Cardiac surgery in patients receiving long term hemodialysis. Short and long term results

AIM: Cardiac surgery carries a high risk in hemodialysis patients and has been questioned for its results; the purpose of this study is to focus on the short and long term results in our institution. METHODS: We retrospectively analyzed the data from 124 hemodialysis patients who underwent cardiac surgery in our unit between January 1980 and December 1998; 14.5% were diabetic; 46% had isolated coronary artery disease (group 1); 29.8% had valvular disease alone (group 2); 14.5% valve and coronary disease (group 3) and 9.6% miscellaneous disease at highest risk (group 4). We analyzed the relationship between several variables (age, sex, hypertension, diabetes, previous myocardial infarction, type of disease, preoperative ejection fraction) and operative mortality (30 days) and late survival. RESULTS: The overall operative mortality was 16.9%. The only risk factor was the type of cardiac disease: operative mortality was higher in groups 3 and 4 combined than in groups 1 and 2 combined (30% versus 12.7%, p=0.07). Ninety-nine patients were followed until January 2002. Late survival rate was 46.6+/-5% at 6 years for all patients, it was significantly better in groups 1 and 2 combined than in groups 3 and 4 combined. The only risk factor for late mortality was arterial hypertension. Fifty-seven patients are still alive, 46 in groups 1 and 2, 11 in groups 3 and 4. Progression of coronary lesions occurred in 6 patients and valvular lesions in 3 patients. The remainder are doing well. CONCLUSION: Cardiac surgery seems to be justified by the severity of the lesions. Its actual results can perhaps, be improved by earlier detection of cardiac disease and better prevention of myocardial hypertrophy and cardiac calcifications.     

Syndactyly--a review and long term results.

Syndactyly is classified and the principles of its surgical treatment discussed. The notes of eighty-five patients who had 222 webs between them were reviewed. A long term follow-up was carried out on thirty-two of these patients who had seventy-six clefts separated. The sexual and anatomical distribution of the syndactyly was investigated. The results of surgery were assessed including complications, and the relationship of complications to the type of graft used and the age at operation. It is suggested that complicated syndactyly is often separated at too early an age.     

Extensive aganglionosis. Treatment and long term results

Extensive aganglionosis (EA) that affects the total colon (including or not part of the small intestine), shows more diagnostic problems and it is associated to higher morbidity and mortality rates than the classic cases of Hirschsprung disease (ED). This study takes into account last years cases and their results in the medium and long term.     

Short and long term outcome of severe acute pancreatitis.

OBJECTIVE: Between 1985 and 1994, 883 cases of acute pancreatitis were treated in Malm?, Sweden (population 233,000). The purpose of this study was to report the short- and long-term outcome of the 79 cases that were severe, according to the Atlanta classification. DESIGN: Retrospective and follow-up study a median time of 7 years since the attack. SETTING: University hospital, Sweden. SUBJECTS: 79 patients with severe acute pancreatitis. MAIN OUTCOME MEASURES: Mortality, cause of death, organ failure, local complications, surgical procedures, mortality since the attack, and endocrine and exocrine dysfunction. RESULTS: Twenty-one patients died from their attack. Organ failure was the predominant cause of death in the 13 patients who died during the first 10 days after admission, whereas infection was the most common cause of death in patients who died later. Mortality was low under the age of 60 and increased with age. Organ failure developed in 72 patients. Twenty-four patients developed pancreatic necrosis or abscesses and 18 patients were treated by necrosectomy and open or closed drainage. At follow-up, 13 patients had died, 2 from pancreatic carcinoma. 35 patients were included in the follow-up survey. 15 of these had diabetes and an additional 4 had impaired glucose tolerance. 9 patients had signs of severe exocrine dysfunction. CONCLUSIONS: There was a high incidence of endocrine and exocrine dysfunction together with, in many patients, ongoing social problems related to chronic alcoholism several years after an attack of severe acute pancreatitis.     

Short and long term outcome after laparoscopic cholecystectomy

BACKGROUND: As an audit of patients undergoing laparoscopic cholecystectomy this study not only reports the short term results, but attempted to assess the long term effect of the operation on the symptom profiles of the patients. METHODS: Three hundred unselected consecutive patients underwent elective laparoscopic cholecystectomy from January 1991 to July 1994. Short term outcome was analysed by reviewing patient files for operation details, postoperative morbidity, complications, and gallbladder histology. Long term (median 2 years) outcome was evaluated by a detailed postal questionnaire. Symptomatic benefit ratios (BR) accruing from the laparoscopic removal of the gallbladder were calculated. RESULTS: Twelve operations (4.0%) were converted to open surgery and were excluded from long term outcome analyses. Median operation time was 93 (range 40-245) minutes. There were no deaths. Overall morbidity was 13 %. Median postoperative hospital stay was 2 days (range 1-18 days) and median time-off work 15 days (range 2-49 days). The overall response rate to the questionnaire was 87%. Only one of the 261 patients (0.4%) suffered from recurrent common bile duct stones so far. As shown by the benefit ratios the symptoms most effectively relieved by laparoscopic cholecystectomy were biliary pain (0.97), nausea (0.95), vomiting (0.96) and jaundice (0.94). Most patients with diarrhoea (0.70) and heartburn (0.66) felt relief. Constipation (0.39) and food intolerance (0.57) were unaffected. Most patients (90%) felt that the operation-initiating symptom had disappeared and 98 percent of the patients considered that they had obtained overall symptomatic improvement by the operation. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe and effective way of treating the most common symptoms related to gallstone disease.     

Continent ileostomy. The present technique and long term results

Continent ileostomies were created in 435 patients in the period 1967-1984. Approximately 50% of the patients were provided with a continent ileostomy in connection with proctocolectomy and in the others a conventional ileostomy was converted to a continent ileostomy. In the majority of patients the indication for proctocolectomy was ulcerative colitis, but 64 patients with Crohn's disease were also included. There was a 1.6% operative mortality overall, but when the material was divided into two groups operated upon during two consecutive time periods, no mortality was recorded in 273 patients operated upon during the latter period. The non-fatal complication rate had also decreased from 23% in the early series to 8% in the group operated upon during the latter period. Revisional surgery because of malfunction of the nipple valve has consecutively decreased from 54% in the original series to less than 10% at the time of writing. Successful outcome of the ileostomy procedure, although revisional surgery was sometimes required, was recorded in 97% of 273 patients operated on during the period 1975-1984.     

Aortic valve replacement in India. Early and long term results

Experience with 261 subjects undergoing aortic valve replacement is presented. The mean age of our patients (29.6 years) is much less an compared to reports from the West. History of rheumatic fever was obtained in 53%. Aortic regurgitation was documented in 72.7% of our subjects whilst the remainder had calcific aortic stenosis. The left ventricular and diastolic pressure was elevated in 24% and the systemic index was less than 3 l/min/m2 in 71%. Associated mitral stenosis was present in 31 subjects (11.8%) who had concomitant open mitral valvotomy. The Starr-Edwards ball valve model 1260 was utilised in the great majority (76.6%). The overall hospital mortality was 9.9% which had decreased to 4.5% during the last five year period. Poor myocardial protection leading to low cardiac output occurring in class IV subjects was the cause of death in most instances. All survivors were followed up for periods ranging from 1 to 12 years (mean 4.2). Thrombo-embolic phenomenon occurred in 1.6 per 100 patient years and the incidence of paravalvar leak has been extremely low (0.4%). This is in striking contrast with reports from other authors. Actuarial analysis at the end of 5 years and 10 years indicates overall probability of survival of 92.9% and 92.2% respectively.     

Short and long term reproducibility of urethral closure pressure profile parameters

Summary In ten incontinent female patients the reproducibility of urethral closure pressure profile parameters obtained with the Brown and Wickham technique in two consecutive measurements and in measurements after a one month interval was assessed. Variances after one month were statistically signifiantly larger than the variances between consecutive measurements. The mean values obtained with one month interval did not differ significantly.     

Management of groin hernias: long term results

The Authors report their experience in the treatment of groin hernias. Over the years, hospital stay and anaesthetic procedure were modified without compromising the quality of results. The Authors conclude that groin hernia may be treated in a outpatient or day surgery regimen saving money.     

Arteriovenous brachio-basilic fistula as hemodialysis port. Original technique and long term results

The authors report a prospective series of patients with-long term vascular access for chronic hemodialysis fashioned with a transposed brachio-basilic fistula. Over a three-year period (1998-2000), 14 patients underwent creation of the arteriovenous fistula. Demographic and clinical data were registered and a length of follow up more than 12 months was in all cases obtained. Of the 14 fistulas performed, 7 were successfully used for dialysis without complication. In seven patients late revision of fistulas was performed. The primary and secondary patency actuarial rates at two years were 50% and 75% respectively. The results of this series highlight as the basilic vein fistula provides reliable vascular access for chronic hemodialysis therapy. The low cost and the low morbidity rates suggest the brachial artery-transposed basilic vein fistulas as a valuable part of vascular access history of patients with chronic renal failure.     

Short and long term effects of antihypertensive therapy in the diabetic rat

To compare the impact of differing antihypertensive regimens on the development of renal injury, studies were performed in three groups of moderately hyperglycemic diabetic rats, and one group of non-diabetic control (C) rats. One diabetic group (DM) received no therapy except insulin. The remaining diabetic groups received insulin and either the angiotensin I converting enzyme inhibitor captopril (CAP), or triple therapy (TRX) with reserpine, hydralazine and hydrochlorothiazide. CAP and TRX modestly and comparably lowered blood pressure. At 6 to 10 weeks, DM rats exhibited elevation of the single nephron glomerular filtration rate (SNGFR), due to elevations of the glomerular capillary plasma flow rate (QA) and the glomerular capillary hydraulic pressure (PGC). In both DM/CAP and DM/TRX rats, blood pressure reduction was associated with selective normalization of PGC, without change in SNGFR or QA. In long-term (70 weeks) studies, DM rats exhibited progressive albuminuria and marked glomerular sclerosis. CAP limited albuminuria and injury to values even lower than those in C rats, whereas TRX served only to delay, but not to prevent, the increase in albuminuria. TRX reduced glomerular sclerosis, but was less effective than CAP. At 70 weeks, CAP and TRX still reduced systemic blood pressure; PGC remained at normal levels with CAP but was no longer controlled with TRX. These results confirm the clinical observation that antihypertensive therapy slows diabetic glomerulopathy, but also suggest that CAP affords superior long-term protection as compared to the other antihypertensive drug regimen studied.     

Hysteroscopic resection of submucous myomas: long term results

STUDY AIM: To evaluate the follow-up after operative hysteroscopic resection of submucous leiomyomas. PATIENTS AND METHODS: Between January 1990 and December 1996, 200 patients underwent operative hysteroscopic resection of 289 uterine leiomyomas. Indications were: menometrorrhagia (n = 159), postmenopausal metrorrhagia (n = 22), infertility (n = 19) as sole etiology. Sixteen patients had infertility and menometrorrhagia. RESULTS: The mean follow-up was 33.4 +/- 19.2 months. Twenty-three patients were lost to follow-up. Due to the large size of the leiomyomas, 35 patients had 2 or 3 resections and a total of 241 hysteroscopic resections were performed. Twelve complications (5%) occurred without death or need for intensive care. An improvement of clinical symptoms was observed in 74% of patients. The predictive factors of failure were: size (> 5 cm), number of intracavitary leiomyomas (> 3), hysterometry (> 12 cm), intramural myoma class 2 and association of leiomyomas. Eight of the 35 infertile patients subsequently became pregnant, but with only two live births (5.8%). CONCLUSION: Hysteroscopic myomectomy appears to be safe, effective and reproducible for the treatment of menstrual disorders. Intramural class 2 and larger leiomyomas constitute the limits of the endoscopic technique.     

Mitral valve repair for commissural prolapse: surgical techniques and long term results.

OBJECTIVE: The aim of this study was to describe the pattern of lesions responsible for commissural prolapse, the techniques of valve repair and their long-term results. METHODS: Between 1992 and 2004, 128 mitral valve repairs were consecutively performed for commissural prolapse. There were 86 males and 42 females, the median age was 57.5 years (range 14-84 years). Forty-six percent of patients were in NYHA III or IV, mean ejection fraction was 61+/-9.4%. The diagnosis of commissural prolapse was recognized by preoperative echocardiography in 32% of the patients and was revealed by intraoperative inspection of the valve in the other cases. The site of the prolapse was the posteriomedial commissure (n=94), the anterior commissure (n=30) or both (n=4). The aetiologies were: infective endocarditis (n=56), degenerative (n=46), ischemic (n=25), congenital mitral regurgitation (n=1). The commissural prolapse was associated with another mitral valvular lesion requiring a specific treatment in 61 cases (47.7%). An associated procedure was carried out in 45 patients. RESULTS: The operative treatment of the commissural prolapse included: commissural closure 65 (50.8%), leaflet resection 31 (24.2%), transposition or shortening of chordae 19 (14.8%), reimplantation or shortening of papillary muscles 3 (2.3%), and replacement of the commissural area by a partial mitral homograft 10 (8%). In-hospital mortality included three deaths (2.3%) and four patients (3.1%) were reoperated: three pericardial drainages for hemopericardium and one for mediastinitis. During the follow-up, one patient died (0.8%) from myocardial infarction and eight patients (6.3%) were reoperated including six (4.7%) for recurrent mitral regurgitation. After a median follow-up time of 76.9 months (range from 15 days to 160 months), 116 patients (90.1%) were in NYHA I. Echocardiographs showed no or minimal insufficiency in 112 patients (87.5%) and mild or moderate insufficiency in 10 patients (7.8%). CONCLUSIONS: The diagnosis of commissural prolapse is difficult by preoperative echocardiography. The aetiology of the mitral disease is variable (endocarditis, degenerative or ischemic mitral regurgitation). Using a variety of techniques, commissural prolapse can be repaired with excellent clinical and echographic long-term results.