Excision of left atrial myxoma under perfused ventricular fibrillation with hypothermia after coronary artery bypass grafting

BACKGROUND

Redo heart surgery has become increasingly common but involves additional high surgical risk, especially redo surgery after coronary artery bypass grafting (CABG).

CASE PRESENTATION

In this study, we report the case of a 57-year-old Chinese male with left atrium myxoma who had previously undergone CABG. Common surgical methods usually include aortic cross-clamping, administering cold cardioplegia perfusion to protect the myocardium, opening the heart, and then removing the tumor. However, for patients with previous CABG, redo thoracotomy and ascending aortic cross-clamping present a greater risk of damage to the grafted vessels. In this study, we chose a right lateral mini-thoracotomy incision and hypothermia-induced ventricular fibrillation to minimize damage and avoid any adverse effects on the bridge vasculature. The patient recovered uneventfully and was discharged seven days after surgery.

CONCLUSIONS

For patients with previous CABG, minimally invasive right thoracotomy under perfused ventricular fibrillation with hypothermia is safe and reliable and can prevent potential damage to the ascending aorta and graft.

Transition Zone Pull-through in Patients with Hirschsprung Disease: Is Redo Surgery Beneficial for the Long-term Outcomes?

INTRODUCTION

Transition zone pull-through (TZPT) is incomplete removal of the aganglionic bowel/transition zone (TZ) in patients with Hirschsprung disease (HD). Evidence on which treatment generates the best long-term outcomes is lacking. The aim of this study was to compare the long-term occurrence of Hirschsprung associated enterocolitis (HAEC), requirement of interventions, functional outcomes and quality of life between patients with TZPT treated conservatively to patients with TZPT treated with redo surgery to non-TZPT patients.

METHODS

We retrospectively studied patients with TZPT operated between 2000 and 2021. TZPT patients were matched to two control patients with complete removal of the aganglionic/hypoganglionic bowel. Functional outcomes and quality of life was assessed using Hirschsprung/Anorectal Malformation Quality of Life questionnaire and items of Groningen Defecation & Continence together with occurrence of Hirschsprung associated enterocolitis (HAEC) and requirement of interventions. Scores between the groups were compared using One-Way ANOVA. The follow-up duration lasted from time at operation until follow-up.

RESULTS

Fifteen TZPT-patients (six treated conservatively, nine receiving redo surgery) were matched with 30 control-patients. Median duration of follow-up was 76 months (range 12-260). No significant differences between groups were found in the occurrence of HAEC (p = 0.65), laxatives use (p = 0.33), rectal irrigation use (p = 0.11), botulinum toxin injections (p = 0.06), functional outcomes (p = 0.67) and quality of life (p = 0.63).

CONCLUSION

Our findings suggest that there are no differences in the long-term occurrence of HAEC, requirement of interventions, functional outcomes and quality of life between patients with TZPT treated conservatively or with redo surgery and non-TZPT patients. Therefore, we suggest to consider conservative treatment in case of TZPT.

Should Redo Surgery be Offered to Patients with Relapsed Glioblastoma? - Outcome Analyses of a Single Institution Comparative Cohort Study

BACKGROUND

Glioblastoma multiforme (GBM) is the predominant malignant brain tumor originating intracranially. The established first-line treatment postsurgery is concurrent chemoradiation as a definitive measure. However, recurrent GBM's pose a challenge for clinicians who rely on institutional experience to determine the most suitable course of action. Second-line chemotherapy may be administered with or without surgery depending on the institution's practice. This study aims to present our tertiary center institution's experience with recurrent GBM patients who underwent redo surgery.

METHODS

In this retrospective study we analyzed the surgical and oncological data of patients with recurrent GBM who underwent redo surgery at the Royal Stoke University Hospitals between 2006 and 2015. The group 1 (G1) comprised the reviewed patients, while a control group (G2) was randomly selected, matching the reviewed group by age, primary treatment, and progression-free survival (PFS). The study collected data on various parameters, including overall survival, PFS, extent of surgical resection, and postoperative complications.

RESULTS

This retrospective study included 30 patients in G1 and 32 patients in G2, matched based on age, primary treatment, and PFS. The study found that the overall survival for the G1 group from the time of first diagnosis was 109 weeks (45-180) compared to 57 weeks (28-127) in the G2 group. The incidence of postoperative complications after the second surgery was 57%, which included hemorrhage, infarction, worsening neurology due to edema, cerebrospinal fluid leak, and wound infection. Furthermore, 50% of the patients in the G1 group who underwent redo surgery received second-line chemotherapy.

CONCLUSIONS

Our study found that redo surgery for recurrent GBM is a viable treatment option for a select group of patients with good performance status, longer PFS from primary treatment, and compressive symptoms. However, the use of redo surgery varies depending on the institution. A well-designed randomized controlled trial in this population would help establish the standard of surgical care.

Redo laparoscopic colorectal resection: a retrospective analysis with propensity score matching

PURPOSE

Reports of redo laparoscopic colorectal resection (Re-LCRR) are scarce. In order to evaluate the safety and short-term outcomes of Re-LCRR, we performed a matched case-control analysis of patients who underwent this procedure for colorectal cancer.

METHOD

This was a retrospective, monocentric study that included patients who underwent Re-LCRR for colorectal cancer between January 2011 and December 2019 at our institution. The patients were compared to a 2:1 matched sample. Matching was conducted based on age, sex, BMI, surgical procedure, and clinical stage.

RESULT

Twenty-nine patients underwent Re-LCRR (RCRR group) and were compared to 58 patients selected by matching who underwent LCRR as primary resection (PCRR group). The median of age of the 29 patients of RCRR group was 75 (IQR 56-81) years and the RCRR group included 14 males. The median operative time of the RCRR group was 167 (IQR 126-232) minutes, and the median intraoperative blood loss was 5 (IQR 2-35) ml. In the RCRR group, there were no cases that required conversion to laparotomy. The short-term outcomes of the two groups did not differ to a statistical extent with respect to operative time (p = 0.415), intraoperative blood loss (p = 0.971), rate of conversion to laparotomy (p = 0.477), comorbidity (p = 0.215), and postoperative hospital stay (p = 0.809). No patients in either group experienced postoperative anastomotic leakage or required re-operation due to postoperative complications, and there was no procedure-related death. However, in terms of oncological factors, although there was no difference in the number of cases with a positive radical margin between the two groups (p = 1.000), the number of harvested lymph nodes in the RCRR group was significantly lower than that in the PCRR group (p = 0.015) and the RCRR group included 10 cases with less than 12 harvested lymph nodes.

CONCLUSION

Re-LCRR is associated with good short-term results and can be safely performed; however, the number of harvested lymph nodes is significantly reduced in comparison to primary resection cases, and further studies are needed to evaluate its long-term prognosis.

Classification of surgical causes of and approaches to the chronically failing ileoanal pouch

BACKGROUND

Although there are various surgical causes of and therapeutic approaches to the chronically failing ileoanal pouch (PF), cases are often detailed without distinguishing the exact cause and corresponding treatment. The aim of our study was to classify causes of PF and corresponding surgical treatment options, and to establish efficacy of surgical approach per cause.

METHODS

This retrospective study included all consecutive adult patients with chronic PF surgically treated at our tertiary hospital between July 2014 and March 2021. Patients were classified according to a proposed sub-classification for surgical related chronic PF. Results were reported accordingly.

RESULTS

 A total of 59 procedures were completed in 50 patients (64% male, median age 45 years [IQR 34.5-54.3]) for chronic PF. Most patients had refractory ulcerative colitis as indication for their restorative proctocolectomy (68%). All patients could be categorized according to the sub-classification. Reasons for chronic PF were septic complications (n = 25), pouch body complications (n = 12), outlet problems (n = 11), cuff problems (n = 8), retained rectum (n = 2), and inlet problems (n = 1). For these indications, 17 pouches were excised, 10 pouch reconstructions were performed, and 32 pouch revision procedures were performed. The various procedures had different complication rates. Technical success rates of redo surgery for the different causes varied from 0 to 100%, with a 75% success rate for septic causes.

CONCLUSIONS

Our sub-classification for chronic PF and corresponding treatments is suitable for all included patients. Outcomes varied between causes and subsequent management. Chronic PF was predominantly caused by septic complications with redo surgery achieving a 75% technical success rate.

Efficacy of Laparoscopic Management of Posterior Urethral Diverticulum in Anorectal Malformations

BACKGROUND

A posterior urethral diverticulum (PUD) is a serious postoperative complication after anorectal malformation correction. Complete resection is technical demanding because of limited retrourethral working space deep in the pelvis.

OBJECTIVE

We pioneered the single-incision laparoscopic approach for PUD excision and evaluated the efficacy.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-six PUD patients undergoing redo surgeries between June 2011 and June 2021 were reviewed.

SURGICAL PROCEDURE

A series of transabdominal retraction sutures were placed through the PUD to facilitate dissection. The contents were evacuated to create a working space. Distal PUD dissection was carried along the submucosal layer to prevent injury of the urethra/pelvic nerve complex. The rectal mucosa was peeled off from the junction site for complete PUD excision. The muscular cuff of the distal rectum was then oversewn.

MEASUREMENTS

Operative time, postoperative recovery, and complications were assessed.

RESULTS AND LIMITATIONS

The mean age of redo surgery was 2.46 yr. The average operative duration was 2.35 h. The mean postoperative hospital stay, resumption of full diet, and bowel movement were 10.23, 2.15, and 1.54 d, respectively. The median follow-up period was 46 mo (12-132 mo). No remnant of PUD, recurrent fistula, or urinary leak was detected. None of the patients had difficulty in urination, urinary dribbling, urinary tract infection, constipation, or soiling. All patients retained morning erection, and two postpubertal patients had ejaculations.

CONCLUSIONS

Our single-incision laparoscopic redo surgery provides an effective approach for PUD excision. It minimizes complications. It also preserves urinary and bowel continence and sexual function.

PATIENT SUMMARY

Complete resection of a posterior urethral diverticulum (PUD) in anorectal malformation is technically demanding because of limited retrourethral working space in the deep pelvis. The outcomes of single-incision laparoscopic PUD excision were satisfactory.

Endovascular Repair for Ascending Aortic Graft Side Branch Pseudoaneurysm: A Report of Two Cases

Introduction

A pseudoaneurysm arising from the side branch of the prosthesis, following ascending aortic replacement, is extremely rare. Re-intervention usually involves open surgery, replacement of the ascending aorta, or ligation of the side branch. Redo surgery with an additional sternotomy carries the risk of cardiac and vascular injuries, and endovascular treatment can reduce such adverse events.

Report

This study describes the successful thoracic endovascular aortic repair (TEVAR) of two cases of pseudoaneurysms arising from the side branch after ascending aortic replacement. Case 1 involved a 79 year old man who underwent ascending aortic replacement and omentopexy for a ruptured tuberculous aortic aneurysm 13 years ago. The pseudoaneurysm was mushroom shaped with a 30 mm protrusion. Case 2 involved an 83 year old man who underwent ascending aortic replacement for Stanford type A acute aortic dissection 11 years ago. The pseudoaneurysm was rod shaped with a 27 mm protrusion. In both cases, the pseudoaneurysm arising from the side branch was not noted on computed tomography (CT) until one year earlier and was first identified at a routine follow up examination. The pseudoaneurysms required surgical repair because of the risk of rupture; however, TEVAR was selected considering the risks of redo surgery and the patients' ages. It was performed via a femoral artery approach without adverse events using a commercially available thoracic aortic device. Post-operative CT scan showed complete exclusion of the pseudoaneurysm.

Discussion

Although TEVAR is usually not indicated for ascending aortic pathologies, if there is an anatomical indication and a compatible stent graft, TEVAR for the ascending aorta should be the first choice in patients who are inoperable, at high risk and undergoing redo surgery.

Minimally invasive direct coronary artery bypass to the left anterior descending artery using right gastroepiploic artery graft for a redo case with poor conduits

A 64-year-old Thai woman underwent coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) for completely occluded left anterior descending artery (LAD) and mitral valve replacement with mechanical valve about a year ago. She presented with unstable angina. Three-dimensional computed tomography angiography (3DCTA) showed occlusion of all the grafts. The left subclavian artery had 99% stenosis. The patient underwent redo CABG via a minimally invasive direct approach. The chest was entered through the left fifth intercostal space. The right gastroepiploic artery (RGEA) and a small length of SVG were harvested. The RGEA was extended using the SVG with an end-to-end anastomosis and used to graft the LAD without cardiopulmonary bypass. The patient's postoperative course was uneventful. Postoperative 3DCTA revealed patent RGEA-SVG graft. Minimally invasive direct coronary artery bypass to LAD with RGEA is a useful alternative approach for redo CABG in patients with not much choice of conduits.

Aortic and mitral bioprosthetic valve dysfunction: surgical or percutaneous solutions?

In the last years, there has been a trend to prefer biological prostheses, especially among young patients, with the aim to avoid anticoagulant treatment. Surgical tissue valves have so far demonstrated their solid long-term durability. However, younger age has been identified as one of the main risk factors for developing structural valve deterioration (SVD). As a consequence, the proportion of subjects at risk for valve dysfunction will constantly rise in the near future. However, while surgical reintervention has always been considered the gold standard for treatment of prosthesis deterioration, the introduction of transcatheter heart valves could offer new therapeutical options, particularly among high-risk patients, aiming a second less invasive chance. The recent standardization of valve durability definitions will soon allow a more comprehensive understanding of the mechanism underlying SVD and guide the choice of prosthesis for patients needing valve replacement.

Is minimally invasive liver surgery a reasonable option in recurrent HCC? A snapshot from the I Go MILS registry

Laparoscopic liver resection (LLR) for Hepatocellular carcinoma (HCC) is a safe procedure. Repeat surgery is more often required, and the role of minimally invasive liver surgery (MILS) is not yet clearly defined. The present study analyzes data compiled by the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) on LLR. To compare repeated LLR with the first LLR for HCC is the primary endpoint. The secondary endpoint was to evaluate the outcome of repeat LLR in the case of primary open versus primary MILS surgery. The data cohort is divided into two groups. Group 1: first liver resection and Group 2: Repeat LLR. To compare the two groups a 3:1 Propensity Score Matching is performed to analyze open versus MILS primary resection. Fifty-two centers were involved in the present study, and 1054 patients were enrolled. 80 patients underwent to a repeat LLR. The type of resection was different, with more major resections in the group 1 before matching the two groups. After propensity score matching 3:1, each group consisted of 222 and 74 patients. No difference between the two groups was observed. In the subgroup analysis, in 44 patients the first resection was performed by an open approach. The other 36 patients were resected with a MILS approach. We found no difference between these two subgroups of patients. The present study in repeat MILS for HCC using the IGoMILS Registry has observed the feasibility and safety of the MILS procedure.

Second redo surgery after two consecutive failures of a colorectal or coloanal anastomosis: is it reasonable?

PURPOSE

Colorectal redo surgery is well known to be a difficult procedure, associated with a high risk of failure. The aim of this study was to look into patients presenting two consecutive failed colorectal (CRA) or coloanal (CAA) anastomosis who underwent a second redo surgery (i.e., third anastomosis).

METHODS

A retrospective study based on a prospective database of second redo surgeries of CRA or CAA, in an expert center. Sixteen patients between 2005 and 2020 were analyzed.

RESULTS

After a mean follow-up of 28 ± 26 months, success of surgery (defined as no stoma at the end of follow-up) was reported in 10/16 patients (63%). One patient with chronic anastomotic leakage and another with early colonic ischemia had no defunctioning stoma reversal. In the remaining four patients with a failed second redo surgery, a definitive stoma was ultimately created for fistula recurrence (n = 1), poor functional results (n = 2), or local cancer recurrence (n = 1). Two risk factors for failure of this second redo surgery were significantly found in a univariate analysis: (1) nature of the primary anastomosis: 3/13 s redo surgeries failed (23%) if a CRA was first made and 3/3 (100%) if it was a CAA (p = 0.036); (2) age: patients with a failed second redo surgery were older (p = 0.04).

CONCLUSION

A 63% rate of success of second redo surgery was observed after two failed CRA or CAA. Although a demanding procedure, it can be proposed to carefully selected and motivated patients.

Redo surgery for trigeminal neuralgia: reasons for re-exploration and long-term outcomes

BACKGROUND

To investigate the causes of failure and recurrence after microvascular decompression (MVD) for trigeminal neuralgia (TGN) and to analyze the results of redo surgery.

METHODS

Sixty-three cases of redo surgery were retrospectively reviewed. Reasons for re-exploration were categorized into 4 groups based on the operative findings. Patient characteristics, outcomes of re-exploration, and operative complications were analyzed by Kaplan-Meier and logistic regression analyses.

RESULTS

Reasons for redo surgery were divided into arterial compression in 13 patients (21%), venous compression in 11 patients (17%), prosthesis-related in 25 patients (40%), and adhesion or negative exploration in 14 patients (22%). Immediate pain relief was obtained in 59 patients (94%) postoperatively with newly developed facial numbness in 17 patients (27%). Of these, 48 patients (76%) maintained pain-free 1 year postoperatively. Overall recurrence was noted in 17 patients (27%) during the median 49-month follow-up period. Most recurrences occurred within 1 year after redo surgery, but the prosthesis-related patients showed a continuous recurrence up to 4 years. Patients having vascular compression showed significantly better pain control than those without vascular contact in Kaplan-Meier analyses (p = 0.0421). No prognostic factor for pain-free 1 year after redo surgery was found.

CONCLUSIONS

Redo surgery is effective for patients with remaining vascular compression rather than those without vascular contact. Teflon contact onto the nerve root should be avoided because it is a potential risk for recurrence and causes poor prognosis after redo surgery.

Repeat aortic valve surgery: contemporary outcomes and risk stratification

OBJECTIVES

Redo aortic valve surgery (rAVS) is performed with increasing frequency, but operative mortality is usually higher compared to that associated with primary aortic valve surgery. We analysed our patients who had rAVS to determine the current outcomes of rAVS as a surgical benchmark in view of the growing interest in transcatheter valve techniques.

METHODS

We retrospectively reviewed 148 consecutive patients [median age 67.7 years (interquartile range 54.9-77.6); 68.2% men] who underwent rAVS following aortic valve replacement (81.6%), aortic root replacement (15%) or aortic valve repair (3.4%) between 2000 and 2018.

RESULTS

Indications for rAVS were structural valve dysfunction (42.7%), endocarditis (37.8%), non-structural valve dysfunction (17.7%) and aortic aneurysm (2.1%). Valve replacement was performed in 69.7%, and 34 new root procedures were necessary in 23%. Early mortality was 9.5% (n = 14). Female gender [odds ratio (OR) 6.16], coronary disease (OR 4.26) and lower creatinine clearance (OR 0.95) were independent predictors of early mortality. Follow-up was 98.6% complete [median 5.9 (interquartile range 1.7-10.9) years]. Survival was 74.1 ± 3.7%, 57.9 ± 5.1% and 43.8 ± 6.1% at 5, 10 and 14 years, respectively. Cox regression analysis revealed female gender [hazard ratio (HR) 1.73], diabetes (HR 1.73), coronary disease (HR 1.62) and peripheral vascular disease (HR 1.98) as independent determinants of late survival.

CONCLUSIONS

Despite many urgent situations and advanced New York Heart Association functional class at presentation, rAVS could be performed with acceptable early and late outcomes. Risk factors for survival were female gender, coronary disease and urgency. In this all-comers patient cohort needing rAVS, only a minority would eventually qualify for transcatheter valve-in-valve procedures.

Starr-Edwards mitral valve-48 years till redo surgery, with over 54 years of patient survival after primary mitral valve replacement

We report a male patient who underwent successful redo cardiac surgery in 2014; tricuspid valve repair and redo mitral valve replacement of a Starr-Edwards mitral valve implanted 48 years previously. Six years after the redo operation, the patient remains well and therefore has an impressive over 54 years of survival following mitral valve replacement surgery.

Revision Surgery Rates After Minimally Invasive Adult Spinal Deformity Surgery: Correlation with Roussouly Spine Type at 2-Year Follow-Up?

BACKGROUND

Spinopelvic parameters have hitherto dictated much of adult spinal deformity (ASD) correction. The Roussouly classification is used for the normal adult spine. We evaluated whether a correlation would be found between the Roussouly type and the rate of revision surgery in patients with ASD undergoing circumferential minimally invasive spinal (cMIS) correction.

METHODS

A multicenter retrospective review of patients who had undergone cMIS surgery for ASD was performed. The inclusion criteria were age ≥18 years and 1 of the following: coronal Cobb angle >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, pelvic incidence (PI) to lumbar lordosis (LL) mismatch >10°, cMIS surgery, and a minimum of 2 years of follow-up data available. The patients were classified by Roussouly type, and the clinical and radiographic outcomes were evaluated.

RESULTS

A total of 104 patients were included in the present analysis. Of the 104 patients, 41 had Roussouly type 1, 32 had type 2, 23 had type 3, and 8 had type 4. Preoperatively, the patients with type 4 had the highest PI (P = 0.002) and LL (P < 0.001). Postoperatively, the PI-LL mismatch, Cobb angle, and sagittal vertical axis were not different among the 4 groups. However, the patients with type 2 had had the highest rate of complications (type 1, 29.3%; type 2, 61.3%; type 3, 34.8%; type 4, 25.0%; P = 0.031). The reoperation rates were comparable (type 1, 19.5%; type 2, 38.7%; type 3, 13.0%; type 4, 12.5%; P = 0.097). The reoperation rates for adjacent segment degeneration or proximal junctional kyphosis were also comparable (P = 0.204 and P = 0.060, respectively).

CONCLUSIONS

We did not find a clear correlation between Roussouly type and the rate of revision surgery for adjacent segment disease or proximal junctional kyphosis in patients who had undergone cMIS surgery for ASD.

One Anastomosis Gastric Bypass after Sleeve Gastrectomy Failure: Does a Single Procedure Fit for all?

INTRODUCTION

Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased accordingly. Several authors argued that with the great diffusion of sleeve gastrectomy (SG), the number of patients who experienced a weight regain at long follow-up was congruous and physiologic, even if not negligible. Recent studies showed that one anastomosis gastric bypass (OAGB) was an effective and safe option also as redo surgery. The aim of the study was to evaluate effectiveness of OAGB as redo surgery after SG in term of anthropometric features and remission of comorbidities.

METHODS

Bariatric patients experiencing weight regain and insufficient weight loss after SG and undergoing OAGB as redo surgery were retrospectively analyzed. During post-OAGB outpatient visit weight, %EWL, BMI, comorbidities, and vitamin deficiencies were evaluated. A further visit was scheduled for the evaluation of postoperative esophagitis/gastritis at upper endoscopy.

RESULTS

Fifty-nine (Reviewer #3-1) patients underwent OAGB as redo-surgery consequently to the worsening of the bariatric outcomes at 29.42 ± 7.29 months from SG (mean weight, BMI and %EWL were 120.89 ± 16.79 kg, 43 ± 4.39 and 19.84 ± 30.29, respectively). Conversely, at a mean follow-up of 34.32 ± 1.71 months (Reviewer #3-3) after OAGB, no weight regain or insufficient weight loss cases were recorded (mean weight 71.25 ± 10.22 kg, mean BMI 24.46 ± 2.06 kg/m2, mean %EWL 69.49 ± 14.4, p < 0.0001) (Reviewer #3-2).

CONCLUSION

OAGB is a safe and effective bariatric procedure in terms of morbidity, mortality, and %EWL also as revision surgery after SG. Further larger studies are needed to address this issue.

Association of age with incidence and timing of recurrence after microdiscectomy for lumbar disc herniation

OBJECTIVE

Recurrent lumbar disc herniation (LDH) is the most frequent reason for reoperation after lumbar microdiscectomy. While several risk factors for recurrent LDH have been well-described, the effect of age on recurrence remains unclear, especially concerning the timing of recurrent LDH.

METHODS

From a prospective registry, we identified all patients who underwent tubular microdiscectomy for LDH. Recurrent LDH was defined as reoperation for LDH at the same index level and side. The associations among age and incidence of recurrent LDH as well as on time to recurrent LDH were statistically evaluated using multivariable analysis of covariance, linear regression, and Cox proportional hazards modelling.

RESULTS

Of the 3013 patients who underwent surgery for LDH, 166 (5.5%) had to undergo reoperation due to LDH recurrence. Uni- and multivariable analysis revealed no influence of age on the incidence of recurrent LDH (both p > 0.05). Linear regression indicated earlier reoperation in older patients, both with (β = -0.248) and without (β = -0.374) correction for confounders (both p < 0.05). An additional survival analysis found that patients aged over 35 years had recurrent LDH significantly earlier (hazard ratio 0.617, p = 0.013).

CONCLUSION

In an analysis of a large prospective database of patients undergoing microdiscectomy for lumbar disc herniation, we found that younger patients do not have a higher reoperation probability than their older counterparts, even after correcting for multiple confounders. However, older patients tend to experience recurrent LDH significantly earlier after the index surgery compared to younger patients.

Challenges Associated with Reoperation in Patients with Glioma

Reoperation for glioma is increasingly common but there is neither firm agreement on the indications nor unequivocally proven benefit from clinical trials. Patient and tumor factors should be considered when offering reoperation and a clear surgical goal set. Reoperation is challenging because of placement of previous incisions, wound devascularization by preceding radiotherapy and/or chemotherapy, chronic steroid use, the need for further adjuvant therapy, and adherent and defective dura. This article reviews indications, challenges, and recommendations for repeat surgery in the patient with glioma.

Redo ventral rectopexy: is it worthwhile?

BACKGROUND

Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP).

METHODS

This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life.

RESULTS

A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation.

CONCLUSIONS

Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.

Natural History of a Carpentier-Edwards Pericardial Aortic Valve Replaced after 25 Years for Structural Valve Degeneration

•

SVD is a main limitation of bioprostheses.

•

Routine use of bioprostheses in younger patients (<60 years of age) is controversial.

•

Data on the durability of surgical aortic bioprostheses beyond 20 years are limited.

•

We report exceptional durability of an aortic bioprosthesis replaced after 25 years.

Long-term outcomes after reoperation for mitral paravalvular leaks: a single-centre experience

OBJECTIVES

We aimed to analyse the pathology of paravalvular leak (PVL), and determine the long-term outcomes of redo mitral valve replacement and risk factors of all-cause mortality.

METHODS

Seventy-nine patients (mean age 70 ± 9 years; 54 female, 68%) who underwent redo mitral valve replacement for mitral PVL between January 2000 and May 2019 were retrospectively reviewed. Indications for PVL intervention were haemolytic anaemia (57/79, 72%), New York Heart Association class III/IV congestive heart failure (56/79, 71%) and prosthetic valve endocarditis with PVL (2/79, 3%).

RESULTS

PVL most commonly occurred at lateral sectors (42/79, 55%). Early mortality occurred in 2 patients (3%) due to low cardiac output syndrome. Two patients (3%) had residual PVL at discharge. Sixteen patients (23%) developed late PVL (mean follow-up, 3.4 ± 2.9 years), among whom 11 (69%) developed PVL at same area as that preoperatively. Additionally, 9 patients (56%) developed PVL at lateral sectors in late follow-up. At 1, 5 and 10 years, the survival rate was 93%, 72% and 45%; rate of freedom from cardiac death was 96%, 92% and 78%; and rate of freedom from PVL recurrence was 94%, 82% and 54%, respectively. Chronic kidney disease was the only risk factor in the multivariate analysis for mortality [P = 0.013; hazard ratio 4.0 (1.4-11.0)].

CONCLUSIONS

Surgery for mitral PVL confers reasonable early and long-term outcomes. Greater attention to the anterolateral annulus may help prevent PVL.

Aortic root destruction after aortic valvuloplasty for bicuspid aortic valve

Ultrasound cardiography showed severe aortic regurgitation (AR) due to bicuspid aortic valve with dilatation of the aortic annulus and sinotubular junction in a 27-year-old man hospitalized with loss of consciousness. He underwent aortic valvuloplasty combined with external suture annuloplasty using an expanded polytetrafluoroethylene (ePTFE) suture. Intraoperative findings revealed thickening and adhesion of the aortic root despite the first surgery. He developed recurrent AR 7 months later and underwent redo surgery. An ePTFE suture was found inside the aorta. Aortic root replacement with a mechanical composite graft was performed, as reconstruction appeared difficult because the aortic annulus was damaged and there were multiple holes on all cusps. Here, we report a rare case of aortic root destruction after external suture annuloplasty.

Hepatocellular carcinoma surgical and oncological trends in a national multicentric population: the HERCOLES experience. Updates Surg. 2020;72:399-411. [PMID: 32170630 DOI: 10.1007/s13304-020-00733-6]

Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63-75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5 years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power.

TAVI-in-homograft (TiH): open transcatheter aortic valve replacement in calcified aortic homograft case reports

Background

Redo surgery in patient who underwent aortic valve replacement with an aortic homograft can result technically challenging because of the massive calcification of the conduit.

Case presentation

We present a case of a patient who underwent open surgery on cardiopulmonary bypass assistance to implant a standard transcatheter aortic bioprosthesis through aortotomy in an off-label procedure and we discuss its safety and feasibility.

Conclusions

The combination of open cardiac surgery and open trans-aortic implant of a transcatheter prosthesis may reduce the surgical risk shrinking the technical difficulties that the implantation of a standard surgical prosthesis would have given.

Revisional But Not Conversional Gastric Bypass Surgery Increases the Risk of Leaks: Review of 176 Redo out of 932 Consecutive Cases

INTRODUCTION

Nowadays, surgeons are dealing more and more with patients experiencing failure of a previous bariatric procedure after the worldwide exponential increase of bariatric surgery. Only a few and contradictory studies investigated both outcomes and complications risk factors in this subset population of bariatric patients. We aimed to study a homogeneous population of patients undergoing redo bariatric surgery (REDO-BS) resulting in bypass anatomy to evaluate early postoperative outcomes and identify risk factors of postoperative complications and mortality.

MATERIAL AND METHODS

In this study, we compared the outcomes of patients undergoing REDO-BS from another former bariatric procedure into Roux-en-Y gastric bypass (RYGP) to those undergoing primary RYGP. Data were extracted from a prospectively maintained database.

RESULTS

One hundred thirty-eight conversional bariatric surgery (CBS) cases resulting in RYGP anatomy and 38 RBS cases of pouch resizing (PR) were compared with 756 primary RYGP. There were no statistical significant difference in outcomes between the primary and CBS groups but patients undergoing PR had a significant higher risk of developing a leak than others. CBS complication risk factors were age (OR = 1.05; p = 0.04), operative time, and T2DM (OR = 4.11; p = 0.03).

CONCLUSIONS

CBS is safe and leads to similar early postoperative outcomes as primary RYGP whereas the indication for revisional surgery such as PR should be carefully evaluated as it is associated with an increased risk of leak.

Laparoscopic Conversion from Single Anastomosis Duodeno-Jejunal Bypass with Sleeve Gastrectomy (SADJ-S) to Roux-en-Y Gastric Bypass (GBP): Improving Unsatisfactory Outcomes

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) can be considered as either a primary procedure or second stage procedure. Malnutrition is rare but could lead to a reversal of the SADI-S. The aim of this manuscript is to present the management and technique of weight regain after proximalization of a SADI-S by converting it to a gastric bypass.

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes.

OBJECTIVES

To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB.

SETTING

High-volume centers for bariatric surgery.

METHODS

Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded.

RESULTS

Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m² at the time of first intervention, 41.8 ± 6.3 kg/m² at redo time, and 30.5 ± 5.5 kg/m² at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6-156) months and overall complications rate was 8.6%.

CONCLUSION

Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis

Purpose

Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients.

Methods

Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up.

Results

A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444).

Conclusion

In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

Pulmonary valve replacement after right ventricular outflow tract reconstruction with homograft vs Contegra®: a case control comparison of mortality and morbidity

Background

Repair of congenital heart defects involving the right ventricular outflow tract may require the implantation of a right ventricle to pulmonary artery conduit. This conduit is likely to be replaced during childhood. This study compares the operative outcomes of the replacement procedure of Contegra® and homografts in pulmonary position.

Methods

From 1999 to 2016, 82 children underwent 87 right ventricle to pulmonary artery conduit replacements (60 Contegra® and 27 homografts). Demographics, operative and clinical data were obtained through a retrospective review of the medical records. The two groups were matched for comparison using propensity score matching. All the procedures were performed by the same team of surgeons.

Results

No statistically significant difference was observed between the two groups when considering the operative data for anesthesia, surgery, cardiopulmonary bypass and aortic clamping durations. A peroperative complication rate of 13.47% and 15.36% in Contegra® and homograft replacement groups respectively (p value = 0.758) was observed. There was no difference regarding the blood loss and fluid input. No statistically significant difference was observed between the two groups for the post-operative morbidity. We considered the Pediatric Risk of Mortality (PRISM) score, the day of extubation, the day of withdrawal of inotropic drugs, the length of the intensive care unit stay and the length of hospital stay. The overall mortality is 2.3% but there is no statistically significant difference between the two groups.

Conclusion

Right ventricle to pulmonary artery conduit replacement procedure can be achieved with a low surgical morbidity or mortality, not influenced by the type of conduit that is replaced. Therefore, the choice between homograft or Contegra® for right ventricle to pulmonary artery reconstruction should not be influenced by the future surgical risk during the replacement procedure.

Trial registration

NCT03048071. Registered 9 February 2017 (retrospectively registered).

Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases

AIM

The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA.

METHOD

This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up.

RESULTS

A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8-27]. The median duration of follow-up was 27 months (IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004-0.122).

CONCLUSION

Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.

Starr-Edwards aortic valve: 50+ years and still going strong: a case report

The advent of the Starr-Edwards mechanical valve marked the beginning of the modern era for heart valve replacement. Nowadays, this valve has been supplanted by lower profile bileaflet mechanical prostheses that are considered to have better haemodynamics, lesser risk of thrombo-embolic complications, and longer durability without structural prosthesis failure. These assumptions often lead physicians to face with the question of systematically replacing functional Starr-Edwards valves in patients undergoing redo operations on other valves. We report the case of a 67-year-old patient who recently underwent mitral valve replacement for symptomatic rheumatic valve disease with an excellent outcome. During the operation, the Starr-Edwards valve in the aortic position implanted 51 years earlier was found to still functioning normally hence was left in place, thereby breaking a new longevity record for a valve prosthesis.

Redo surgery for extensive chronic type A dissecting aneurysm following a Bentall operation

INTRODUCTION

Despite the technical improvements, redo surgery on the aortic root and arch is still associated with high morbidity and mortality due to the trauma of repeat open-heart surgery and technical complexity. We present the case of extended chronic type A dissecting aneurysm that developed after a Bentall operation, which was successfully treated by applying a modified long elephant trunk technique and surgical aortic fenestration.

CASE PRESENTATION

A 77-year-old man, who had previously undergone a Bentall procedure and an abdominal surgery, developed a type A aortic dissection. At presentation, the aortic dissection extended from the proximal arch to the terminal aorta, which were treated with an axillobifemoral bypass. After 8 months follow-up, the dissecting aneurysm had extended and the visceral arteries were perfused from the false lumen, without re-entry. We successfully repaired a complicated and extended chronic type A dissecting aneurysm by applying a modified long elephant trunk technique and surgical aortic fenestration. Postoperatively, the thoracic aorta false lumen was thromboexcluded, and the visceral perfusion was preserved through the fenestration.

CONCLUSION

In the treatment of complicated aortic arch diseases especially in redo cases, appropriate strategies are mandatory to achieve optimal outcomes. In the extended aortic dissection without the reentry for visceral perfusion, a primary entry closure may lead to visceral ischemia. Modified long elephant trunk technique combined with fenestration technique may be one of the useful techniques to treat the complicated aortic dissection extending to the terminal aorta.

Posterior leaflet reconstruction using autologous pericardium in mitral repair

A 75-year-old woman experienced recurrent mitral regurgitation caused mainly by a shrunken and tethered posterior mitral leaflet with a dilated left ventricle. Posterior leaflet motion was severely restricted. We successfully resolved the tethering and restored valve coaptation and competence using posterior leaflet reconstruction, which is a modified method of posterior leaflet augmentation using autologous pericardium. This technique can recover the posterior leaflet function by improving tissue volume and tethering.

A Rare and Late Complication After Left Ventricular Assist Device Explantation

Late complications can arise after explantation of a left ventricular assist device. We report the case of a patient who presented at the age of 19 years with peri-partum cardiomyopathy and was initially managed with a biventricular support device, which was subsequently upgraded to an ambulatory left ventricular assist device. This was successfully explanted after myocardial recovery via a minimally invasive approach 7 months later. The patient re-presented 5 years following explantation with hemoptysis. At redo sternotomy, a 10-cm remnant of the outflow graft was found to be eroding the surface of the right lung. The conduit was excised and the stump oversewn. Eleven months later, she presented again with hemoptysis, and a pseudo-aneurysm was identified on the computed tomography scan. She underwent urgent open repair with peripheral cannulation and deep hypothermic total circulatory arrest. The Dacron stump was found to be partially dehisced, leaving a 2-3 cm defect in the ascending aorta. The defect was repaired with a bovine pericardial patch. The patient made a good recovery and was successfully discharged.

Redo pull-through surgery in Hirschsprung disease: Short-term clinical outcome

INTRODUCTION

Although surgery is effective in most patients with Hirschsprung disease (HD), some have persistent obstructive symptoms. Additional medical treatment is generally sufficient, but a small fraction of these patients needs secondary surgery. Series on redo surgery are scarce. Aim of this study is to evaluate complications and clinical outcome of patients in need of redo surgery for HD.

MATERIALS AND METHODS

Sixteen patients underwent redo endorectal pull-through surgery in our center between 2007 and 2015. Medical records were reviewed and demographics, indication for redo surgery, surgical procedures, complications, and clinical outcome were scored.

RESULTS

The median age at the time of redo was 4.6years (range: 2months-21years). Median follow-up after redo was 3years (range: 9months-7years). Before redo surgery, all patients (100%) had obstructive symptoms, one patient had recurrent enterocolitis, and four patients were fecally incontinent despite adequate attempts of bowel management. Surgical procedure consisted of a transanal endorectal pull-through (TERPT) in all patients, with additional laparotomy in 7 (44%) and protective stoma in 8 patients (50%). Complications within 30days after redo surgery were anastomotic dehiscence (3; 19%), wound abscess (2; 13%), rectovaginal fistula (1; 7%) or enterocutaneous fistula (1; 7%). During follow-up, nine patients needed additional surgery, mainly to close the stoma. At final follow-up there were no patients with stenosis, obstructive symptoms, remaining rectovaginal fistula, or small bowel obstruction. Only one patient experienced enterocolitis. Six patients (43%) reported soiling or fecal incontinence.

CONCLUSION

TERPT for redo surgery for HD is effective in resolving sustained severe obstructive symptoms after primary surgery, but the outcome is complicated by a relatively high rate of soiling and fecal incontinence.

Redo coronary bypass grafting for congenital left main coronary atresia: a case report

BACKGROUND

Congenital left main coronary atresia is an extremely rare coronary anomaly. Long-term surgical outcomes and the optimal management strategies for recurrence of ischemia remain uncertain. Herein, we present a case involving successful redo coronary artery bypass grafting for unstable angina 27 years after the initial coronary artery bypass grafting for congenital left main coronary atresia.

CASE PRESENTATION

A 33-year-old woman was referred to our department with unstable angina. At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery and the obtuse marginal branch using saphenous vein grafting for left main coronary atresia. Although a coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch and a patent saphenous vein graft to the obtuse marginal branch, the left anterior descending artery was not being perfused by the grafts because of a disruption of blood flow to the left anterior descending artery from the left internal thoracic artery. Therefore, we performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch, which was to be connected to the left anterior descending artery, resulting in amelioration of the ischemia of the left anterior wall. The patient was discharged 10 days after the operation and has been in good health for over 3 years without recurrence of chest symptoms.

CONCLUSIONS

Coronary revascularization using a saphenous vein and left internal thoracic artery grafts is effective in achieving an adequate blood supply to the distal coronary arteries, and this effect can last for decades. However, careful follow-up is necessary because recurrent myocardial ischemia due to the development of a coronary artery occlusion may occur in adulthood.

Revision of Biliopancreatic Diversion for Side Effects or Insufficient Weight Loss: Codification of a New Procedure

PURPOSE

Addressing the problem of proctologic sequelae after Scopinaro's classical BPD, we elongated the common limb from 50 to 200 cm at the expense of the alimentary limb and simultaneously, with the aim of avoiding weight regain, reduced the gastric pouch from 500 to 40 ml. After increased experience with the new procedure, we observed a favourable tendency towards further weight loss. Thus, we subsequently extended the indication to the procedure to patients with unsatisfactory weight loss after Scopinaro's classical BPD (SBPD).

METHODS

We retrospectively reviewed our clinical experience with the new procedure.

RESULTS

From March 2008 to December 2014, 38 patients were submitted to the revisional procedure. The indication to surgical revision was proctologic in 26 patients and unsatisfactory weight loss in 12. After the revisional procedure, a significant reduction in bowel movements per day was observed, together with a significant reduction in body weight (from preoperative 87.1 ± 21 to 69.2 ± 13.5 kg at post-operative year 1 and 68.1 ± 11.9 kg at year 5; p < 0.001) and a parallel reduction in BMI (from preoperative 33.03 ± 7.6 to 26.8 ± 4.1 at post-operative year 1 and 26.9 ± 2.8 at year 5; p < 0.001). Mean excess BMI percent loss was 49.5 ± 94.6% at post-operative month 3, 76.51 ± 74.9% at year 1 and 76.2 ± 31.3% at year 5. Nutritional and metabolic parameters remained stable. Similar results were observed, analysing separately both groups of patients.

CONCLUSIONS

Our preliminary data suggest that the proposed procedure could represent a safe and effective revisional tool to treat invalidating proctologic sequelae after SBPD, or when weight loss may be deemed unsatisfactory.

Conversion of Open Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass: a Single-Center, Single-Surgeon Experience with 6 Years of Follow-up

BACKGROUND

The aim of this study is to assess feasibility, relief of complications and mid- and long-term weight loss results following the conversion of open vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Retrospective analysis of patients undergoing conversion of open VBG to RYGB (open and laparoscopic) between 1 April 2000 and 1 January 2015 was performed. (Post)operative complications were listed. Weight loss was assessed using excess weight (EW), percentage excess weight loss (%EWL) and body mass index (BMI) at 1-year intervals after surgery. Ideal weight was determined by recalculating individual lengths to a BMI of 25 kg/m(2). Application of polynomial regression models was used to quantify weight loss over time.

RESULTS

Ninety patients were identified in the database. Mean time between bariatric interventions was 9.6 years. Reasons for conversion were insufficient weight loss (82.2%) and outlet obstruction (17.8%). Early complications were encountered in eight patients of which three were reoperated. Patients who underwent conversion for inadequate weight loss after VBG were retrospectively analyzed regarding weight loss: 78.0% EWL after 1 year, 71.4% after 2 years, 62.1% after 3 years, 64.1% after 4 years, 70.2% after 5 years, and 68.9% after 6 years. Outlet obstruction was relieved in 94%. Patient satisfaction was assessed by telephone: 86.4% would repeat the conversion.

CONCLUSIONS

Conversion of open VBG to RYGB is feasible and safe and can be performed with an acceptable complication rate. It gives excellent weight loss results and relief of outlet obstruction.

Feasibility of the TAMIS technique for redo pelvic surgery

AIM

The aim of this study was to report on the feasibility of transanal minimally invasive surgery (TAMIS) as a novel approach to redo colorectal or ileoanal anastomoses.

METHODS

From October 2014, a prospective institutional database was created for all consecutive patients who underwent redo surgery by TAMIS for presacral sinus or anastomotic stenosis after low anterior resection or pouch-related problems following restorative proctocolectomy. Intra-operative feasibility, 30-day postoperative outcomes, intestinal continuity and complications after 6-month follow-up were evaluated.

RESULTS

Of 17 included patients, 14 underwent anastomotic reconstruction and three completion proctectomy. The median operation time was 265 min (range 201-413). A successful rendezvous with simultaneous transabdominal access was achieved in 15 patients, and the procedure was completed by TAMIS alone in two. Five patients were readmitted within 30 days (29 %). Two (14 %) patients developed an anastomotic leakage within 30 days and 4 (24 %) developed a pelvic abscess requiring reintervention. One patient developed an urethra stenosis and was managed with a suprapubic catheter. Median follow-up was 9 (6-15) months. Within 6-month follow-up, the redo-TAMIS 1 patient developed a delayed anastomotic leak and 1 patient had a recurrent presacral abscess after stoma closure. Intestinal continuity was reached in 71 % of the patients at 6-month follow-up.

CONCLUSION

TAMIS is a valuable approach in redo pelvic surgery, but is still associated with high complication rates related to the complexity of the underlying problem.

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.

Reusing the patent internal mammary artery as a conduit in redo coronary artery bypass surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with previous internal mammary artery/internal thoracic artery (ITA) grafts, can the internal mammary artery/ITA be reused/recycled in redo coronary artery bypass surgery? Fourteen papers were found using the reported search of which 10 represented the best evidence to answer the clinical question. There was variation in patient selection, the number of patients reported, outcome measures recorded, and methods and duration of follow-up. The results were mostly in favour of using a recycled ITA when it could be safely harvested. Most studies were retrospective. One large series of 60 patients who underwent redo coronary artery bypass grafting (CABG) using previously implanted ITAs had a mean time to reoperation of 117 ± 68 months. They reported no operative deaths; no patients required further or subsequent target vessel revascularization; 30-day mortality was 8.3% and myocardial infarction rate was 3%. Another two series of 16 and 12 patients underwent recycling of arterial grafts during coronary artery revascularization with no perioperative deaths in either. Postoperative angiography was performed in 10 patients in one of these studies, which showed excellent flow in all redone left internal thoracic artery (LITA) grafts. One study reported results from a prospective cohort of 9 patients who underwent redo coronary artery bypass grafting. Interval between operations was between 1 and 132 months. There was no perioperative mortality, but 1 patient required reintervention (to an interposition vein graft). A further study of 4 patients who underwent redo CABG using ITAs that were patent but with severe stenosis at the distal anastomosis had no mortality. Postoperative angiography showed patency of all grafts. There have also been 4 case reports on reusing the ITA/ITA in redo CABG with no damage to the reused LITA, no perioperative mortality and satisfactory follow-up at up to 29 months. Evidently, the recycled ITA can be used in redo coronary artery bypass grafting. Papers found were retrospective series or case reports. As such, there is no direct comparison in outcomes between the recycled ITA and first-time ITA harvest or any other conduit for CABG. In conclusion, we find that when it is possible to harvest a previously used ITA, studies have shown it to be a safe and viable conduit in redo CABG with good long-term outcomes.

Three-dimensional printed prototypes refine the anatomy of post-modified Norwood-1 complex aortic arch obstruction and allow presurgical simulation of the repair

Three-dimensional (3D) printed prototypes of malformed hearts have been used for education, communication, presurgical planning and simulation. We present a case of a 5-month old infant with complex obstruction at the neoaortic to transverse arch and descending aortic junction following the neonatal modified Norwood-1 procedure for hypoplastic left heart syndrome. Digital 3D models were created from a routine 64-slice CT dataset; then life-size solid and magnified hollow models were printed with a 3D printer. The solid model provided further insights into details of the anatomy, whereas the surgical approach and steps of the operation were simulated on the hollow model. Intraoperative assessment confirmed the anatomical accuracy of the 3D models. The operation was performed in accordance with preoperative simulation: sliding autologous flaps achieved relief of the obstruction without additional patching. Knowledge gained from the models fundamentally contributed to successful outcome and improved patient safety. This case study presents an effective use of 3D models in exploring complex spatial relationship at the aortic arch and in simulation-based planning of the operative procedure.

Balloon dilation of jejunal afferent loop functional stenosis following left hepatectomy and hepaticojejunostomy long time after pylorus-preserving pancreaticoduodenectomy: a case report

We present a rare case of functional stenosis of the jejunal loop following left hepatectomy and hepaticojejunostomy long after pylorus-preserving pancreaticoduodenectomy (PPPD), which was successfully managed by balloon dilation. A 70-year-old Korean man had undergone PPPD 6 years before due to 1.8 cm-sized distal bile duct cancer. Sudden onset of obstructive jaundice led to diagnosis of recurrent bile duct cancer mimicking perihilar cholangiocarcinoma of type IIIb. After left portal vein embolization, the patient underwent resection of the left liver and caudate lobe and remnant extrahepatic bile duct. The pre-existing jejunal loop and choledochojejunostomy site were used again for new hepaticojejunostomy. The patient recovered uneventfully, but clamping of the percutaneous transhepatic biliary drainage (PTBD) tube resulted in cholangitis. Biliary imaging studies revealed that biliary passage into the afferent jejunal limb was significantly impaired. We performed balloon dilation of the afferent jejunal loop by using a 20 mm-wide balloon. Follow-up hepatobiliary scintigraphy showed gradual improvement in biliary excretion and the PTBD tube was removed at 1 month after balloon dilation. This very unusual condition was regarded as disuse atrophy of the jejunal loop, which was successfully managed by balloon dilation and intraluminal keeping of a large-bore PTBD tube for 1 month.

[Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]

INTRODUCTION

Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.

PATIENTS AND METHODS

This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.

RESULTS

The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.

CONCLUSION

Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

Hybrid intraoperative pulmonary artery stenting in redo congenital cardiac surgeries

Objective

Reconstruction of branch pulmonary arteries (PAs) can be challenging in redo congenital heart surgeries. Treatment options like percutaneous stent implantation and surgical patch angioplasty may yield suboptimal results. We present our experience with hybrid intraoperative stenting which may be an effective alternative option.

Methods

We retrospectively analyzed data of all patients with PA stenosis who underwent intraoperative PA branch stenting in our institution between January 2011 and December 2012.

Results

Ten patients [6 females, median age 10 (1.4 to 37) years], underwent hybrid stenting of the PA. Primary cardiac diagnoses were pulmonary atresia with ventricular septal defect (VSD) in three patients, pulmonary atresia with intact ventricular septum in two, Tetralogy of Fallot (TOF) in one, Double outlet right ventricle (DORV) with pulmonary stenosis (PS) in one, complex single ventricle in two and VSD with bilateral branch PA stenosis in one patient. Concomitant surgeries were revision/reconstruction of RV-PA conduit in 4, Fontan completion in 4, repair of TOF with conduit placement in 1 and VSD closure in 1 patient. The left PA was stented in 7, the right in 2 and both in 1, with a total of 11 stents. There were no complications related to stent implantation. Two early postoperative deaths were unrelated to stent implantation. At mean follow-up period of 14.8 (12–26) months, stent position and patency were satisfactory in all survivors. None of them needed repeat dilatation or surgical reintervention.

Conclusion

Hybrid stenting of branch PA is a safe and effective option for PA reconstruction in redo cardiac surgeries. With meticulous planning, it can be safely performed without fluoroscopy.

The problematic Soave cuff in Hirschsprung disease: manifestations and treatment

PURPOSE

Following a Soave pull-through for Hirschsprung disease (HD), some children struggle with obstructive symptoms. We hypothesized that these symptoms could result from a functional obstruction of the pull through caused by the Soave cuff, and that cuff resection might improve bowel emptying.

METHODS

We reviewed patients referred to our center from 2008 to 2012 with obstructive problems following a Soave pull-through for HD (CCHMC IRB # 2011-2019). Only patients with an obstructing Soave cuff were analyzed. Patients with other reasons for obstruction (anastomotic stricture, transition zone, aganglionic segment) were excluded.

RESULTS

Thirty-six patients underwent reoperation at our center for obstructive symptoms after an initial Soave pull-through. Seventeen of these patients had a Soave cuff only as the potential source of obstruction. Pre-operative symptoms included enterocolitis (10), constipation (6), and failure to thrive (1). Nine patients (53%) required irrigations to manage distension or enterocolitis pre-operatively. 14/17 patients (82%) had a palpable cuff on rectal exam. Eight patients (47%) had radiographic evidence of a cuff demonstrated by distal narrowing (4) or a prominent presacral space (4). Four children (23%) underwent excision of the cuff only. Thirteen (76%) had removal of the cuff and proximally dilated colon [(average length 7.2cm) (12 performed transanally, and five needed laparotomy as well.)] Post-operatively, episodes of enterocolitis were reduced to zero, and need for irrigation to treat distension was reduced by 50%. Nine patients have voluntary bowel movements, and five are clean on enemas. 3/6 patients with pre-operative constipation or impaction now empty without enemas. (Follow up 1-17months, mean 7months.)

CONCLUSIONS

Recurrent enterocolitis, constipation, or failure to thrive can indicate a functional obstruction due to a Soave cuff when no other pathologic cause exists. Physical exam or contrast enema can identify a problematic cuff. Reoperation with cuff resection can dramatically improve bowel emptying.