One-stage hybrid procedure without sternotomy for treating thoracic aortic pathologies that involve distal aortic arch: a single-center preliminary study

Objective

This study aims to evaluate the initial results of a hybrid procedure without sternotomy for treating descending thoracic aortic disease that involves distal aortic arch. It also intends to report our initial experience in performing this procedure.

Methods

A total of 45 patients (35 males and 10 females) with descending thoracic aortic disease underwent a hybrid procedure, namely, thoracic endovascular aortic repair (TEVAR) combined with supra-arch branch vessel bypass, in our center from April 2009 to August 2014. Right axillary artery to left axillary artery bypass (n=20) or right axillary artery to left common carotid artery (LCCA) and left axillary artery bypass (n=25) were performed. The conditions of all patients were followed up from the 2^nd month to the 65^th month postoperative (mean, 26.0±17.1). Mortality within 30 days, complications such as endoleak after the hybrid procedure, and stenosis or blockage of the bypass graft during the follow-up period was assessed.

Results

All the patients underwent a one-stage procedure. One case of death and one case of cerebral infarction were reported within 30 days. One patient died of the sudden drop in blood pressure during the 2^nd day of operation. Meanwhile, another patient suffered from cerebral infarction. Two patients underwent open surgery, and one of them had to undergo a second TEVAR during the follow-up period. Moreover, endoleak occurred in two patients and a newly formed intimal tear was observed in one patient. Overall, 93.2% of the patients survived without any complication related to the hybrid procedure.

Conclusions

Initial results suggest that the one-stage hybrid procedure is a suitable therapeutic option for thoracic aortic pathologies that involve distal aortic arch. However, this procedure is not recommended for type-B aortic dissection, in which a tear is located in the greater curvature or near the left subclavian artery (LSA), because of the high possibility of endoleak occurrence.     

Comparison of risk-scoring systems in predicting hospital mortality after abdominal aortic aneurysm repair

OBJECTIVE:

To compare the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Portsmouth adjustment (P-POSSUM), the Hardman index and the Glasgow aneurysm score (GAS) in the prediction of hospital mortality after abdominal aortic aneurysm (AAA) repair.

METHODS:

Medical charts of 146 AAA patients treated between January 1996 and January 2007 were reviewed. The P-POSSUM, Hardman index and GAS were calculated for each patient. The scores were tested and compared for their discriminatory ability to predict hospital death.

RESULTS:

Of the 146 patients with ruptured and unruptured AAAs (133 underwent open repair, five underwent extra-anatomical bypass and eight underwent endovascular aneurysm repair), 18 died (12%) after AAA repair. The areas under the receiver operating characteristic curves for the GAS, Hardman index and P-POSSUM for predicting hospital mortality were 0.740, 0.730 and 0.886, respectively. The area under the receiver operating characteristic curve for the P-POSSUM was significantly higher than those of other scores.

CONCLUSION:

In the present study, the P-POSSUM was the best predictor of hospital mortality for patients undergoing AAA repair.     

Strategies for the coronary surgeon to remain “competitive and co-operative” in the PCI era

Background

The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong.

Methods

Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization.

Results

The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature.

Conclusions

Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.     

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery

BACKGROUND:

Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.

METHODS:

A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.

RESULTS:

The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.

CONCLUSIONS:

In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.     

Pulmonary multislice computed tomography findings in acute aortic dissection

Objective

To document the type and incidence of pulmonary multislice computed tomography (CT) findings at presentation in patients with acute aortic dissection.

Materials and methods

Multidetector CT scans of 36 patients with a diagnosis of acute aortic dissection or intramural hematoma were retrospectively reviewed.

Results

Pleural effusion, dependent stasis, mosaic attenuation, interlobular septal thickening, thickening of the peribronchovascular interstitium, vascular enlargement, compression atelectasis were common findings. Additionally air trapping, emphysema, consolidation, nodules, bronchiectasis or scarring were also noted.

Conclusions

Various pulmonary imaging findings may accompany acute aortic dissection. These findings and their clinical significance should be further investigated.KEY WORDS : Acute aortic dissection, computed tomography, MDCT, lung     

Aortic dissection after open repair of an infrarenal aortic aneurysm

INTRODUCTION:

A case of thoracic-abdominal dissection after open surgical exclusion of an infrarenal aortic aneurysm is presented.

CASE PRESENTATION:

A 62-year-old woman was diagnosed with an infrarenal abdominal aortic aneurysm with a rapid increase in maximal diameter. She underwent surgery for aneurysm exclusion by an end-to-end aortoaortic bypass with Dacron collagen (Intervascular; WL Gore & Associates Inc, USA). After 15 days, she was admitted to the emergency department with intense epigastric and lumbar pain. Computed tomography angiography with contrast revealed an aortic dissection with origin in the proximal bypass anastomosis and cranial extension to the thoracic aorta. The true lumen at the level of the eighth thoracic vertebra was practically collapsed by the false lumen. The celiac trunk, and the mesenteric and renal arteries were perfused by the true lumen. After the acute phase of the aortic dissection, surgical repair was planned. Two paths of false lumen were found – one at the thoracic aorta and the second in the proximal bypass anastomosis. Surgical repair comprised two approaches. First, a Valiant Thoracic stent graft (Medtronic Inc, UK) was implanted distal from the left subclavian artery, expanding the collapsed true lumen and covering the false and dissected lumen. Second, an infrarenal Endurant abdominal stent graft (Medtronic Inc) was implanted. This second device was complemented with an aortic infrarenal extension using a Talent abdominal stent graft (Medtronic Inc) in the infrarenal aortic neck to achieve a hermetic seal. The postoperative clinical course was uneventful, and her symptoms were completely resolved in six months.

CONCLUSION:

Arteritis must be taken into account in young patients with high inflammatory markers. Covered stents and endoprosthetic devices seem to be effective methods to seal the dissected lumen.     

Associations of Pretransplant Weight and Muscle Mass with Mortality in Renal Transplant Recipients

Summary

Background and objectives:

The association between pretransplant body composition and posttransplant outcomes in renal transplant recipients is unclear. It was hypothesized that in hemodialysis patients higher muscle mass (represented by higher pretransplant serum creatinine level) and larger body size (represented by higher pretransplant body mass index [BMI]) are associated with better posttransplant outcomes.

Design, setting, participants, & measurements:

Linking 5-year patient data of a large dialysis organization (DaVita) to the Scientific Registry of Transplant Recipients, 10,090 hemodialysis patients were identified who underwent kidney transplantation from July 2001 to June 2007. Cox regression hazard ratios and 95% confidence intervals of death and/or graft failure were estimated.

Results:

Patients were 49 ± 13 years old and included 49% women, 45% diabetics, and 27% African Americans. In Cox models adjusted for case-mix, nutrition-inflammation complex, and transplant-related covariates, the 3-month-averaged postdialysis weight-based pretransplant BMI of 20 to <22 and < 20 kg/m², compared with 22 to <25 kg/m², showed a nonsignificant trend toward higher combined posttransplant mortality or graft failure, and even weaker associations existed for BMI ≥ 25 kg/m². Compared with pretransplant 3-month- averaged serum creatinine of 8 to <10 mg/dl, there was 2.2-fold higher risk of combined death or graft failure with serum creatinine <4 mg/dl, whereas creatinine ≥14 mg/dl exhibited 22% better graft and patient survival.

Conclusions:

Pretransplant obesity does not appear to be associated with poor posttransplant outcomes. Larger pretransplant muscle mass, reflected by higher pretransplant serum creatinine level, is associated with greater posttransplant graft and patient survival.     

Hybrid intraoperative pulmonary artery stenting in redo congenital cardiac surgeries

Objective

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

Methods

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

Results

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

Conclusion

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

The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution

Background

Resection and reconstruction of the inferior vena cava (IVC) is occasionally required in the surgical treatment of intra-abdominal tumours. IVC reconstruction can be performed with biological or synthetic graft material, with most centres preferring synthetic grafts. In spite of the potential advantages of biological grafts in terms of handling characteristics, and safety, very limited data are available about their use in patients requiring an IVC resection.

Methods

Medical records of 32 patients who underwent an IVC resection and reconstruction from 1990 and 2011 with autogenous peritoneo-fascial (N = 22) and bovine pericardial (N = 10) grafts were reviewed.

Results

A tangential resection with patch repair was performed in 10 patients, whereas in the remaining 22 it was necessary to resect and replace a segment or all of the retrohepatic IVC. A concomitant liver resection was performed in 14 patients, nephrectomy in 10 and pancreaticoduodenectomy in 2 patients. There were no acute or late complications related to graft thrombosis or infection. Three patients died as a consequence of multi-organ failure. Overall survival at 1 and 5 years was 78% and 48%, respectively.

Conclusions

The preferential use of synthetic grafts in IVC replacement is not evidence based. Selection of an appropriate prosthetic graft for IVC reconstruction should be based on the safety and its handling features. The use of biological grafts for IVC repair is a valid alternative to current synthetic materials and may in fact be superior in terms of biocompatability, ease of handling, reduced rate of infection and improved long-term patency without permanent anticoagulation.     

Experience of ECMO in Primary Graft Dysfunction after Orthotopic Heart Transplantation

Background

Primary graft dysfunction is the main cause of early mortality after heart transplantation. Mechanical circulatory support has been used to treat this syndrome.

Objective

Describe the experience with extracorporeal membrane oxygenation to treat post-transplant primary cardiac graft dysfunction.

Methods

Between January 2007 and December 2013, a total of 71 orthotopic heart transplantations were performed in patients with advanced heart failure. Eleven (15.5%) of these patients who presented primary graft dysfunction constituted the population of this study. Primary graft dysfunction manifested in our population as failure to wean from cardiopulmonary bypass in six (54.5%) patients, severe hemodynamic instability in the immediate postoperative period with severe cardiac dysfunction in three (27.3%), and cardiac arrest (18.2%). The average ischemia time was 151 ± 82 minutes. Once the diagnosis of primary graft dysfunction was established, we installed a mechanical circulatory support to stabilize the severe hemodynamic condition of the patients and followed their progression longitudinally.

Results

The average duration of extracorporeal membrane oxygenation support was 76 ± 47.4 hours (range 32 to 144 hours). Weaning with cardiac recovery was successful in nine (81.8%) patients. However, two patients who presented cardiac recovery did not survive to hospital discharge.

Conclusion

Mechanical circulatory support with central extracorporeal membrane oxygenation promoted cardiac recovery within a few days in most patients.     

Outcomes of prenatally diagnosed tetralogy of Fallot: Implications for valve-sparing repair versus transannular patch

OBJECTIVES:

To assess outcomes of prenatally diagnosed tetralogy of Fallot and determine factors associated with the choice to undergo a valve-sparing repair versus transannular patch, and the use of prostaglandins at birth.

METHODS:

All cases at The Hospital for Sick Children (Toronto, Ontario) with a fetal diagnosis of tetralogy of Fallot from 1998 to 2006, were reviewed for demographic and fetal echocardiographic data to determine factors associated with the valve-sparing repair and need for perinatal support.

RESULTS:

Sixty-four fetuses met inclusion criteria (median gestational age 22 weeks) with 47 live births. Twenty-six underwent valve-sparing repair (median age 5.7 months) and 14 underwent transannular patch repair (median age 4.5 months). There were seven deaths before surgery and one post-transannular patch repair. One patient required a transannular patch repair after the initial valve-sparing repair. Twelve of 29 (41%) patients received prostaglandins at birth. Type of surgical repair, use of prostaglandins and postnatal death were among the outcomes investigated. The mean pulmonary valve (PV) z-score was −3.0±2.0 and the mean PV/aortic valve (AoV) ratio was 0.65±0.10. Lower PV z-score (P=0.04), smaller PV/AoV ratio (P=0.04) and the presence of nonantegrade arterial duct flow (P=0.02) were associated with prostaglandin use. A higher PV/AoV ratio was associated with valve-sparing repair (P=0.04). Fetal z-scores of the PV, AoV and right pulmonary artery at 29 to 32 weeks gestational age correlated with respective postnatal z-scores (P=0.01).

CONCLUSION:

Fetal echocardiographic variables were associated with the use of prostaglandins and valve-sparing repair in fetuses with tetralogy of Fallot, and at 29 weeks, correlated with postnatal valve diameters.     

Techniques and outcomes of transcatheter closure of complex atrial septal defects – Single center experience

Objective

To prospectively study the techniques and outcomes of transcatheter closure of complex Atrial septal defects (ASD).

Study design and settings

Prospective single center study with experience in catheter closure of ASD. All patients with complex ASD suitable for device closure.

Objective

Analysis of outcomes of transcatheter closure of complex ASD in JIPMER Hospital over the past 5-year period.

Methods

Complex ASD was predefined and patients satisfying inclusion and exclusion criteria are included. All the patients had meticulous Transesophageal echocardiography (TEE) imaging beforehand. Modifications of the conventional techniques were allowed on a case per case basis according to operator preference. Successfully intervened patients were followed up clinically.

Results

Out of the 75 patients enrolled, 69 patients had successful device closure (success rate 92%) despite challenging anatomy. Fifty-six (74%) patients had ASD ≥25 mm. Fifteen patients (20%) had defect size ≥35 mm and 20 patients (26.6%) had devices implanted with ≥35 mm waist size. Fifty percent of patients had complete absence of aortic rim and 25% had deficient posterior rim. Twenty percent of patients had malaligned septum. Mean follow up period was 3.2 years.

Conclusions

Trans catheter closure is feasible in anatomically complex substrates of Secundum ASD. Careful case selection, scrupulous imaging protocol, and expertise in modified techniques are mandatory for successful outcomes.     

Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Background

Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk.

Objectives

To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation.

Methods

From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation.

Results

Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly.

Conclusions

Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up.     

Robotic mitral valve repair in infective endocarditis

Background

Robotic mitral surgery is the most common robotic cardiac procedures. However, in mitral endocarditis the repair become more challenging especially in minimally approach. We applied robotic surgery in mitral endocarditis repair and reviewed our surgical methods and results.

Patients

From January 2012 to December 2013, 12 patients with mitral endocarditis in National Taiwan University Hospital were operated via robotic assisted repair. Age of them was among 21 to 65 years old, mean 43.

Results

The vegetation involves anterior leaflet in 3, posterior leaflet in 8 and commissural leaflet in 4. Mean cardiopulmonary bypass time is 124 minutes and cross clamp time is 89 minutes. There was no stroke and no operation death. Mitral valve repair technique including anterior leaflet patch augmentation in 2, direct closure of rupture hole on anterior leaflet in one, plication commissural leaflet in 2, and artificial chordae in 10. There was no mitral regurgitation detected immediately after weaning of cardiopulmonary bypass. All of them got free-from-regurgitation or -stenosis rate was 100% at one-year follow.

Conclusions

Although mitral infective endocarditis is complex and difficult to repair, robotic mitral repair in infective endocarditis is feasible. Even in the complex repair group, the cardiopulmonary bypass time is not prolonged and the result is good.     

Deferred consent in a minimal-risk study involving critically ill subarachnoid hemorrhage patients

INTRODUCTION:

Alterations from first-party and surrogate decision-maker consent can enhance the feasibility of research involving critically ill patients.

OBJECTIVE:

To describe the use of a deferred-consent model to enable participation of critically ill patients in a minimal-risk biomarker study.

METHODS:

A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient’s surrogate decision maker.

RESULTS:

Twenty-seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self- (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion.

DISCUSSION:

Use of a deferred consent model enabled participation of critically ill patients in a minimal-risk biomarker study with no withdrawals.

CONCLUSIONS:

Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low-risk and minimally interventional time-sensitive studies of critically ill patients are required.     

Outcomes in adult recipients of right-sided liver grafts in split-liver procedures

Background:

The split-liver technique provides a good left lateral graft in children, but its results in adults remain controversial.

Methods:

From 1992 to 2007, 37 patients received 38 cadaveric right-sided grafts. Donors and recipients were selected for good quality grafts and elective indications; the latter included a high proportion of tumour cases and primary sclerosing cholangitis. Grafts included 31 extended right grafts (ERGs; segments IV–VIII and I and the inferior vena cava [IVC]) and seven right grafts (RGs; segments V–VIII) including five without the IVC and middle hepatic vein (MHV).

Results:

Mortality was 5% (two patients). There were four retransplantations (11%) for arterial thrombosis (1), portal vein thrombosis (2) and primary non-function (1). The retransplantation rate was higher in RG than in ERG (three vs. one patient; P= 0.015). Of the five patients without MHV, three were retransplanted and one had small-for-size syndrome leading to late death. After a mean follow-up of 5 years, 1-, 3- and 5-year graft and patient survival rates were 84%, 80% and 71%, and 91%, 88% and 78%, respectively. One-year patient and graft survival rates after ERG transplantation were 96% and 92%, respectively.

Conclusions:

Split-liver transplantation is a safe alternative to whole organ transplantation when an ERG is carried out. Right graft is associated with increased risk of graft loss, especially if the MHV is omitted. Split-liver transplantation with an ERG offers excellent outcomes and should be encouraged when good quality grafts are available.     

Liver transplant outcomes in a Canadian First Nations population

BACKGROUND:

A higher incidence of autoimmune disorders may predispose First Nations (FN) individuals to higher rates and more severe episodes of rejection, graft loss and mortality following liver transplantation for advanced liver disease.

METHODS:

A retrospective review of patient outcomes in a single centre providing long-term follow-up care for FN and non-FN patients transplanted for advanced liver disease was conducted.

RESULTS:

A total of 20 FN and 129 non-FN charts were available for review. FN subjects were younger at transplantation (mean [± SD] age 32.4±4.1 years versus 46.3±1.4 years; P=0.00005), less often male (35% versus 58%; P=0.05), more commonly transplanted for autoimmune hepatitis (30% versus 4.7%; P=0.006), less often from urban residences (25% versus 74%; P=0.0001) and less compliant with medical care (20% versus 80%; P=0.007). After a mean follow-up period of 11.0±1.5 years and 8.4±0.5 years in FN and non-FN subjects, respectively, the incidence and severity of rejection, graft and patient survival were similar between cohorts.

CONCLUSION:

Although demographic profiles, nature of the underlying disease and compliance differed, the rates and severity of rejection, graft and patient survival were similar in FN and non-FN patients who underwent liver transplantation for advanced liver disease.     

Laparoscopic repair of Morgagni hernia by artificial pericardium patch in an adult obese patient

Background

Morgagni hernia is a kind of rare congenital diaphragmatic hernia. We reported a case of Morgagni hernia repaired successfully with artificial pericardium patch via the laparoscopic approach.

Methods

The patient was admitted with a 3-month history of postprandial nausea and vomiting, and accompanied by epigastric pain. Computed tomography (CT) scans showed a large anteromedial diaphragmatic hernia. The hernial contents were reduced back into the abdominal cavity and the diaphragmatic defect was repaired with artificial pericardium patch by laparoscopic intracorporeal suture.

Results

We achieved satisfactory intracorporeal repair of this large diaphragmatic defect. The patient had excellent recovery and started on oral diet on the first postoperative day, and then was discharged just two days after operation.

Conclusions

The minimally invasive advantage of laparoscopic approach offers a secure, reliable and satisfactory way to confirm the diagnosis and achieve the repair of non-complicated Morgagni hernia.     

All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation

Objectives

This paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT).

Methods

A patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17 mm); one segment VII HV (11 mm); two segment VI HVs (6 mm and 16 mm), and three segment V HVs. The graft weighed 663 g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6–0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch.

Results

Overall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs.

Conclusions

All-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.