie may simplify the treatment of perianal fistula

Seton for treatment of perianal fistula can be of the cutting or a loose type. We adopted a simple technique for tighten the seton by applying a necktie shape tie on the vascular loop, hence it can be used for drainage on the beginning, and for cutting purpose later on. In this retrospective study we report our experience on this seton tie method.

Material and methods Patients operated for perianal fistula between 2012 and 2014 were reviewed.

Results Of 63 patients operated, 23 (35%) had a necktie-tie seton. There were 15 (65%) men. Age 34.1 ± 10.6. Six (26%) had a recurrent fistula, 2 (9%) with loose seton in place. The external opening: anterior four (17%), lateral fifteen (65%), posterior three (13%), one patient (4%) had two opening. The internal opening was identified: posterior seventeen (74%), anterior four (17%) and right posterior two (8%). Nineteen (82%) had a trans-sphenteric tract, four (17%) females had an anterior location. Operative time was 32 min (range 22–55). The seton was tightened 4 times (range 2–5) with 2 weeks interval. Healing was achieved in 7 weeks (range 5–11). In 24 months (range 12–35) follow-up, no reported anal incontinence. Recurrence was observed in one patient (4%).

Conclusion The necktie tightening of the vascular loop seton is a simple, safe, easily performed and may simplify the seton management of perianal fistulae.

Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer

BACKGROUND

Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.

MATERIALS AND METHODS

Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.

RESULTS

One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.

CONCLUSION

Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

Transanal Endoscopic Microsurgery Implementation in Ultra-Low Anterior Resection

BACKGROUND

Distal rectal cancer resection is an ongoing challenge for the colorectal surgeon. In recent years new technical approaches, especially with implementation of transanal platforms were developed to help in the visualization and resection of these tumors. Nevertheless, the use of these platforms is demanding with significant complications during the onset phase.

METHODS

Patients with very low rectal cancer were operated on in a single tertiary center with a combined abdominal and transanal endoscopic microsurgery (TEM) approach. Demographic, pathological, and surgical data were collected retrospectively with an emphasis on distal margin involvement.

RESULTS

Nineteen patients were operated on during the study period. All patients had negative distal resection margins with a low complication rate. The distant metastasis and local recurrence rates were low with a mean follow-up of 2 years.

CONCLUSIONS

TEM provides an appealing and viable option for the resection of low rectal cancer in a combined transabdominal and transanal approach in patients with a good response after neoadjuvant treatment. This is one of the available platforms a colorectal surgeon might benefit from having in his armamentarium. It has a very low complication rate with maintenance of oncological principles, enabling a clear visualization of the distal rectum, and thus ensures free distal resection margins.

Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution

BACKGROUND

The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery.

METHODS

Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected.

RESULTS

141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively.

CONCLUSION

The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.

Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?

BACKGROUND

Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary.

MATERIALS AND METHODS

All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed.

RESULTS

Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %.

CONCLUSION

Routine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.

Massive and recurrent diverticular hemorrhage, risk factors and treatment

AIM

Diverticular hemorrhage may be massive or recurrent, requiring surgical management. The aim of our study is to define risk factors that predict rebleeding or need for urgent operation in patients with diverticular hemorrhage.

METHODS

Retrospective study was conducted on patients who were admitted for diverticular hemorrhage. Data pertaining to patient and bleeding characteristics, method of diagnosis, blood transfusion and type of operation were collected. Multivariate analysis model compared patients who experienced single bleeding episode with those with recurrent episodes, and patients who underwent surgery with those who did not.

RESULTS

One hundred and four patients met the inclusion criteria. Thirty four patients experienced more than one bleeding episode. Ten patients needed surgery for recurrent bleeding. Five patients presented with hemodynamic instability, none of them required surgical treatment. Neither patients' comorbidity nor anticoagulant and antiaggregant treatments were associated with increased risk for recurrent hemorrhage. Diabetes mellitus was correlated with decreased risk for recurrent hemorrhage, OR = 0.21, (CI 95% (0.06-0.73)); p = 0.014. Independent risk factor for massive recurrent diverticular hemorrhage requiring surgery was right sided diverticulosis, OR = 4.6(CI 95% (2.1-19)); p = 0.006.

CONCLUSIONS

Right colon diverticulosis rather than patient characteristics and medical treatment should prompt for aggressive management with lower threshold for surgical intervention.

Factors associated with the location of local rectal cancer recurrence and predictors of survival

PURPOSE

The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC.

METHODS

Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980-2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database.

RESULTS

One hundred and fifty-seven patients were identified with a mean follow-up 59.8 ± 50.1 months and time to LRRC of 31.7 ± 30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P = 0.019) and lateral (P = 0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P = 0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2-8.4; P < 0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3-2.7, P < 0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1-2.1; P = 0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2-2.7; P = 0.008) were associated with reduced LRRC 5-year survival.

CONCLUSIONS

The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

Fast-track rehabilitation accelerates recovery after laparoscopic colorectal surgery

BACKGROUND

Fast-track (FT) rehabilitation protocols have been shown to be successful in reducing both hospital stay and postoperative complications, as well as enhancing overall postoperative patient recovery. We are reporting the outcomes of our first group of patients undergoing colorectal surgery following the FT protocol.

PATIENTS AND METHODS

We performed a prospective study of patients, between January 1, 2007 and January 31, 2010, who underwent laparoscopic colorectal resections in accordance with the guidelines of FT rehabilitation protocol. Recovery parameters including time to removal of naso-gastric tube and urinary catheter, time to bowel function and to resume diet, and length of hospital stay were evaluated. Postoperative outcomes, that is, postoperative complications and mortality, reoperations, and readmissions were also studied.

RESULTS

A total of 71 patients, 30 women and 41 men, underwent FT rehabilitation for laparoscopic colorectal surgery. The mean age of the patients was 60 ± 16 years. The most common surgical procedures were right hemicolectomy 30% and anterior resection 27%. Liquid and regular diet were initiated on postoperative day 1.2 ± 0.4 and 2.1 ± 0.4, respectively. Overall postoperative morbidity was 8.5%. The mean length of stay was 4.4 ± 1.7 days, with only 3 readmissions. Forty-five patients fulfilled the FT care plan and were discharged on postoperative day 3. No reoperations or mortality were observed.

CONCLUSIONS

FT rehabilitation results in favorable postoperative outcomes. Our data provides evidence and suggests that FT protocols should be implemented as a reliable method of preparation and recovery for laparoscopic colorectal surgery.

Surgical management of anal cancer

Squamous cell carcinoma (SCC) is the most common malignancy of the anal canal and anal region. The prevalence of transformation to SCC is much higher in patients with a concomitant human immundefficiency virus (HIV) infection. Historically, treatment of anal SCC consisted of surgical resection with wide local excision for small sized tumors and abdominoperineal resection (APR) for larger and locally invasive cancer. The introduction of chemoradiation by Nigro et al. revolutionized the treatment of SCC. It has improved local recurrence rates as well as survival and need for colostomy. Nowadays, primary surgical treatment is indicated for anal margin tumors that are smaller than 2 cm, and are not poorly differentiated. However, extensive surgery is reserved for those with persistent, progressing and recurrent disease after treatment with the Nigro protocol. Surgical approach for anal canal and margin cancer is to be discussed in this review.

Transanal endoscopic microsurgery: also for the treatment of retrorectal tumors

Retrorectal tumors are an uncommon pathological entity. Their clinical importance arises from their occasional malignant nature or malignant transformation. The treatment of choice for most presacral tumors is surgical excision. The approach depends upon the upper limit of the lesion and the presumptive pathology. We reviewed the main features of these tumors with emphasis on transanal endoscopic microsurgery (TEM) as a viable surgical approach for the treatment of the lesions, undertaken in our institution. We present our small case series, consisting of six patients with retrorectal lesions who underwent local excision via TEM. Early and late postoperative outcomes are presented. TEM for retrorectal lesions appears to be a feasible and safe approach. A remarkably low morbidity favors TEM in selected patients.

Repeated transanal endoscopic microsurgery is feasible and safe

BACKGROUND

The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade malignant lesions in the low and middle rectum are well recognized. This study examined the feasibility and safety of a repeated TEM procedure.

PATIENTS AND METHODS

Patients who underwent a repeat TEM for excision of rectal lesions, either for involved resection margins or for local recurrence, between the years 2000 and 2010, were identified. Rectal lesion characteristics were retrieved. Mean operative times, length of hospital stay, and intra- and postoperative complications were compared between primary and repeated procedures. The postoperative histopathology reports were reviewed, and the adequacy of resection was determined. All patients completed a questionnaire based on the Wexner score for anal sphincter function evaluation.

RESULTS

Fourteen patients (3 female, 11 male) underwent a repeat TEM operation during the study period. All procedures were completed endoscopically. Indications for repeated TEM were involved margins in 12 patients and recurrence of benign tumor in 2. Mean operative time, mean length of hospital stay, and rate of postoperative complications were similar for primary and repeated TEM procedures (62.5 ± 17 versus 55 ± 23 minutes, P=.181; 1.7 ± 1.3 versus 1.7 ± 1.12 days, P=.99; and 35.7% versus 21.4%, P=.66, respectively). The Wexner score was comparable at baseline and after the first and the second TEM procedures (1.5 ± 2.3, 1.5 ± 2.3, and 3.3 ± 3.1, respectively; P=.188). No cases of fecal incontinence following a repeat TEM were documented.

CONCLUSIONS

Repeated TEM is feasible and safe and may be appropriate for selected patients.

Changes in end-tidal carbon dioxide due to gastric perforation during pneumoperitoneum in the rat

BACKGROUND

Carbon dioxide is the most widely used gas to establish pneumoperitoneum during laparoscopic surgery. Gastrointestinal trauma may occur during the peritoneal insufflation or during the operative phase itself. Early diagnosis of these injuries is critical.

OBJECTIVES

To assess changes in end-tidal carbon dioxide (ETCO2) following gastric perforation during pneumoperitoneum in the rat.

METHODS

Wistar rats were anesthetized, tracheotomized and mechanically ventilated with fixed minute volume. Each animal underwent a 1 cm abdominal longitudinal incision. A 0.3 x 0.3 cm cross-incision of the stomach was performed in the perforation group but not in the controls (n = 10/group) and the abdomen was closed in both groups. After stabilization, CO2-induced pneumoperitoneum was established at 0, 5, 8 and 12 mmHg for 20 min periods consecutively, each followed by complete pressure relief for 5 min.

RESULTS

Ventilatory pressure increased in both groups when pneumoperitoneal pressure 5 mmHg was applied, but more so in the perforated stomach group (P = 0.003). ETCO2 increased in both groups during the experiment, but less so in the perforated group (P = 0.04). It then returned to near baseline values during pressure annulation in all perforated animals but only following the 0 and 5 mmHg periods in the controls.

CONCLUSIONS

When subjected to pneumoperitoneum, ETCO2 was lower in rats with a perforated stomach than in those with an intact stomach. An abrupt decrease in ETCO2 during laparoscopy may signal gastric perforation.

Impact of early reoperation after resection for colorectal cancer on long-term oncological outcomes

AIM

Whether reoperation in the postoperative period adversely affects oncologic outcomes for colorectal cancer patients undergoing resection has not been well characterized. The aim of this study was to determine whether long-term oncological outcomes are affected for patients who undergo repeat surgery in the early postoperative period.

METHOD

From a prospective colorectal cancer database, patients who underwent resection for colorectal cancer between 1982 and 2008 and were reoperated within 30 days after surgery (group A) were matched for age (±5 years), gender, year of surgery (±2 years), American Society of Anesthesiology score, tumor site (colon or rectum), cancer stage and differentiation with patients who did not undergo reoperation (group B). The two groups were compared for overall survival (OS), disease-free survival (DFS) and local recurrence (LR).

RESULTS

In total, 89 reoperated patients (45 rectal, 44 colon cancer) were matched to an equal number of non-reoperated patients. Anterior resection (39.2%) and right hemicolectomy (19.1%) were predominant primary operations. Indications for reoperation were anastomotic leak/abscess (n=40, 45%), massive bleeding (n=15, 16.9%), bowel obstruction (n=11, 12.4%), wound complications (n=9, 10.1%) and other indications (n=14, 15.6%). Group A had significantly greater overall morbidity (100% vs 27%, P=0.001) and required more blood transfusions (20.2% vs 7.9%, P=0.045). Adjuvant therapy use, on the other hand, was more common in group B (23.6% vs 12.3%, P=0.1). The 5-year OS and DFS were lower in the reoperated group (OS 55.3% vs 66.4%, P=0.02; DFS 50.8% vs 60.8%, P=0.06, respectively). Five-year LR was slightly lower in the reoperated group (2.9% vs 6.3%, P=0.34).

CONCLUSIONS

Compared with non-reoperated patients matched for patient, tumour and operative characteristics, patients reoperated in the early postoperative period have worse long-term oncological outcomes. Adoption of strategies to reduce the risk of reoperation may be associated with the additional advantage of improved oncological outcomes in addition to the short-term advantages.

Missed Inadvertent Gastrointestinal Injuries during Abdominal Operations: Characteristics, Diagnosis, and Treatment

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations’ characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21–87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1–13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.

Missed inadvertent gastrointestinal injuries during abdominal operations: characteristics, diagnosis, and treatment

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations' characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21-87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1-13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.

Outcomes after laparoscopic intestinal resection in obese versus non-obese patients

BACKGROUND

The degree of benefit derived from laparoscopic bowel resection in obese compared with non-obese patients is poorly understood.

METHODS

A total of 436 obese patients (body mass index (BMI) at least 30 kg/m(2), mean 34·9 kg/m(2)) who underwent laparoscopic bowel resection during 1992-2008 were identified from a prospective database. An equal number of non-obese patients (mean BMI 24·8 kg/m(2)) was case-matched by age, sex, year of surgery, American Society of Anesthesiologists score, diagnosis and type of operation. Patients with previous major abdominal surgery were excluded. Postoperative morbidity and recovery were compared between obese and non-obese patients.

RESULTS

Mean duration of operation (171·5 versus 157·3 min; P = 0·017), estimated blood loss (EBL; 224·9 versus 164·6 ml; P = 0·001) and conversion rate (13·3 versus 7·1 per cent; P = 0·003) were increased significantly in obese patients. Overall postoperative morbidity was also greater (32·1 versus 25·7 per cent; P = 0·041), particularly wound infection rate (10·6 versus 4·8 per cent; P = 0·002). Among laparoscopically completed operations, obese patients had higher rates of overall morbidity (31·5 versus 24·2 per cent; P = 0·026) and wound infection (10·2 versus 4·4 per cent; P = 0·002). Conversion was associated with increased EBL, intraoperative complications, overall morbidity and length of stay in both groups. The effect of conversion in worsening outcomes was comparable in obese and non-obese patients, except for a greater increase in incision length (11·0 versus 8·0 cm; P = 0·001) and EBL (304·8 versus 89·8 ml; P = 0·001) in obese patients.

CONCLUSION

Laparoscopic bowel resection results in greater morbidity in obese than in non-obese individuals. This difference remains comparable whether the procedure is completed laparoscopically or converted.

Colorectal cancer complicating inflammatory bowel disease: similarities and differences between Crohn's and ulcerative colitis based on three decades of experience

INTRODUCTION

The aim of this study was to evaluate patient- and tumor-related characteristics for patients undergoing surgery for cancer complicating inflammatory bowel disease (IBD), and to assess differences between patients with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

Data on all IBD patients with colon and rectal cancer (CRC) undergoing surgery between 1980 and 2007 were evaluated from prospectively maintained CRC and IBD databases. Clinical presentation, tumor stage, presence of associated dysplasia, and short- and long-term outcomes after surgery were investigated. Outcomes for IBD patients were compared with a matched group of patients with sporadic cancer.

RESULTS

A total of 240 IBD patients (64 CD and 176 UC) with CRC were identified. At the time of CRC diagnosis, 68% UC and 26% CD patients had pancolitis. About 92% of the patients who underwent preoperative colonoscopy were noted to have suspicious lesions. Although 92.5% of the patients had a preoperative histopathologic diagnosis of cancer or dysplasia, incidental diagnosis of cancer in the resection specimen was made in 3%. Examination of the resection specimen revealed synchronous dysplasia in 48% of the patients and synchronous cancer in 12% patients. Tumor location was rectum in 36%, right colon in 28%, sigmoid colon in 17%, transverse colon 10%, and left colon in 9% of patients. CD patients were diagnosed at a more advanced cancer stage than UC. Local recurrence and overall 5-year survival rates were comparable (5.6% vs. 6.7%, P = 0.78 and 77% vs. 72%, P = 0.5, respectively) for patients with IBD and sporadic cancer.

CONCLUSIONS

Most IBD cancer can be diagnosed or suspected on the basis of endoscopic findings, biopsy of areas of active colitis, and an incidental finding of malignancy after colorectal resection for other indications is rare. CD patients present with a more advanced cancer stage. Optimal endoscopic surveillance may identify most patients with IBD cancer.

Prophylactic Fluconazole Does Not Improve Outcome in Patients with Purulent and Fecal Peritonitis due to Lower Gastrointestinal Perforation

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative Candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 ± 18 vs 21.4 ± 18.3 days, 14.8 ± 14.2 vs 9.3 ± 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher ( P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients’ outcome compared with those without empiric treatment.

Prophylactic fluconazole does not improve outcome in patients with purulent and fecal peritonitis due to lower gastrointestinal perforation

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 +/- 18 vs 21.4 +/- 18.3 days, 14.8 +/- 14.2 vs 9.3 +/- 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher (P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients' outcome compared with those without empiric treatment.

Intrasplenic preconditioning: a model for the study of xenostimuli accommodation

BACKGROUND

Discordant xenotransplantation, the grafting of organs from one phylogenic species to another, results in hyper-acute rejection (HAR). HAR is associated with the deposition of recipient preformed xenoreactive natural antibodies and complement on the endothelium of the donor organ, leading to activation and apoptosis of the endothelium, an event associated with xenograft rejection. Endothelial resistance to HAR, termed "accommodation," an active protection of graft endothelium, may be achieved by previous stimulation of endothelial cells by discordant xenoantibodies.

MATERIALS AND METHODS

Forty-eight male Wistar rats were used to evaluate HAR induction in an isolated, dually perfused in-situ rat liver transfused with human blood. This ex-vivo model served to mimic rat-to-human liver xenotransplantation. Preconditioning of the liver endothelium was induced by rat intrasplenic injection of human blood (n=8) or effluent of previously xenotransfused rat liver (n=8), i.e., high versus low xenoantibody solution, each undertaken 1d before liver xenotransfusion. Two other groups were not preconditioned. Preconditioned and non-preconditioned rats were perfused directly with human blood, and eight rats were used as controls (non-preconditioned Krebs-perfused). Eight rats were perfused directly with human blood, and eight rats were used as controls. The effluent that exited these first-line livers was used to perfuse the second-line livers.

RESULTS

Portal and hepatic artery perfusion pressures, resistances, rates of oxygen extraction, lactic acid and pH, and wet-to-dry weight ratio values were significantly increased in livers xenotransfused with blood indicating HAR, compared with unchanged values in livers perfused with Krebs solution. Portal pressure and resistance were best protected from HAR by the blood preconditioning in the blood perfused group, while the hepatic artery perfusion system was better protected by the perfusate precondition-blood perfused group. The physiologic effects of HAR were attenuated in most second-line livers.

CONCLUSIONS

Attenuation of HAR in rats' livers is achieved by preconditioning with xenoantibodies and/or by "filtering out" xenoantibodies present in the circulation, and is suggestive of accommodation. This novel method may be useful in future studies aimed at refining methods for accommodating xenotransplantation.

Abdominal computed tomography for diagnosing postoperative lower gastrointestinal tract leaks

BACKGROUND

Computed tomography (CT) is the most readily available imaging tool for diagnosis of postoperative lower gastrointestinal tract (LGIT) leak. The accuracy and sensitivity of CT for diagnosing a leak from a hollow viscous or anastomotic bowel leakage are still not well established. This retrospective study was conducted in order to define the role of CT in this setting.

STUDY DESIGN

The medical records of patients who underwent early relaparotomy (within 30 days) due to LGIT leak following a previous surgery in our department between 1998 and 2006 were reviewed. The ones whose abdominal CTs were done within 72 h prior to the repeated surgery with the aim of ruling out an intraabdominal infection or leak were studied, and the results were compared to the postsurgical findings.

RESULTS

Seventy patients were reoperated shortly following abdominal surgery due to postoperative LGIT leak. Forty-one of them had undergone 45 CT studies within 72 h before reoperation. Another 29 patients underwent a second procedure based on clinical presentation. Reoperation was done after an interval of 7.3 +/- 4.4 days in patients who underwent CT studies and after 4.5 +/- 2.3 days in patients without CTs (p = 0.003). Preoperative CTs identified only 47% of the leaks.

CONCLUSIONS

CT studies on patients shortly after abdominal surgery are not definitive. A negative CT study does not rule out LGIT leak. Clinically based decision making and exploratory relaparotomy still do play a role in those patients with suspicion for LGIT leak.

Mannitol attenuates kidney damage induced by xanthine oxidase-associated pancreas ischemia-reperfusion

BACKGROUND

Ischemia and subsequent reperfusion (IR) may induce local and remote organ reperfusion injury. It may be propagated by xanthine oxidase (XO)-generated oxidant stress. We investigated whether pancreas IR directly and acutely induces renal dysfunction and if this outcome could be prevented by mannitol.

MATERIALS AND METHODS

Rat pancreases were isolated and perfused with Krebs-Henseleit solution enriched with 5% bovine albumin. Other rats donated kidneys that were perfused at constant pressure mode. Each pancreas underwent 45 min of either perfusion (control) or ischemia (no flow). Both organ perfusion systems were then combined and the kidneys were perfused with the pancreatic 15-min reperfusate for 2 h. A third group consisted of paired ischemic pancreases and nonischemic kidneys treated with mannitol 250 mg/kg body weight during reperfusion.

RESULTS

The controls demonstrated no abnormal perfusion or metabolite changes. Pancreas and renal perfusion pressures increased by >50% in the ischemia group immediately upon reperfusion; it remained above the values of controls during the 2-h kidney reperfusion. Conversely, perfusion pressure in the treatment group was not significantly different from the control. The reduced glutathione level increased significantly, as did XO, immediately upon starting reperfusion in both organs appertaining to the ischemic group; this misbalance was not documented in the controls and the mannitol-treated groups. Urine output was severely reduced in the IR kidneys.

CONCLUSION

Ischemia/reperfusion of the rat pancreas evokes immediate renal dysfunction. Kidney oxidant-antioxidant balance is disturbed, but can be prevented with mannitol. These two figures underline the role of oxidative stress in promoting acute renal damage in the presence of pancreas IR.

Renal apoptosis following carbon dioxide pneumoperitoneum in a rat model

PURPOSE

Laparoscopically recruited kidneys regain normal function more slowly than laparotomy harvested organs for several possible reasons. We investigated the effects of CO(2) induced pneumoperitoneum on kidney function, as reflected by blood and urine creatinine levels, and its relation with renal cell apoptosis.

MATERIALS AND METHODS

CO(2) pneumoperitoneum was established in anesthetized Wistar male rats that were randomly allocated at 6 per group into 1 of 6 groups with an intraperitoneal pressure of 0 (control), 5, 8, 12, 15 or 18 mm Hg. Pressure was maintained for 60 minutes in all groups. Three additional groups were subjected to 30-minute pneumoperitoneum at 0, 12 and 18 mm Hg, respectively. The rats were kept alive for the ensuing 24 hours, after which blood and urine creatinine were analyzed and the abdominal organs were harvested. Various areas of the organs were analyzed for apoptotic cells using the TUNEL method. Cells were randomly counted in 10 eyeshots in 3 sections each using an ocular micrometer.

RESULTS

Creatinine levels in blood and urine changed as pressure and pneumoperitoneum duration progressed. Isolated TUNEL positive nuclei were detected in the outer medulla and the cortex of control kidneys. There was a significantly higher number of TUNEL positive nuclei in the cortex and the medulla of all pressurized kidneys (p <0.05), which increased in parallel with increasing intraperitoneal pressure and pneumoperitoneum exposure time.

CONCLUSIONS

The CO(2) pneumoperitoneum gradient and its duration affect renal function and induce apoptosis. This could be a mechanism involved in renal delayed graft dysfunction in recipients of laparoscopically harvested kidneys.

Inhaled Nitric Oxide Improves Pulmonary Functions Following Massive Pulmonary Embolism: A Report of Four Patients and Review of the Literature

Acute pulmonary embolism increases pulmonary vascular resistance and may lead to acute right ventricular failure and cardiocirculatory collapse and respiratory failure, possibly resulting in substantial morbidity and mortality. Inhaled nitric oxide (NO) dilates pulmonary blood vessels and has been used to reduce pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension and acute respiratory distress syndrome. This case series describes our experience with inhaled NO administered to four patients suffering from acute massive pulmonary embolism following abdominal surgery. The four described patients recovering from small bowel resection, pancreatoduodenectomy, hemipelvectomy, or recent gastrointestinal bleeding had severe respiratory and hemodynamic deterioration due to pulmonary embolism. Each received inhaled NO (20-25 ppm) via the inspiratory side of the breathing circuit of the ventilator. Pulmonary and systemic blood pressures, heart rate, and lung gas exchange improved in all the patients within minutes after the initiation of NO administration. Inhaled NO may be useful in treating acute massive pulmonary embolism. This potential application warrants further investigation.

[Cardiac surgery without transfusion in 2005]

PURPOSE

Between January 1991 and October 2003, 200 Jehovah Witnesses adult patients underwent elective cardiac surgery. To asses the impact on continuing progress of blood saving protocols and the increasing operative risk of patients proposed to surgery, we have re-assessed our results in this specific population.

METHODOLOGY

Files of the first 100 patients operated upon between 1991 and 1998 were reviewed, and compared to the following 100 ones treated between 1998 to today. All patients were scored using the Euroscore model.

RESULTS

In the latest series, patients are older (68 vs 51) and 13% underwent an iterative procedure, although there was none in the first series. Three deaths occurred after one month at the beginning of our experience, only one in the latest series. Operative risk factors had distinctly deteriorated, with more redux, and ejection fraction lower than 35%. Major progress to maintain morbi-mortality stability were multifactorial: preoperative erythropoietin in order to reach an haemoglobin minimal value of 14 g/dL, Cornell University protocol, mini-ECC, warm blood cardioplegia, ultra-early extubation.

CONCLUSION

Cardiac surgery without transfusion can be realised with an equivalent risk to that of classical surgery, despite an operative risk aggravation, due to the association of recent conservative techniques.

Kidney allograft outcome in simultaneous pancreas-kidney transplantation

BACKGROUND

In simultaneous pancreas-kidney transplantation, with both organs coming from the same donor, the addition of a pancreas to the kidney transplant does not jeopardize the kidney allograft outcome despite higher postoperative SPK morbidity. Pancreas allograft outcome has recently improved due to better organ selection and more accurate surgical techniques.

OBJECTIVE

To demonstrate the positive impact of SPK on kidney allograft outcome versus kidney transplantation alone in insulin-dependent diabetes mellitus patients with end-stage renal failure.

METHODS

We performed 39 consecutive SPKs in 14 female and 25 male IDDM patients with renal failure after an average waiting time of 9 months. Multi-organ donor age was 30 years (range 12-53). The kidneys were transplanted in the left retroperitoneal iliac fossa following completion of the pancreas transplantation; kidney cold ischemia time was 16 +/- 4 hours. Induction anti-rejection therapy was achieved with polyclonal antithymocytic globulin and methylprednisolone, and maintenance immunosuppression by triple drug therapy (prednisone, cyclosporine or tacrolimus, and azathioprine or mycophenolate mofetil). Infection and rejection were closely monitored.

RESULTS

All kidney allografts produced immediate urinary output following SPK. Two renal grafts had mild function impairment due to acute tubular damage but recovered after a short delay. Three patients died from myocardial infarction, cerebrovascular event and abdominal sepsis on days 1, 32 and 45 respectively (1 year patient survival 92%). An additional kidney allograft was lost due to a renal artery pseudo-aneurysm requiring nephrectomy on day 26. Nineteen patients (49%) had an early rejection of the kidney that was resistant to pulse-steroid therapy in 6. No kidney graft was lost due to rejection. Patients with acute kidney-pancreas rejection episodes suffered from severe infection, which was the main cause of morbidity with a 55% re-admission rate. Complications of the pancreas allograft included graft pancreatitis and sepsis, leading to a poor kidney outcome with sub-optimal kidney function at 1 year. Kidney graft survival at one year was 89% or 95% after censoring the data for patients who died with functioning grafts.

CONCLUSIONS

Eligible IDDM patients with advanced diabetic nephropathy should choose SPK over kidney transplantation alone from either a cadaver or a living source.

[Spontaneous regression of a false aneurysm of the ascending aorta following surgery for dissection]

We report the case of a 50-year-old man admitted to hospital for a type A aortic dissection. After conventional surgical repair, he was asymptomatic and underwent computed tomography imaging at 15 days, 3 and 6 months. The first CT scan showed a small perigraft circulating false aneurysm which totally disappeared on the last exam. This case emphasizes the potential role of CT scan in the follow-up of patient after aortic surgery and the likely favorable outcome of some false aneurysm.

Pedicled pericardium for repair of right ventricular outflow tract and pulmonary arterial stenoses in tetralogy of Fallot: a six-year experience

From June 1988 through June 1994, 20 children with symptomatic tetralogy of Fallot, associated with hypoplastic or stenotic pulmonary arteries in 19 cases, were operated on in our institution. Mean age at operation was 49.5 +/- 43 months (ranging from 10 months to 12.5 years). Mean weight was 13.5 +/- 6.5 kg (range 6.2 to 30 kg) and mean body surface area was 0.6 +/- 0.2 m2. Mean preoperative hematocrit value was 47.6% +/- 11.1%, and mean preoperative arterial oxygen saturation ratio was 75.7 +/- 9.5. Six patients (30%) had prior systemic-pulmonary arterial shunts. Pulmonary arterial stenoses were congenital or iatrogenic (or both) and were located principally on the left pulmonary artery (63%), on the pulmonary bifurcation (15%), or separately on the left and right pulmonary arteries (21%). In all children the pulmonary arterial tree was repaired with the patient's own pedicled pericardium. Mean follow-up is 36 +/- 25.2 months (range 1 to 71 months). Hospital mortality rate was 0%. There was one late death, and two children were lost to long-term follow-up. No child required reoperation. Seventeen children returned for evaluation, consisting of physical examination, electrocardiogram, chest roentgenogram, and Doppler echocardiogram, and 11 underwent late catheterization or magnetic resonance imaging of the chest to evaluate the pulmonary arterial repair. All children were in New York Heart Association class I or II. Right ventricular function was normal by echocardiography in 100% with a mean right ventricular systolic pressure of 39.37 +/- 8.4 mm Hg. Mild to moderate pulmonary regurgitation was present in the majority of patients. The results of pulmonary arterial repair were good in 100%. There was no residual stenosis, and we observed uniform enlargement of the repaired pulmonary arteries over a 5-month to 6-year follow-up period. These results are of particular interest inasmuch as other materials previously used for repair of pulmonary arteries do not grow and may even shrink, resulting in residual stenosis.

Ten-year experience with surgical treatment of partial atrioventricular septal defect: risk factors in the early postoperative period

Partial atrioventricular septal defects are electively repaired with good results. However, recent reports suggest that such repair is potentially a high-risk surgical procedure. Our aim was to determine the risk factors of adverse outcome early after surgical treatment of atrioventricular septal defects in our hospital. A retrospective study was done in 100 consecutive patients from 2 months to 50.6 years old (median 3.6 years) who underwent surgical correction between January 1984 and December 1993. An intermediate form of the lesion was noted in 31% of cases. Congestive heart failure occurred in 50% of cases. Preoperative left atrioventricular valve incompetence (moderate to severe) was present in 63% of patients. Severe abnormalities of left subvalvular apparatus were noted in 28% of patients. The cleft of the left atrioventricular valve was closed in 76% of cases. The study was done to determine risk factors associated with hospital mortality (13%), postoperative residual left atrioventricular valve incompetence (23%), and early reoperation (14%) within the first 30 postoperative days. Univariate analysis showed that age at the date of operation and cleft closure were not related to an early adverse outcome. A stepwise logistic regression with variables selected by univariate analysis identified infections and severe abnormalities of left subvalvular apparatus as predictive factors of early death (odds ratio, 28.07 and 6.18, respectively), preoperative left atrioventricular valve regurgitation as a predictive factor of residual postoperative left atrioventricular valve regurgitation (odds ratio, 5.34), and severe abnormalities of left subvalvular apparatus as a predictive factor of early reoperation (odds ratio, 5.27). These results emphasize the importance of the severity of the morphologic features of the left subvalvular apparatus, the occurrence of early postoperative infections, and the presence of residual left atrioventricular valve regurgitation as risk factors in the early period after surgical correction of partial atrioventricular septal defects.

Donor-recipient size matching in pediatric heart transplantation: a word of caution about small grafts

BACKGROUND

The increased shortage of donor organs led centers to extend the conventional donor criteria, particularly regarding donor-recipient size mismatching. Little information is available in the pediatric age group.

METHODS

Between December 1987 and May 1994, 73 pediatric orthotopic heart transplantations were performed. Indications for heart transplantation included congenital heart defect (29 patients), cardiomyopathy (40 patients), valvular disease (1 patient), and retransplantation (3 patients). Patients ranged in age from 9 days to 18 years (mean: 5.7 +/- 5 years). The following factors were evaluated: cardiomyopathy, congenital heart disease, age, pretransplantation pulmonary hypertension, previous sternotomy, status at transplantation, donor to recipient weight ratio, graft ischemic time, degree of donor inotropic support, ABO compatibility, gender mismatch.

RESULTS

The overall mortality rate before discharge (7 days to 4.5 months) was 27.4%. Donor heart failure occurred in 31.5%. Donor heart failure and early mortality were strongly correlated (p = 0.0002). Risk factors for donor heart failure were pretransplantation pulmonary hypertension (p = 0.024), donor/recipient ratio (p = 0.033), and major donor inotropic support (p = 0.034). Donor heart failure rate was 50% in donor/recipient ratio less than 1, 33% in donor/recipient ratio between 1 and 1.6, and 7% in donor/recipient ratio more than 1.6. Donor/recipient ratio less than 1 was the only significant risk of postoperative death by univariate (p = 0.0045) and multivariate (p < 0.01) analysis.

CONCLUSIONS

Donor heart failure remains the main cause of early mortality in pediatric heart transplantation. The use of oversized donor may be beneficial, particularly in patients with pretransplantation pulmonary hypertension. The use of undersized donor grafts should be strongly discouraged.

Sarcoid cardiomyopathy precipitated by pregnancy with cocaine complications

We report the case of a 27-year-old previously healthy multiparous black woman who developed congestive heart failure 5 days postpartum. It was initially diagnosed and treated as idiopathic peripartum cardiomyopathy. Five weeks later, pulmonary sarcoidosis was diagnosed by transbronchial biopsy specimen, and steroid therapy was begun. An endomyocardial biopsy specimen 1 month later indicated cardiac sarcoidosis. She responded well to steroid therapy; however, 16 months later, she had a cardiac arrest and died. Autopsy confirmed the diagnosis of cardiac sarcoidosis.

Surgical treatment of multiple ventricular septal defects using a biologic glue

The closure of multiple ventricular septal defects remains a surgical challenge. Mortality and morbidity are high. Left ventricular incision and multiple patches or stitches impair septal motion and function. We searched for a method that would cause minimal left ventricular and septal dysfunction. The use of fibrin seal for closing ventricular septal defects was considered. The method was first tested in animals so as to assess the internal resistance of the fibrin seal to stretching and fragmentation in addition to its adhesiveness and hence the absence of left-to-right embolization of the fibrin seal clot and the long-term success of the ventricular septal defect closure further to complete resorption of the ventricular septal defect clot. This experimental work was very satisfactory. Between April 1986 and September 1991, 15 children were operated on with the use of this technique. The overall hospital mortality rate was 6%. There were no reoperations for residual ventricular septal defects. All the long-term survivors (n = 13) were in excellent clinical condition with no or trivial residual shunt attested by color flow mapping investigation. This experimental and clinical experience suggests that satisfactory results can be achieved with the use of fibrin seal for the closure of multiple muscular ventricular septal defects.

Pediatric cardiac transplantation for congenital heart defects: surgical considerations and results

Among 54 children who underwent 55 heart transplantations, 24 (44%) (mean age, 4.9 +/- 4.8 years; range, 9 days to 18 years) had congenital defects with the following diagnoses: single-ventricle variants (6), hypoplastic left heart syndrome variants (5), transposition complex (6), and miscellaneous defects (7). Twenty patients (83%) had undergone 43 prior operations. Additional surgical procedures included repositioning of transposed great arteries (11), reconstruction of the aortic pathway (4), reconstruction of the pulmonary pathway (8), correction of situs inversus (1), and correction of anomalous pulmonary (1) or systemic (1) venous drainage. Reconstructive procedures were performed using donor or recipient tissue or both. There were six early deaths (hyperacute rejection, 1 patient; pulmonary hypertension, 1; graft failure, 2 patients; infection, 2) and six late deaths (sudden death, 2; chronic rejection, 2; nonspecific graft dysfunction, 1; lymphoproliferative disease, 1). The survival rate was 43% +/- 12% at 3 years. No deaths were related to surgical technique. Survival was not significantly different in pediatric recipients with cardiomyopathy (67% +/- 9%; p = 0.22). Accelerated coronary artery disease was noted in 4 operative survivors (22%; 70% confidence limits, 12% to 36%). All late survivors were free from cardiac symptoms after a mean follow-up of 34 +/- 24 months (range, 6 to 71 months). Based on this study, we reached three conclusions. (1) Careful planning of both harvesting and transplantation procedures allows heart transplantation in recipients with congenital heart diseases. (2) The surgical technique may be demanding, but the early risk is not increased.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cavo-bipulmonary anastomosis. Apropos of 3 cases]

Cavo-bipulmonary anastomosis (CBPA) in an anastomosis between the superior vena cava and the right pulmonary artery in continuity with the left pulmonary artery. This shunt is used in complex cyanotic congenital heart disease with pulmonary stenosis. It is the first stage of a total cavo-pulmonary shunt (TCPS). Thirty patients underwent this procedure at Laënnec Hospital between April 1988 and April 1990. The surgical indications were retained when TCPS appeared to be too risky, mainly because of the associated malformations, the correction of which was performed at the same time. There were to early deaths; one patient was lost to follow-up and 27 patients have been followed up for an average period of 12 +/- 6 months. The surgical result was judged according to the degree of cyanosis; a poor result was defined as systemic saturation of less than 75% and a haematocrit of over 55%. One child died 5 months after surgery; there were 16 good results and 10 poor results. Seven patients were reoperated to carry out the second stage of the TCPS. The average gain in saturation was 9.7% in our series. Analysis of the patients who died or who had poor surgical results showed an anatomic cause in 11 of the 13 cases (pulmonary arteriovenous fistula, stenosis of the branches of the pulmonary artery, regurgitation of an atrioventricular valve) or a physiopathological cause (mean pulmonary artery pressure greater than 20 mmHg, or ventricular failure). The CBPA is a palliative procedure to reduce ventricular load, repair stenosis of the right pulmonary artery and to prepare the patient for a total cavopulmonary shunt.

Heart transplantation in children: risk factors of early and late mortality

In order to identify predictive risk factors of poor outcome following heart transplantation in children, we performed a retrospective analysis of our pediatric recipient population: 31 children, aged 15 days to 15 years (mean = 5.2 +/- 4.9 years). The preoperative diagnosis was cardiomyopathy in 17 (55%), congenital heart disease in 13 (42%) and end-stage valvular disease in 1 (3%). There were 5 operative deaths: hyperacute rejection (2), low cardiac output syndrome (3); 4 in-hospital deaths: infection (2), multiorgan failure (2) and 4 late deaths: acute rejection (1), chronic rejection (1), lymphoma (1), unknown (1). The actuarial probability of survival (+/- SE) was 62% +/- 10% at 1 year and 53% +/- 12% at 2 years. Univariate analysis was used to evaluate the following risk factors: age, diagnosis, hemodynamic decompensation, previous cardiac surgery, ischemic time of the graft, technique of graft preservation, preoperative pulmonary artery pressure, occurrence of postoperative low cardiac output syndrome (LCOS) with pulmonary hypertension (PHT). The occurrence of early LCOS with PHT significantly increased both early and late mortality (78% early mortality, 100% overall mortality). This syndrome occurred in 9 patients (29%) and was attributed to primary graft failure in 2, increased pulmonary vascular resistances in 6 and multiple factors in 1. Although not significant, two factors may increase early survival: young age (less than or equal to 1 year) at operation and improved technique of graft preservation.

Extrathoracic heart (ectopia cordis). Report of two cases and review of the literature

We report 2 cases of extrathoracic heart (ectopia cordis) operated on a few hours after birth at Laennec Hospital, Paris. The first patient had an associated diastasis of the rectus muscles. The second one, in whom diagnosis was made by ultrasound during fetal life, had a normal abdominal wall. In both cases it was possible to accommodate the heart in the left pleural cavity after a wide dissection of the posterior mediastinum. Both babies, however, died soon after the operation. Double outlet right ventricle was found in both. We have reviewed those cases previously described and discuss the importance of prenatal echocardiographic diagnosis in this rare condition.

Anomalous left coronary artery arising from the pulmonary artery: a series of 27 infants undergoing operation in the first years of life

Between 1977 and 1987, 27 infants (aged 3 to 54 months) underwent surgical treatment for correction of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). All had a direct aortic reimplantation. The overall operative mortality was 18.5% (five deaths). The follow-up period was from 2 months to 8 years (mean, 38 months). No late deaths occurred. During the 10 years, modifications of the surgical procedure and myocardial preservation were introduced (ie, complete resection of the pulmonary trunk made anastomosis easier; since 1982, cardioplegia in both coronary systems has been used, and left atrial-to-aortic assistance was introduced). The latter was carried out when surgical repair was associated with acute cardiac failure and a high left atrial filling pressure at the end of cardiopulmonary bypass. In view of the results during the latter part of this series, it is felt that surgery should not be restricted in younger patients (< 12 months). If medical treatment is unsuccessful, surgery aims to avoid irreversible left ventricular dysfunction and development of severe endocardial fibroelastosis.