Surgical management of liver diseases invading the hepatocaval confluence based on IH classification: The surgical guideline in our center

AIM To investigate the short-term outcomes and risk factors indicating postoperative death of patients with lesions adjacent to the hepatocaval confluence.METHODS We retrospectively analyzed 54 consecutive patients who underwent hepatectomy combined with inferior vena cava(IVC)and/or hepatic vein reconstruction(HVR)from January 2012 to January 2016 at our liver surgery center.The patients were divided into5 groups according to the range of IVC and hepatic vein involvement.The patient details,indications for surgery,operative techniques,intra-and postoperative outcomes were compared among the 5 groups.Univariate and multivariate analyses were performed to explore factors predictive of overall operative death.RESULTS IVC replacement was carried out in 37(68.5%)patients and HVR in 17(31.5%)patients.Type I2H2 had the longest operative blood loss,operative duration and overall liver ischemic time(all,p0.05).Three patients of Type I3H1 with totally occluded IVC did not need IVC reconstruction.Total postoperative morbidity rate was40.7%(22 patients)and the operative mortality rate was 16.7%(9 patients).Factors predictive of operative death included IVC replacement(p=0.048),duration of liver ischemia(p=0.005)and preoperative liver function being Child-pugh B(p=0.025). CONCLUSION IVC replacement,duration of liver ischemia and preoperative poor liver function were risk factors predictive of postoperative death.We should be cautious about IVC replacement,especially in Type I2H2.For Type I3H1,it was unnecessary to replace IVC when the collateral circulation was established.     

Surgical outcomes of hepatocellular carcinoma invading hepatocaval conlfuence

BACKGROUND: Combined liver and inferior vena cava (IVC) resection followed by IVC and/or hepatic vein reconstruc-tion (HVR) is a curative operation for selected patients with hepatocellular carcinoma (HCC) invading the hepatocaval conlfuence. The present study aimed to elucidate the prog-nostic factors for patients with HCC invading the hepatocaval conlfuence.
METHODS: Forty-two consecutive patients underwent hepa-tectomy, combined with IVC replacement and/or HVR for HCC between January 2009 and December 2014 were included in this study. The cases were divided into three groups based on the surgical approaches of HVR: group 1 (n=13), tumor in-vaded the hepatocaval conlfuence but with one or two hepatic veins intact in the residual liver, thus only the replacement of IVC, not HVR; group 2 (n=23), the hepatic vein of the residual liver was also partially invaded, and the hepatic vein defect was repaired with patches locally; group 3 (n=6), three hepatic veins at the hepatocaval conlfuence were inifltrated, and the hepatic vein remnant was re-implanted onto the side of the tube graft. The patient characteristics, intra- and postopera-tive results, and long-term overall survival were compared among the three groups. The survival-related factors were analyzed by univariate and multivariate analysis.
RESULTS: The group 1 had higher preoperative alpha-fetopro-tein level (P<0.001), shorter operation time, hepatic ischemic time and hospital stay compared with groups 2 and 3 (P<0.05). The 1-, 3-, and 4-year overall survival rates of group 1 were 84.6%, 23.1% and 23.1%, respectively; group 2 were 78.3%, 8.7% and 8.7% respectively and group 3 were 83.3%, 0 and 0, respectively. The multivariate analysis showed that the inde-pendent poor prognostic factors of overall survival were pre-operative higher HBV DNA level (≥103 copies/mL;P=0.001), tumor size (≥9 cm;P<0.0001), age (≥60 years;P=0.010) and underwent HVR (P<0.0001).
CONCLUSIONS: Patients with reconstructing hepatic vein with patches locally (group 2) or to the artiifcial graft (group 3) had worse long-term survival than those without HVR (group 1). HVR was one of the unfavorable prognostic factors of overall survival.     

Factors influencing outcome after emergency surgical repair of acute type A aortic dissection.

OBJECTIVE: We retrospectively reviewed our more recent experience with acute type A aortic dissection in order to identify possible risk factors influencing current surgical results. METHODS: Between January 1990 and January 1998, 122 patients (86 males and 36 females; mean age 60 +/- 12 years) underwent emergency repair of acute type A aortic dissection using a standard surgical approach. Seventy-four (61%) patients required isolated replacement of the dissected ascending aorta, 27 (22%) required additional replacement of the aortic arch and 21 (17%) required total aortic root replacement. Surgical outcome was evaluated in terms of operative mortality and morbidity. Results of patients presenting with preoperative complications (Group C) (i.e. cardiac tamponade, cerebral stroke, cardiogenic shock, acute myocardial infarction, anuria or visceral ischemia) were compared with those of uncomplications cases (Group U) and with a calculated risk of expected operative mortality (EOM-rate) based on an analysis of each patient set of preoperative risk factors. Sixteen preoperative and 18 perioperative variables were also analyzed to identify conditions influencing morbidity and mortality. RESULTS: Fifty-seven patients (47%) presented with preoperative complications (Group C) and 65 (53%) did not (Group U). Overall operative mortality was 22% (27 patients). Mortality within subgroups was 40 and 6% for complicated and uncomplications cases, respectively (p < 0.001). The 85% of the overall mortality occurred in Group C patients. During the experience, the operative mortality rate actually observed ranged from 0 to 38% and was similar to the calculated expected risk, thus proving a direct relationship with the amount of complicated cases operated on each year. Multivariate analysis revealed that older age and hemopericardium significantly increased the risk of operative death, while male gender, preoperative complications, postoperative bleeding, duration of circulatory arrest and aortic cross-clamp time significantly predicted morbidity (p = 0.02). CONCLUSIONS: Current results of emergency repair of acute type A aortic dissection are strictly dependent on the number of complicated cases referred for operation. Earlier diagnosis and prompt referral before development of preoperative complications appear essential to improve surgical results.     

Ex Vivo Liver Resection Followed by Autotransplantation to a Patient With Advanced Alveolar Echinococcosis With a Replacement of the Retrohepatic Inferior Vena Cava Using Autogenous Vein Grafting: A Case Report and Literature Review

Alveolar echinococcosis (AE) of the liver is a rare disease. In advanced cases of this parasitic disease, the inferior vena cava (IVC) can be invaded; in these cases, the optimal treatment is liver transplantation and replacement of the IVC. Considering the donor shortage and the drawbacks of immunosuppressive therapy, ex vivo liver resection followed by autotransplantation may be the first choice for these patients.We report the first case of advanced AE successfully treated by an ex vivo liver resection, followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting. This graft included the following regions: the bilateral great saphenous vein, part of the retrohepatic inferior vena and the middle hepatic vein with no invasion, the inferior mesenteric vein, and part of the side wall of the infrahepatic vena cava. This patient had an uneventful postoperative recovery; currently, she has been enjoying a normal life and is 12 months postoperative with no immunosuppressive therapy or AE recurrence.In conclusion, ex vivo liver resection followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting might be a useful surgical practice for advanced AE.     

Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection

AIM: To evaluate the efficacy of technical modifications of total hepatic vascular exclusion(THVE) for hepatectomy involving inferior vena cava(IVC).METHODS: Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8(2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage.RESULTS: Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra- to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technicalmodifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication(i.e., Clavien-Dindo grade of Ⅲ or more).CONCLUSION: The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.     

Re-do aortic valve replacement: does a previous homograft influence the operative outcome?

BACKGROUND AND AIM OF THE STUDY: Late reoperation for failed aortic homograft is widely regarded as a high-risk procedure. A review is presented of the authors' experience of redo-aortic valve replacement (re-do AVR) examining factors which affect, and whether a previous aortic homograft replacement influences, operative outcome. METHODS: A retrospective review was conducted of consecutive re-do AVR performed at the authors' institution between 1998 and 2002. RESULTS: During the study period, 178 patients (125 males, 53 females; mean age 52.4 years; range: 16-85 years) underwent re-do AVR. The group included first-time (72%), second-time (20%), and more than third-time re-do AVR (8%). Forty-six patients (26%) received a homograft (group I), and 132 (74%) a stented biological/mechanical valve (group II). The two groups were matched for baseline clinical characteristics and operative variables. The type of explanted valve, and preoperative and operative variables, were analyzed using univariate and multivariate models. Primary outcome was defined as 30-day mortality, and secondary outcome as postoperative complications. The overall 30-day mortality was 12.3%, but was much lower (4.5%) for elective isolated and multiple re-do AVR. Univariate analysis showed significant predictors of 30-day mortality to be: age >65 years (p = 0.02); renal dysfunction (p = 0.005); preoperative unstable status (p = 0.03); preoperative NYHA class III/IV dyspnea (p = 0.02); non-elective operation (p = 0.01); preoperative arrhythmia (p = 0.005); history of chronic obstructive pulmonary disease (COPD) (p = 0.002); preoperative cardiogenic shock (p = 0.03); impaired left ventricular ejection fraction (LVEF) <50% (p = 0.04); and other valvular procedure(s) performed simultaneously (p = 0.01). In a multivariate analysis, the only significant predictors of 30-day mortality were impaired LVEF (p = 0.03) and a history of COPD (p = 0.007). Group I patients had a significantly shorter mean hospital stay (10.2+/-5.9 versus 14.1+/-12.5 days; p = 0.009), but there were no significant differences between groups in terms of postoperative complications. CONCLUSION: A previous aortic homograft replacement was not associated with an increased operative risk at the time of re-do AVR. A history was COPD was an important predictor of 30-day mortality, and this finding requires further investigation.     

Safety of portal vein resection using centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein

BACKGROUND/AIMS: To achieve complete resection of pancreatic cancer, portal vein resection has been performed with increasing frequency at the time of pancreaticoduodenal resection (pancreaticoduodenectomy or total pancreatectomy). In the meantime, visceral congestion and liver ischemia are of great concern during the procedure. We investigated safety of portal vein resection using a centrifugal pump-assisted bypass between the superior mesenteric vein and the umbilical vein. METHODOLOGY: A retrospective comparison was performed in 49 consecutive patients who underwent pancreatoduodenal resection with or without portal vein resection using the bypass for pancreatic cancer. Twenty-two patients underwent portal vein resection using the bypass (group 1). The other 27 patients undergoing pancreatoduodenal resection without portal vein resection comprise the control group (group 2). RESULTS: Total operative time was 756 +/- 159 min and 526 +/- 109 min (p<0.001) and median blood loss was 2090 mL and 1200 mL in groups 1 and 2, respectively. However, the centrifugal pump-assisted bypass allowed stable bypass flow, and neither intestinal edema nor ischemic change of the liver was observed during portal vein resection and the subsequent reconstruction. Postoperatively, the peak postoperative AST, ALT and total bilirubin levels showed no significant difference and postoperative day of starting a liquid diet was similar between the groups (9.0 +/- 5.4 vs. 9.8 +/- 3.8 days, p=0.48). In addition, the rates of morbidity (55% vs. 48%) including biliary and pancreatic leak as well as mortality (9% vs. 4%) did not significantly differ between the 2 groups. CONCLUSIONS: The centrifugal pump-assisted bypass may be useful to prevent hepatic ischemia and visceral congestion during portal vein resection procedures, resulting in similar postoperative outcomes to the control after pancreaticoduodenal resection for pancreatic cancer.     

Preoperative optimization of the liver for resection in patients with hilar cholangiocarcinoma

Optimal preoperative preparation is required to reduce operative risk of major hepatectomy in jaundiced patients. The role of percutaneous preoperative biliary drainage (PTBD) is, apart from assessment of intraductal extent of the tumour, to allow contralateral hypertrophy if portal vein embolization (PVE) is performed. The increased use of PTBD over a 10-year period was associated with increased resectability rate in this study, while PTBD-related complications decreased. Efficient hypertrophy of the future liver remnant (FLR) requires biliary drainage to reduce the risk of postoperative liver dysfunction. Preoperative staging laparoscopy avoided unnecessary surgical exploration in 20% of patients previously considered resectable.     

Perioperative myocardial ischemia in patients undergoing noncardiac surgery--I: Incidence and severity during the 4 day perioperative period. The Study of Perioperative Ischemia (SPI) Research Group

To determine the incidence and characteristics of perioperative myocardial ischemia, the electrocardiographic (ECG) changes consistent with ischemia during the 4 day perioperative period were documented and characterized in 100 patients with or at risk for coronary artery disease undergoing noncardiac surgery. Using continuous two channel ECG monitoring (leads CC5 and CM5), the frequency and severity of ECG ischemic episodes defined by ST segment depression greater than or equal to 1 mm or elevation greater than or equal to 2 mm during the preoperative (up to 2 days), intraoperative and early postoperative (first 2 days) periods were compared. Preoperatively, 28 patients (28%) exhibited 105 episodes of ischemia; intraoperatively, 27 patients exhibited 39 episodes and postoperatively, 42 patients exhibited 187 episodes. There was no difference between the pre- and intraoperative episode characteristics. However, postoperative ischemic episodes were the most severe. The mean ST change was 1.5, 2 and 2.6 mm for pre-, intra- and postoperative episodes, respectively (p less than 0.0001 postoperative versus pre- or intraoperative); duration of ischemic episodes was 69, 45 and 207 min, respectively (p less than 0.005 postoperative versus preoperative, p less than 0.001 versus intraoperative) and area under the ST curve was 88, 74 and 383 mm.min (p less than 0.009 postoperative versus preoperative, p less than 0.005 versus intraoperative). Ninety-four percent of all postoperative ischemic episodes were silent; 80% of all episodes occurred without acute change (+/- 20% of control) in heart rate and 77% of intraoperative episodes occurred without acute change in blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relation between peri-operative antithrombin activity and deep vein thrombosis after elective hip replacement surgery

BACKGROUND: The purpose of the study was to evaluate whether the postoperative depletion or the preoperative antithrombin (AT) activity is related to the occurrence of deep vein thrombosis (DVT) in patients receiving low-molecular-weight heparin for DVT prevention after elective hip replacement surgery. PATIENTS AND METHODS: In 93 patients AT-activity and standard laboratory parameter were determined on the preoperative day and daily for one week after operation. Furthermore, a color-coded compression sonography was performed before and 8-10 days after surgery. The amount of blood loss and blood transfusions was evaluated. Patients were divided into two groups in respect to the occurrence of a postoperative DVT. RESULTS: The overall incidence of DVT was 8.6% (n = 8). Patients with DVT had a significantly lower preoperative AT-activity (80.6 +/- 3.31%) compared to those without DVT (98.1 +/- 1.12%, p < 0.001), however, without being predictive for DVT (positive predictive value 0.71). There was no association between postoperative fall of AT, the lowest postoperative AT activity, blood loss or blood substitution and DVT. CONCLUSIONS: It has to be expected that a small fraction of patients for elective hip surgery present with AT-activity levels possibly being insufficient for a therapeutic effect of low-molecular-weight heparin even preoperatively. Those patients are subject to a significant higher risk of DVT postoperatively.     

Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy

BACKGROUND: The aim of this study was to compare the early postoperative results of thymectomy operations after partial sternotomy and videothoracoscopy for myasthenia gravis. METHODS: A total of 51 thymectomy operations were reviewed. The surgical procedure was simple thymectomy with partial sternotomy in the first 19 patients (Group I) and videothoracoscopic thymectomy (Group II) in the remaining patients. Both groups were compared in terms of preoperative data (age, gender, classification, duration of disease, medications), operative data (operation time, the mean amount of drainage, the duration of chest tube drainage), and postoperative data (duration of hospital stay, complications and pain). RESULTS: Groups were statistically uniform in terms of preoperative and operative data. Statistically significant differences were noted for the duration of chest tube drainage (48.8 vs. 29.8 hours, p < 0.001), the amount of drainage (264.4 vs. 178.6 ml, p = 0.001), the length of hospital stay (5.6 vs. 2.3 days, p = 0.000), and the visual analogue scale score (4.8 vs. 3.1, p < 0.001). CONCLUSIONS: Thymectomy with videothoracoscopic surgery demonstrated a more comfortable and faster recovery period without deterioration in myasthenic status.     

Natural History of Kawashima Palliation in Single-Ventricle and Interrupted Inferior Vena Cava Heart Disease in China 11 Years Result

Background: The long-term outcomes of patients treated with a Kawashima procedure and keeping the antegrade pulmonary blood flow (AnPBF) in single-ventricle (SV) and interrupted inferior vena cava (IVC) heart disease is still uncertain as yet. Methods: We investigated 18 patients who underwent the Kawashima procedure with SV physiology and an interrupted IVC between January 2009 and June 2018, perioperative, operative and postoperative characteristics were recorded. Results: A total of 18 patients underwent the Kawashima procedure at a median age of 2.7 years (range 0.5–24.7 years), of which 12 (66.7%) were male and 6 (33.3%) were female. The mean saturation was 76.2 ± 8.5% in preoperative period and 94.2 ± 2.2% in postoperative period. All patients had kept AnPBF. The median duration of mechanical ventilation was 12 h (range 2.5–22.5 h) and the median duration of pleural drainage was 5 days (range 2–27 days). The median hospital stay was 9 days (range 6–70 days). There was no operative death and no mortality was seen in early postoperative period. Follow-up was 100% completed, with an average follow-up period of 6.1 ± 2.7 years (range 1–11 years). 4 patients died during the follow-up. The overall 5 and 10 years’ survival rates estimated by Kaplan-Meier method were 88% and 68%, respectively. Although there were no significant differences in the duration of postoperative follow-up between the death group and the survival group (p > 0.05), the major systemic ventricular end-diastolic diameter (SVEDD) (p = 0.018) and the degree of AVVR (p = 0.001) showed significant difference between the two groups. The diameters of main pulmonary artery showed significant growth in both the death group (p = 0.015) and the survival group (p = 0.012) over time. SVEDD had no significant increase in the survival group (p = 0.665) but was significantly larger in the death group (p = 0.014). Multivariable risk factors of late mortality in patients treated with Kawashima procedure were follow-up AVVR (p = 0.044; HR: 3.124; 95%CI: 1.030–9.473) and SVEDD (p = 0.031; HR: 9.766; 95%CI: 1.226–77.8). 14 patients (100%) were all in New York Heart Association (NYHA) functional class I and the mean saturation was 93 ± 2% at last follow-up. Only one patient finished Fontan completion. Conclusions: The Kawashima procedure with AnPBF can be safely performed with acceptable early and long outcomes. Although some previous studies have shown the risk of pulmonary arteriovenous malformations (PAVMS) after Kawashima procedure in the mid- and long-term, our findings are in contradiction with it. No PAVMs occurred in all the survivors. Kawashima procedure with open AnPBF may be a good option for unsuitable Fontan candidates.     

Cardiac factors predictive of 10-year survival after coronary surgery]

Although the predictive factors of postoperative mortality after coronary artery surgery are well known, those predictive of long-term survival have received less attention. This study reviews the outcome of a group of 480 patients between 50 and 65 years of age, operated between 1984 and 1986. The patients were classified in two groups according to the presence or absence of internal mammary artery bypass grafts: Group I (304 patients with saphenous vein bypass grafts alone) and group II (176 patients with an internal mammary artery +/- saphenous vein bypass grafts). The long-term results were assessed according to 3 criteria: isolated cardiac mortality: cardiac mortality associated with a repeat revascularisation procedure and cardiac mortality associated with reoperation or recurrence of angina. Cardiac survival at 10 years was significantly better after internal mammary-LAD bypass: 91.4% (CI 87.1-95.1) than after saphenous vein bypass grafting alone: 79.6% (CI 74.8-84.4) (p = 0.012). Univariate analysis identified the following poor predictive factors: three vessel disease (p = 0.03), preoperative left ventricular dysfunction with an ejection fraction inferior to 45% (p = 0.0001), incomplete revascularisation (p = 0.0003), use of venous bypass graft alone (p < 0.014) and perioperative infarction (p = 0.0254). For each criterion of survival (cardiac isolated or associated with a new revascularisation and/or recurrence of angina), multivariate analysis identified three independent predictive factors of long-term extramortality: not using internal mammary artery-LAD bypass graft, incomplete revascularisation and preoperative hypertension. This study confirms the beneficial effects of internal mammary-LAD artery grafting on long-term survival after coronary artery surgery, and also demonstrates the prejudicial effects of hypertension.     

Risk of reoperation for structural failure of aortic and mitral tissue valves

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the risk of reoperation for patients with a failing stented tissue valve. METHODS: Between 1980 and 1999, 259 patients (118 males, 141 females; mean age 60.1+/-15.4 years) underwent redo valve replacement to replace a failing stented tissue valve. Of these patients, 94 (36.3%) underwent redo aortic valve replacement (AVR), 105 (40.5%) redo mitral valve replacement (MVR), and 60 (23.2%) redo aortic and mitral valve replacement (DVR). Twenty patients (7.7%) had previous coronary artery bypass grafting (CABG); further CABG were performed in 32 cases (12.4%). Preoperatively, 216 patients (83.3%) were in NYHA functional class III or IV. RESULTS: The early mortality was (6.5%; n = 17), including three patients who had AVR, five DVR, and nine MVR. A higher preoperative NHYA status (p <0.0004) and emergency surgery (p <0.0001) were significantly associated with an increased risk of operative death (univariate analysis). Age at surgery (p = 0.45), previous CABG (p = 0.45), position of the valve replaced (p = 0.2), type of implant (p = 0.06) and presence of coronary artery disease (p = 0.51) were not associated with a significant risk of operative mortality. Including those patients who died, 88 (34.0%) experienced a peri- or postoperative complication, seven of which (2.7%) were permanent. CONCLUSION: A failing tissue valve can be replaced, with acceptable operative mortality and morbidity. The choice of valve is a balance of its advantages and disadvantages, and these must be discussed with the patient. It appears, however, that the trend towards reducing the age at which tissue valve implantation is performed may be justified.     

Aortic valve replacement and combined aortic valve replacement and coronary artery bypass grafting: predicting high risk groups

To determine which groups of patients are at highest risk for operative or late mortality, 259 consecutive patients who underwent operation between 1978 and 1984 were studied; 170 underwent aortic valve replacement and 89 underwent aortic valve replacement combined with coronary artery bypass grafting. Multivariate analysis of risk factors selected emergency operation and patient age older than 70 years as the strongest predictors for operative death. Although patients having aortic valve replacement and coronary artery bypass grafting had a higher operative mortality rate (13.5 versus 3.5%), the combined operation had no independent predictive effect on early or late results. At a mean follow-up time of 48 months after surgery, 72% of the survivors of operation were living, 10% were lost to follow-up and 18% were dead. Seventy-seven percent of long-term survivors were in New York Heart Association functional class I or II. The incidence of thromboembolism, paravalvular leak, bacterial endocarditis and hemorrhage each occurred at a rate of less than 1% per patient-year. The factors associated with late death were preoperative age, male sex, left ventricular end-diastolic pressure, cardiac index and functional class. Despite an increase in operative mortality, patients undergoing emergency operation were not at higher risk of late death. Operative mortality is concentrated among several high risk groups. For patients undergoing elective operation, operative mortality is low, especially if the patient is less than 70 years old. Late results are good for all groups of patients undergoing operation, including those who are at greater risk of dying at operation.     

Surgical complications and mortality in octogenarian patients undergoing revascularization surgery]

Our objective was to identify preoperative, operative and postoperative factors associated with complications and mortality in patients equal to or greater than 70 years of age with coronary artery disease treated with coronary bypass surgery. From january 1990 to june 1994 of those that underwent 37 coronary artery bypass surgery. 32 were men (86.5%) and five women (13.5%). History of cardiovascular disease, diabetes mellitus, systemic arterial hypertension, pulmonary disease, hypercholesterolemia, renal function, and severity of coronary artery disease were considered. Also analysed were aortic clamp and cardiopulmonary bypass time, number and type of grafts. Use of intraaortic balloon counterpulsation, inotropic drugs, ventilatory support, hemorrhage, infection, renal and liver failure, neurological, rhythm and conduction abnormalities and myocardial ischemia were also considered. Identified risk factors: diabetes mellitus, (p = 0.028), ejection fraction < 30% (p = 0.023), ventricular wall motion abnormalities (p < 0.05), aortic clamp > 60 minutes (p = 0.026), cardiopulmonary bypass < 120 minutes (p = 0.022), reverse saphenous vein grafts (p = 0.014), prolonged ventilatory support, inotropic drugs and intraaortic balloon counterpulsation. CONCLUSIONS: Surgery should be reserved for patients with at least three vessel or left main coronary artery disease or proximal lesion of the left anterior descending artery with severe ischemia, deteriorated myocardial function and angina with no response to medical treatment; age of the patient is not a contraindication.     

Postoperative complications in patients with portal vein thrombosis after liver transplantation： Evaluation with Doppler ultrasonography

AIM: To study the postoperative complications in patients with preoperative portal vein thrombosis (PVT) undergoing liver transplantation (LT) and to evaluate the complications with Doppler ultrasonography. METHODS: Retrospective studies were performed on 284 patients undergoing LT (286 LT) with respect to pre- and postoperative clinical data and Doppler ultrasonography. According to the presence and grade of preoperative PVT, 286 LTs were divided into three groups: complete PVT (c-PVT), partial PVT (p-PVT) and non-PVT, with 22, 30 and 234 LTs, respectively. Analyses were carried out to compare the incidence of early postoperative complications. RESULTS: PVT, inferior vena cava (IVC) thrombosis, hepatic artery thrombosis (HAT) and biliary complications were found postoperatively. All complications were detected by routine Doppler ultrasonography and diagnoses made by ultrasound were confirmed by clinical data or/and other imaging studies. Nine out of 286 LTs had postoperative PVT. The incidence of the c-PVT group was 22.7%, which was higher than that of the p-PVT group (3.3%, P < 0.05) and non-PVT group (1.3%, P < 0.005). No difference was found between the p-PVT and non-PVT groups (P > 0.25). Of the 9 cases with postoperative PVT, recanalizations were achieved in 7 cases after anticoagulation under the guidance of ultrasound, 1 case received portal vein thrombectomy and 1 case died of acute injection. Ten LTs had postoperative IVC thrombosis. The c-PVT group had a higher incidence of IVC thrombosis than the non-PVT group (9.1% vs 2.6%, P < 0.05); no significant difference was found between either the c-PVT and p-PVT groups (9.1% vs 6.7%, P > 0.5) or between the p-PVT and non-PVT groups (P > 0.25). Nine cases with IVC thrombosis were cured by anticoagulation under the guidance of ultrasound, and 1 case gained natural cure without any medical treatment after 2 mo. HAT was found in 2 non-PVT cases, giving a rate of 0.7% among 286 LTs. Biliary complications were seen in 12 LTs. The incidence of biliary complications in the c-PVT, p-PVT and non-PVT groups was 9.1%, 3.3% and 4.3%, respectively (P > 0.25 for all), among which 2 stenosis led retransplantations and others were controlled by relative therapy. CONCLUSION: C-PVT patients tend to have a higher incidence of PVT and IVC thrombosis than non-PVT patients after LT. The incidence of postoperative complications in p-PVT patients does not differ from that of non-PVT patients. A relatively low incidence of HAT was seen in our study. Doppler ultrasonography is a convenient and efficient method for detecting posttransplant complications and plays an important role in guiding treatment.     

Cardiac troponin I after heart surgery corrective operation in infancy and childhood

BACKGROUND: Perioperative myocardial damage is an important determinant for postoperative cardiac function and recovery. Cardiac troponin I (cTNI) is a specific marker for myocardial damage. The aim of our study was to evaluate pre- and postoperative cTNI levels, the pattern of elevation in the first four postoperative days and the prognostic value after pediatric cardiac operation. METHODS: Cardiac troponin I levels were measured in 115 children mean age 36 +/- 45 months (range 4 days to 189 months) undergoing elective operation of a congenital heart defect. Routine measurements were made preoperatively, immediately after cardiopulmonary bypass and serially 8, 18, 42, 90, 138 hours thereafter. Data from 13 patients undergoing surgery without cardiopulmonary bypass served as controls. Postoperative cTNI levels were correlated with intra- and postoperative parameters (such as duration of aortic crossclamping, cardiopulmonary bypass time and need for postoperative inotropic support). RESULTS: All preoperative cTNI levels were in the normal range. Postoperatively, the highest median cTNI levels were found in patients after repair of tetralogy of Fallot (TOF), atrioventricular septal defect (AVSD) and implantation of a homo- or xenograft. Postoperative cTNI levels correlated significantly with duration of cardiopulmonary bypass and aortic crossclamping, operative approach (ventriculotomy versus atriotomy) and inotropic support (p < 0.0001). Peak cTNI levels were found immediately after surgery in 77.4% of our patients, 8 hours postoperative in 13.9% and at 18 hours after the surgery in 5.2% of the patients. In three children cTNI continued to increase; a secondary increase was found in one patient. Two of these children died, two had a prolonged postoperative recovery. CONCLUSION: The postoperative level of cardiac troponin I could be used as a marker of perioperative myocardial injury caused by ischemia and operative trauma. Peak levels usually could be obtained immediately after surgery, but a further increase of cTNI during the following 18 hours may occur and is not necessarily related to impaired recovery. However still increasing cTNI levels after 18 hours postoperatively and a secondary increase as well may be used as indicators of poor outcome.     

Mitral valve replacement for isolated mitral regurgitation: Analysis of clinical course and late postoperative left ventricular ejection fraction

One hundred five patients underwent mitral valve replacement for relief of isolated mitral regurgitation between 1974 and 1979. There were 4 in-hospital deaths (4 percent) and 12 late deaths giving an 82 percent predicted 5 year survival rate. An age of 60 years or more at the time of surgery and a preoperative left ventricular ejection fraction of less than 0.40 were the only variables that correlated with decreased survival at 3 to 5 years after operation (p <0.05). Postoperatively, 87 (98 percent) of 89 long-term survivors were in New York Heart Association functional class I or II (68 in class I and 19 in class II). Survival did not differ between patients with porcine versus mechanical valve replacement, but patients with a mechanical valve had a greater incidence of postoperative cerebrovascular accident ($\text{8.6}\text{100}$ patient years) than did patients with a porcine valve (2.8/100 patient years) (p <0.002). Ejection fraction at rest was determined with multigated cardiac imaging 12 to 75 months post-operatively in 34 of 89 long-term survivors. The mean preoperative ejection fraction was 0.62 ± 0.09 (mean ± 1 standard deviation) and the mean postoperative ejection fraction was 0.50 ± 0.15 (p <0.001). When the preoperative value was compared with the postoperative value at rest the ejection fraction increased by 0.10 or more in 1 patient (3 percent), remained within ±0.09 of the preoperative value in 12 patients (35 percent) and decreased by 0.10 or greater in 21 patients (62 percent). Sixteen (94 percent) of 17 patients whose postoperative ejection fraction was greater than 0.50 were in functional class I postoperatively compared with 11 (65 percent) of 17 patients whose postoperative ejection fraction was 0.50 or less (p <0.05). No preoperative factor, including preoperative ejection fraction or cardiothoracic ratio, predicted the postoperative ejection fraction. A postoperative exercise ejection fraction was obtained in 29 patients, and an abnormal ejection fraction change with exercise (increase <0.05) was observed in 20 patients (69 percent). Patient age at the time of study correlated inversely with the change in ejection fraction from rest to exercise; no other variables were predictive.It is concluded that, in addition to age, only preoperative left ventricular function as measured by ejection fraction predicts survival in patients undergoing mitral valve replacement for isolated mitral regurgitation. Clinical recovery is good even though the majority of long-term survivors have a postoperative decrease in ejection fraction.     

Combined resection of the portal vein for pancreatic cancer: preoperative diagnosis of invasion by portography and prognosis

BACKGROUND/AIMS: Pancreatic cancer often invades the portal vein because of the anatomical position. Pancreatic cancer with portal vein invasion was not considered operable, and thus the resectability rate was low. METHODOLOGY: Between March 1976 and February 1994, 140 of 243 patients underwent resection, a resectability rate of 58%. A total of 81 (58%) of these patients underwent portal vein resection. We assessed 56 patients in whom the depth of invasion had already been determined histopathologically and whose superior mesenteric arterial portograms were readable. The 56 patients were classified into 4 groups: normal (Type I), stricture on one side of the portal vein (Type II), stricture on both sides of the portal vein (Type III), complete obstruction (Type IV). The length of the longitudinal lesions on portograms was also measured. RESULTS: In 93% (27/29 cases) of portographic Type I or II lesions with longitudinal lesions of 2 cm or less, portal vein invasion was limited to the tunica media. No patients with cancer invasion into the lumen survived more than 1 year. CONCLUSIONS: For patients with pancreatic cancer Type I or II, preoperative portography findings and longitudinal lesions of 2 cm or less, portal vein resection is indicated, and long-term survival can be expected.