Atlanto-axial joint of atlanto-axial subluxation patients due to rheumatoid arthritis before and after surgery, morphological evaluation using CT reconstruction

This study investigated the preoperative morphology and postoperative fusion of the atlanto-axial joint (AAJ) in patients with atlanto-axial subluxation (AAS) due to rheumatoid arthritis (RA) using computed tomography (CT). Furthermore, we examined the relationship between the preoperative morphology of AAJ and other radiographic results. Thirty patients with AAS due to RA treated by C1–2 transarticular screw fixation (TSF) were reviewed. The morphology of the AAJ was evaluated using sagittal reconstruction views on CT before and 1 year after surgery. Thereafter, the atlanto-dental interval (ADI) value at the neutral and maximal flexion position and atlanto-axial angle (AAA) at the neutral position was assessed in preoperative lateral cervical radiographs. The preoperative morphology of the AAJ on CT reconstruction views was graded as follows: Grade 1 showed maintenance of the joint space, Grade 2 showed the joint space narrowing and Grade 3 showed the destructive abnormality of subchondral bone. After surgery, the ADI value at the neutral position was assessed in lateral cervical radiographs. Furthermore, the fusion in the AAJ was investigated using CT sagittal reconstruction views taken 1 year after surgery. The preoperative CT image of the AAJ demonstrated Grade 1 in 12 cases (Group A), Grade 2 in 9 cases (Group B) and Grade 3 in 9 cases (Group C). There was no significant difference in age, gender and duration of RA among the three groups. The average ADI value at the flexion position was 11.0 mm in Group A, 12.3 mm in Group B and 12.7 mm in Group C (p > 0.313). The average ADI value at the neutral position before surgery was 4.5 mm in Group A, 7.3 mm in Group B and 11.4 mm in Group C (p < 0.003). The mean AAA value was 20.8° in Group A, 21.8° in Group B and 8.4° in Group C (p < 0.033). The average ADI value after TSF was 1.7 mm in Group A, 2.1 mm in Group B and 3.0 mm in Group C (p > 0.144). Fusion in the AAJ 1 year after surgery was demonstrated in 14 cases (46.7%; Group A, 0 case; Group B, 5 cases; Group C, 9 cases). According to the preoperative grading of the AAJ, the postoperative fusion in the AAJ was demonstrated in 0 of 32 joints (0%) in Grade 1, 7 of 18 joints (38.9%) in Grade 2 and all of 10 joints (100%) in Grade 3. In conclusion, this study showed that a destructive abnormality of subchondral bone in the AAJ induced an enlargement of the ADI and anterior inclination of the atlas in patients with AAS due to RA. The current study also showed that fusion in the AAJ was demonstrated in 14 of 30 patients after C1/2 TSF. This was easy to recognize in AAS patients whose joint destruction extended to the subchondral bone.     

Aneurysm Diameter and Proximal Aortic Neck Diameter Influence Clinical Outcome of Endovascular Abdominal Aortic Repair: A 4-Year EUROSTAR Experience

Our objective was to evaluate the effect of preoperative aneurysm and aortic neck diameter on clinical outcome after infrarenal abdominal endovascular aneurysm repair (EVAR). Data of patients in the European Collaborators Registry on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry base who underwent EVAR with Talent stent grafts were analyzed. Patient characteristics and clinical outcomes were compared among four groups defined by preoperative abdominal aortic aneurysm (AAA) and proximal aortic neck diameter: A, AAA ≤60 mm and neck ≤26 mm; B, AAA >60 mm and neck ≤26 mm; C, AAA ≤60 mm and neck >26 mm; and D, AAA >60 mm and neck >26 mm. Over a 7-year period, 1,317 patients underwent EVAR. Patients in groups B and D were significantly older and had a higher American Society of Anesthesiologists score compared with groups A and C (p=0.002 and 0.003, respectively). Mortality rate was highest in group D (p=0.002), as were rupture and conversion rates (p=0.015 and 0.037, respectively). This study demonstrates that patients with an AAA >60 mm and a proximal aortic neck >26 mm have worse clinical outcome after EVAR. Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28-30, 2005.     

Predictors of Outcome After Abdominal Aortic Aneurysm Rupture: Edinburgh Ruptured Aneurysm Score

Background Many surgeons adopt a selective policy of intervention for a ruptured abdominal aortic aneurysm (AAA). This study aimed to develop an objective method of identifying patients suitable for attempted repair. Methods Consecutive patients selected for attempted repair of ruptured AAA over a 31-month period (January 2000 to July 2002) were entered into an observational study. Altogether, 53 preoperative physiological and biochemical variables were recorded and related to operative outcome. Results A total of 105 patients underwent attempted repair of a ruptured AAA. There were 39 (37%) deaths in hospital or within 30 days of operation. On univariate analysis, hemoglobin <9 g/dl (p = 0.038), blood pressure <90 mmHg (p = 0.036), and Glasgow Coma Scale <15 (p = 0.016) were found to be risk factors that predicted death. Of 70 patients with no or one risk factor, 20 (29%) died. Of 30 patients with two factors, 15 (50%) died, and of the five patients with all three factors, four (80%) died. There was a significant association between mortality and cumulative risk factors (p = 0.003). Conclusion These three risk factors are easily assessed in the emergency setting and might form the basis of a scoring system to inform the outcome of ruptured AAA.     

A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube?

A prospective randomised study of end-to-end bile duct reconstruction with or without T-tube drainage during orthotopic liver transplantation (OLT) was undertaken in 60 patients well matched for age, sex, aetiology of liver disease, operative blood loss, cold ischaemic time, preoperative serum bilirubin level and Child-Pugh score. Significant biliary complications in the T tube group occurred in five patients and included bile duct stricture (n=2), bile leak/peritonitis (n=1) and cholangitis (n=2). Bile duct strictures occurred in six patients in the no T tube group (P>0.05, NS). Hepatic artery stenosis was identified in one patient from each group in association with a biliary stricture. Biliary complications in both groups were associated with a prolonged graft cold ischaemic time (P<0.01). As no significant difference was noted in the number of early and late biliary complications between the two groups, the routine use of a T tube has been discontinued.     

Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement?

Objective: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. Methods: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n = 179) were included. We studied their characteristics, treatment decisions, and survival. Results: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p = 0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p = 0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. Conclusions: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery.     

Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism

Background: A small group of patients with renal disease‐related secondary or tertiary hyperparathyroidism require surgical parathyroidectomy. Among them, 5–20% require further re‐exploration and excision of parathyroid tissue because of recurrent disease. The aims of the present study were to review the characteristics and outcomes of patients undergoing parathyroidectomy for renal disease related hyperparathyroidism and to identify the risk factors for recurrent hyperparathyroidism. Methods: Review of data from a dedicated head and neck database at Royal Prince Alfred Hospital between 1988 and 2004. Results: There were 115 patients of whom 68 (59%) patients were treated with subtotal parathyroidectomy (STP), 43 (37%) were treated with total parathyroidectomy (TP) and 4 (3%) were treated with TP with autotransplant. Of those, 11 (9.6%) patients developed recurrent hyperparathyroidism (9 had STP, 1 had TP and 1 had TP with autotransplant). On re‐exploration, persistent hyperplastic parathyroid tissue was located at the site of partially excised parathyroid gland (64%), autotransplanted parathyroid tissue (9%), anterior mediastinum (18%) and intrathyroidal parathyroid (9%). Predictors for recurrent hyperparathyroidism are STP (P= 0.049), preoperative symptom of calciphylaxis or calcinosis (P= 0.024), elevated preoperative calcium level (P= 0.007) and elevated post‐operative PTH levels (P= 0.014). Post‐operative PTH levels less than 10 pmol/L has a positive predictive value of 97.5% for cure (P= 0.02). Conclusion: More aggressive surgical approach could be indicated in patients with preoperative hypercalcaemia and calcinosis/calciphylaxis. Post‐operative PTH can be utilized as a marker for cure after parathyroidectomy in hyperparathyroidism of renal disease.     

Endovaskuläre AAA-Therapie

Purpose. We analyzed the clinical efficacy of endovascular AAA repair in midterm follow-up and scrutinized the causes of graft-dependent endoleaks (type I EL). For this purpose, we investigated whether a restrictive patient selection can reduce the incidence of type I EL. Patients and results. A consecutive series of 83 patients who underwent elective endovascular AAA repair during 4/1995 and 9/1999 was analyzed. Mean follow-up was 12 months. Twenty tube grafts and 63 bifurcated grafts were used. With the help of a risk score classifying preoperative AAA morphologies into three risk groups, morphological AAA difficulties and clinical outcomes were set in reference and morphological alterations of the crucial fixation sites were amassed. Perioperative mortality was 1 of 83 (1.2%) and primary technical success 80 of 83 (96.4%). We observed one rupture 36 months postoperatively that responded to endovascular treatment. Conversion was 6 of 83 (7.2%). Type I EL occurred in 13 of 83 patients (15.7%). Of 13 type I EL patients, 9 (69.2%) responded to secondary endovascular treatment, while 4 of 13 patients (30.8%) had to be converted due to type I EL. While 70 of 83 patients (84.3%) without type I EL showed a significant decrease of maximum AAA diameter (D_max) 12 months postoperatively, D_max did not show shrinkage in 13 of 83 patients (15.7%) with type I EL (p=0.0035). In 4 of 20 patients (20%) treated with tube grafts, type I EL occurred besides a significant dilatation of the distal aortic neck 12 months postoperatively, whereas in 16 of 20 patients (80%) treated with tube grafts, neither type I EL nor a significant dilatation of the distal aortic neck was observed (p=0.0354). Of 63 patients treated with bifurcated devices, 9 (14.3%) showed type I EL and a significant dilatation of iliac artery diameters 18 months postoperatively, while 54 of 63 patients (85.7%) without type I EL did not show a significant expansion (left common iliac artery p=0.0269, right common iliac artery p=0.0071). We found a significant relationship between preoperative AAA morphologies with a higher risk score and the occurrence of type I endoleaks (p=0.022). Conclusions. The causes of the complications in the cohort observed were morphological alterations of the aortoiliac vessels, technical difficulties regarding the exact fitting of endovascular grafts, or a combination of these problems. Restrictive morphological patient selection, precise preoperative imaging, and differentiated graft choice as well as correct fitting of the graft will have the potential to decrease the incidence of type I endoleaks in the future.     

Prevention of ischemic colitis following aortic reconstruction: personal experience of the role of transmural oximetry in the decision for inferior mesenteric artery reimplantation

BACKGROUND: The colonic ischemic necrosis is one of the most serious complication in the surgical reconstruction of abdominal aorta aneurysm (AAA) due to surgical inappropriate binding of the inferior mesenteric artery (IMA). METHODS: A retrospective analyzed of a group of 118 infrarenal AAA surgically treated is presented. RESULTS: The most common cause of ischemic colitis (75% of cases) is the surgical binding of an opened IMA or its failed reimplantation. CONCLUSIONS: In this paper according to their personal experience and the literature data, the authors outline a diagnostic behaviour to select the patients needing the reimplantation of IMA; they suggest to complete the pre operative information with an instrumental evaluation during the surgical treatment.     

Outcome after emergency repair of symptomatic,unruptured abdominal aortic aneurysm: Results in 42 patients and review of the literature

Objective To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition.

Patients and methods Forty-two patients underwent emergency repair for symptomatic, unruptured AAA.

Results Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA.

Conclusion Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.     

Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.     

Arthrofibrosis following ACL reconstruction—reasons and outcome

Introduction Arthrofibrosis is a complication that severely influences the clinical outcome after anterior cruciate ligament (ACL) reconstruction. This retrospective clinical study analyses risk factors and outcome after arthrolysis in a large population.Material and methods Two hundred twenty-three patients who had undergone arthrolysis after ACL reconstruction were examined. Range of motion (ROM) was reduced due to arthrofibrosis of the joint in 70% (n=156). Other reasons, such as cyclops syndrome or osteoarthritis were found in 30% (n=67). The mean time interval between arthrolysis and follow-up was 4.29 years. We recorded timing of surgery, additional injuries, state of the knee before reconstruction, range of motion, pain during rehabilitation, beginning, duration and type of rehabilitation, severity and etiology of joint stiffness and the time between ACL reconstruction and revision. The present state of the knee was documented using the IKDC form.Results A significant correlation of arthrofibrosis and preoperative irritation (p<0.001), preoperative limited ROM (p=0.001), perioperative pain (p=0.046) and early beginning of muscle training (p=0.064) was found. Combination of a remaining loss of extension and development of degenerative joint disease was also significant (p=0.001). The decrease of sports activity compared with the level before ACL injury was highly significant (p<0,001). The criteria to minimize the risk of arthrofibrosis and the optimal timing of arthrolysis are pointed out.     

Laparoscopically assisted distal gastrectomy for early gastric cancer

Background: The purpose of this study was to compare clinical outcomes between laparoscopically assisted and open distal gastrectomy for early gastric cancer. Methods: The records of 21 patients who underwent laparoscopically assisted distal gastrectomy (LG) for preoperative diagnosis of intramucosal gastric carcinoma between January 1996 and August 1998 were reviewed and compared with those of 31 open distal gastrectomy patients during the same period. Results: Age, gender, and size and histologic differentiation of the lesions were matched. Those located at the body of the stomach (p= 0.011) and those macroscopically depressed (p= 0.049) were subjected more frequently to open surgery. Laparoscopically assisted gastrectomy required significantly longer operative time (p < 0.001) with less extensive lymph node dissection (p < 0.001). However, time to start of walking (p= 0.032), time to flatus (p= 0.002), duration of postoperative fever (p= 0.027), and postoperative hospital stay (p= 0.001) were significantly shorter in the LG group, and this group had a lower white blood cell count on the first postoperative day (p= 0.010). Blood loss and time to oral intake were comparable between the groups. Complications included one conversion to open surgery, one leakage, and one stenosis in the LG group, and two leakages and an atelectasis in the OG group. Conclusions: Although LG requires longer surgical time, this retrospective study suggests that it is superior to open surgery in terms of faster postoperative recoveries, shorter hospital stays, and cosmetic outcomes. Received: 25 December 1998/Accepted: 15 July 1999     

Concomitant Aortic and Renal Artery Reconstruction in Patients on an Intensive Antihypertensive Medical Regimen: Long-Term Outcome

n = 22) or bilateral (n= 19) aortorenal bypass or renal endarterectomy (n= 2). Operative mortality was 4.7% (2 of 43). The estimated 5-yr probability of survival was 83% (95% C.I. 0.70, 0.99). Late follow-up data on blood pressure control were available for review in 32 patients at a median follow-up of 37 months. Hypertension was cured in 1 (3%) and improved in an additional 15 (47%) patients. The numbers of antihypertensive medications taken preoperatively (mean = 2.7) declined at late follow-up (mean = 1.6). Notably, the largest reduction was observed with beta blockers (p= 0.006), central sympatholytics (p= 0.041), and angiotensin converting enzyme (ACE) inhibitors (p= 0.052). The number of preoperative antihypertensive medications was not significantly related to survival or to blood pressure improvement. However, uncontrolled preoperative hypertension despite antihypertensive therapy was associated with a favorable blood pressure response to operation (p < 0.001). Patients on an intensive antihypertensive regimen can safely undergo concomitant renal artery and aortic reconstruction for the empiric management of hypertension. Poorly controlled preoperative hypertension in the presence of multiple antihypertensive agents is a favorable marker for improved postoperative blood pressure control.     

Safety of Conservative Management of Bile Leakage after Hepatectomy with Biliary Reconstruction

Background  The risks associated with the conservative management of bile leakage after hepatectomy and associated cholangiojejunostomy are not well defined. Aim  The aim of this study was to evaluate incidence and severity of complications associated with bile leakages after liver resection with biliary reconstruction. Patients and methods  Clinical data from 1,034 consecutive patients who underwent liver resection were prospectively collected and reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (group 2; p < 0.001). Serum albumin and bilirubin levels were the only preoperative factors significantly different between the two groups. Lymphadenectomy was more frequently performed in patients of group 1 (88% vs 16.7, p < 0.001). Results  Mortality rates were similar in the two groups (8% in group 1 vs 2.3% in group 2, p = 0.28). One or more postoperative complications occurred in 68% in group 1 and in 40.4% in group 2 (p = 0.02). The incidence of sepsis (32% vs 7.1%, p = 0.01), intra-abdominal abscess (12% vs 0, p = 0.04), and abdominal bleeding (28% vs 0, p = 0.006) was significantly higher in group 1. Bile leaks spontaneously healed in 52% of patients in group 1 vs 76.2% in group 2 (p = 0.04). In order to identify independent predictive factors for abdominal bleeding, we compared clinical data of patients with abdominal bleeding (seven patients) and without abdominal bleeding (18 patients) after hepatectomy and biliary reconstruction. Stepwise logistic regression analysis identified the number of reconstructed bile ducts as an independent predictive factor of abdominal bleeding (p = 0.038). Conclusions  Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which is related to the number of bile ducts requiring reconstruction.     

Surgical revascularization of renal artery after complicated or failed percutaneous transluminal renal angioplasty

PURPOSE: The purpose of this study was to evaluate the feasibility and effectiveness of surgical reconstruction of the renal artery after complicated or failed percutaneous transluminal renal angioplasty (PTRA). METHODS: This was a retrospective study of 45 consecutive patients who were referred to our centers for surgical renal artery reconstruction after 52 complicated or failed PTRA procedures performed between 1980 and 2003. There were 27 women and 18 men, with a median patient age of 28 years (25th percentile, 13.5 years; 75th percentile, 59.5 years). The mean number of PTRA per artery per patient was 1.4 +/- 0.6. Renal artery stenosis was due to arterial fibrodysplasia in 25 patients, atherosclerosis in 17, and inflammatory arteritis in three. RESULTS: Forty-eight renal artery revascularizations were performed (3 bilateral). The procedure consisted of in situ surgery in 38 patients (79%) and extracorporeal repair in 10 (21%). Primary nephrectomy was required in three patients. One patient did not undergo surgical repair after failed PTRA because of kidney atrophy. Major technical problems were encountered during surgical revascularization in 14 (74%) of the 19 patients treated after complicated PTRA and in four (12%) of the 33 patients treated after failed PTRA. Multiple organ failure led to one death on postoperative day 90 in a patient with atherosclerosis and severe kidney insufficiency. Postoperative thrombosis of the repaired renal artery led to kidney loss in three patients, but only one patient required secondary nephrectomy. Primary patency for the overall series of renal revascularizations was 93.5% +/- 6.5% at 5 years. CONCLUSION: Surgical reconstruction after complicated or failed PTRA is feasible and effective and allows kidney salvage in most patients. Technical problems during surgical revascularization may require extracorporeal repair in some patients. The results of this study underline the need for careful patient selection and skillful PTRA technique.     

Predictors of Early Discharge following Open Abdominal Aortic Aneurysm Repair

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.     

Preoperative Chemotherapy Does Not Increase Morbidity or Mortality of Hepatic Resection for Colorectal Cancer Metastases

Hepatic metastasis from colorectal cancer (mCRC) is best treated with a multidisciplinary approach. Conflicting data exist regarding the impact of preoperative chemotherapy on morbidity and mortality after hepatectomy. We hypothesized that preoperative chemotherapy does not adversely impact complications or mortality associated with hepatectomy. A retrospective analysis was performed and included patients with mCRC who underwent hepatectomy from 1996 to 2006. Patients were separated into two groups: those who received preoperative chemotherapy and those who did not. Univariate and multivariate analyses were performed to determine the factors associated with morbidity and mortality. Kaplan–Meier analyses were performed to determine disease-free survival (DFS) and overall survival (OS). One hundred eighty-six patients were analyzed: 112 (60%) received preoperative chemotherapy for a median of 4.2 months. Eighty patients (43%) underwent major hepatectomy. When comparing the two groups, there were no differences in hepatic tumor size (median 3 cm; p = 0.35), type of resection (p = 0.62), stage (p = 0.44) or location (p = 0.10) of the primary tumor, preoperative carcinoembryonic antigen (CEA) level (p = 0.80), or number of nodes in lymphadenectomy (p = 0.62). Only number of positive nodes after colectomy (p = 0.02), age (p ≤ 0.0001), and combined resection/radiofrequency ablation (RFA) (p = 0.004) were statistically different between the two groups. There was no difference in rates of morbidity (p = 0.81), mortality (p = 0.29), DFS (p = 0.25) or OS (p = 0.30). We conclude that the use of preoperative chemotherapy did not increase the risk of complications or death for patients undergoing hepatectomy for metastatic colorectal cancer. Pre-hepatectomy chemotherapy appears to be safe and is an important part of the multidisciplinary approach for this disease.     

Mortality after Esophagectomy: Risk Factor Analysis

p = 0.001; RR = 2.6) and performance status ( p = 0.04; RR = 1.9). Delimiting the data pool using a calculated risk of 0.2 accurately identified outcomes in 79% of patients and predicted 41% of deaths. The optimal model for the overall prediction of risk of mortality was defined by age ( p = 0.001; RR = 3.9), intraoperative blood loss ( p < 0.001; RR = 1.7), pulmonary complications ( p = 0.002; RR = 6.6), and the need for inotropic support ( p = 0.003; RR = 10.2). The individual risk of mortality after esophagectomy can be predicted preoperatively with a model based on patient age and performance status. The findings underscore the importance of preoperative evaluation of cardiopulmonary function, meticulous operative technique, and aggressive respiratory care in the management of the esophagectomy patient.     

Relationship between the morphology of the atlanto-occipital joint and the radiographic results in patients with atlanto-axial subluxation due to rheumatoid arthritis

The upper cervical spine is a common focus of destruction from rheumatoid arthritis (RA). Atlanto-axial subluxation (AAS) presents with marked frequency among patients with instability. However, there are occasional patients who show no motion between the occipital bone and atlas on a dynamic cervical radiograph in AAS patients. This study investigated the morphology of the atlanto-occipital joint (AOJ) in AAS patients due to RA using computed tomography, and examined the relationship between its morphology and other radiographic results. Twenty-six consecutive patients with AAS due to RA treated by surgery were reviewed. The subjects included 18 females and 8 males. The average patient age was 59.3 years. The mean duration of RA was 14.3 years. In all the patients, the AOJ was morphologically evaluated using sagittal reconstruction view on computed tomography before surgery. Moreover, the ADI value was investigated at the neutral and maximal flexion position, and atlanto-axial angle (AAA) at the neutral position in preoperative lateral cervical radiographs. The morphology of the AOJ on a CT sagittal reconstruction view was classified into three types as follows: a normal type which showed a maintenance of the joint space, a narrow type which showed a disappearance of the joint space and a fused type which showed the fusion of the AOJ. The pre-operative CT sagittal reconstruction image of the AOJ demonstrated a normal type bilaterally in six cases (Group A). In 15 cases (Group B), CT image demonstrated narrowing on at least one side of the AOJ. In five cases (Group C), CT images demonstrated fusion on at least one side of the AOJ. The average ADI value at the flexion position was 10.7 mm in Group A, 11.7 mm in Group B, and 12.6 mm in Group C. There was no significant difference among those groups. The average ADI value at the neutral position before surgery was 2.8 mm in Group A, 5.9 mm in Group B, and 10.4 mm in Group C. There was no significant difference between Group A and B (P > 0.105), and Groups B and C (P > 0.032), however, there was a significant difference between Groups A and C (P < 0.004). The average AAA value was 25.3° in Group A, 19.3° in Group B and 3.4° in Group C. There was no significant difference between Groups A and B (P > 0.230), however, there was a significant difference between Groups A and C (P < 0.002), and Groups B and C (P < 0.007). This study showed that fusion or ankylosis of the AOJ induced an enlargement of the ADI and anterior inclination of the atlas in the neutral position, despite the fact that normal findings of AOJ showed a slight displacement of the atlas to axis in RA patients showing AAS involvement. This morphology may progress to SAS and VS due to AOJ after atlanto-axial arthrodesis. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.     

Outcome and Survival of Patients Aged 65 Years and Younger after Abdominal Aortic Aneurysm Rupture

Advanced age (> 80 years) confers a survival disadvantage after operative repair of a ruptured abdominal aortic aneurysm (AAA). This study aimed to determine if young age (≤65 years) confers a survival benefit. Consecutive patients undergoing attempted repair of a ruptured AAA between 1995 and 2001 were included in the study. Demographic, clinical, and operative factors were analyzed together with in-hospital mortality, duration of postoperative hospital stay, and long-term survival. Of 378 patients admitted with a ruptured AAA, 52 (14%) were ≤ 65 years of age and 326 (86%) were > 65 years. There were 4 (8%) women in the younger cohort compared to 74 (23%) women in the older group (p = 0.015). Four (8%) patients in the younger group were thought to be unsuitable for surgical repair compared to 77 (24%) patients in the older cohort (p = 0.009). Of the 48 younger patients who underwent attempted operative repair, 22 (46%) died in hospital, compared to 108 (43%) of 249 patients > 65 years (p = 0.753). The median (range) postoperative hospital stay of survivors was 11 days (6–59 days) in the younger cohort and 15 days (6–121 days) in the older group (p = 0.005). Patients ≤ 65 years of age undergoing operative repair of ruptured AAA have no survival advantage over older patients. These data support AAA screening for the “at risk” and age-defined population. This work was presented to the 53^rd International Congress of the European Society for Cardiovascular Surgery, Ljubljana, 2004 and published in abstract form in Interactive Cardiovascular and Thoracic Surgery 2004;3(S1):81.