Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present.

BACKGROUND: Subglottic stenosis is an ancient but persistent problem as a cause of airway obstruction. The etiology and the results of surgical treatment with thyrotracheal anastomosis were reviewed. METHODS: Fifty-six patients with subglottic stenosis were studied. All were subjected to laryngotracheal reconstruction by thyrotracheal anastomosis with partial resection of the cricoid. RESULTS: Of all 56 cases of subglottic stenosis, 48 (86%) had history of previous tracheal intubation, and only 8 (14%) had different non-neoplastic obstructive processes such as scleroma, direct injury, hamartoma, and amyloidosis. Immediate results were good in all cases. After 1 year follow-up, results of thyrotracheal anastomosis were successful in 44 (91%). In 4 other cases a restenosis was observed. Eight patients were lost to follow-up. CONCLUSIONS: Subglottic stenosis is still frequent after tracheal intubation, but other causes must be considered. Laryngotracheal reconstruction with thyrotracheal anastomosis with partial cricoid resection was feasible with good results in 91% of the cases with follow-up, but this procedure must be performed by a skilled surgical team.     

Schneiderian papillomas: a clinicopathologic study of 30 cases.

Schneiderian papillomas are tumors involving the nasal cavity and paranasal sinuses that tend to recur. A long-term clinical follow-up of 30 patients revealed histologically confirmed recurrences in 20 of the 30 patients (67%) and probable recurrences in two additional patients (combined recurrence percentage 73%). Recurrences were most frequent within 1-2 years following primary thrapy and were generally more frequent in patients with more extensive disease and involvement of paranasal sinuses. Histologic features were not helpful in predicting recurrence. One patient in the study (1/30 = 3%) developed a carcinoma at the site of a histologically confirmed benign Schneiderian papilloma after four recurrences over a period of 9 years. No patients died from the tumor. Twenty patients were alive and free of disease at last follow-up; four patients died of unrelated causes and without evidence of disease; four patients are alive with evidence of disease; and two patients died with disease but of unrelated causes. These tumors often pursue a relentless local course requiring multiple surgical excisions but are rarely responsible for death of the patient and seldon undergo a malignant "transformation" (less than 5%).     

Late results with bioprosthetic valves in the elderly

AIM: We report the long-term outcome of aortic and mitral bioprostheses in patients over 65 years of age at the time of implantation. The aim was to determine actuarial patient survival, causes of death, and the rate of documented primary structural deterioration. METHODS: One hundred ten patients > or = 65 years of age (mean, 73.4; range, 65-82) underwent successful bioprosthetic valve replacement (aortic, n = 71; mitral, n = 32; both, n = 7) from 1979 to 1985. The valve was pericardial in 39 cases and porcine in 78. The mean follow-up was 8.5 years (101.9 months-total; 934 patient-years; range, 2 months to 15 years). RESULTS: Actuarial patient survival was 79.6% (71-86) at 5 years and 62.4% (52-71) at 10 years. Forty-four patients died, 21 from valve-related causes and 23 from other causes. Thirteen patients (11.8%) had reoperation for valve-related complications: 10 structural deteriorations, 2 paravalvular leaks, and 1 case of endocarditis. One surgical death occurred (7.7%). Twenty-six percent of the patients were receiving anticoagulants because of atrial fibrillation, and 6.4% developed severe bleeding (2.9% patient-years). CONCLUSIONS: Long-term follow-up of these patients > 65 years of age, undergoing bioprosthetic value replacement surgery revealed a low rate of documented primary structural deterioration (0.95% per patient-year), a low mortality rate on reoperation (7.7%), and a high mortality rate due to non-value-related causes (52.3%).     

Late results after surgical treatment of renovascular hypertension. A follow-up study of 122 patients 2-18 years after surgery.

During the period 1963-1980, 122 patients were operated on for renovascular hypertension at surgical department D, vascular section, Rigshospitalet, Copenhagen. Seventeen patients, with a median age of 24 years, had fibromuscular hyperplasia and 95 patients, with a median age of 48 years, had atherosclerosis. Twenty-four of the latter had bilateral renal artery lesions and 71 had unilateral disease. Ten patients had various other causes of renovascular hypertension. Operative mortality was 4.9%, decreasing to two per cent in the last 8 years. At discharge, 71% of the patients were normotensive without medication, 18% were improved, and 11% were unimproved. At follow-up in 1982, the actuarial 10-year survival rates for patients with unilateral and bilateral atherosclerotic disease were 65% and 48%, respectively. There was no difference between survival rates for patients with fibromuscular hyperplasia and an age- and sex-matched, population. Sixty-nine patients were reexamined with a median follow-up of 9 years. Of the survivors with atherosclerosis, 87% benefitted from the operation: 50% were normotensive without medication and 37% were improved. Of patients with fibromuscular hyperplasia, 93% benefitted from operation: 79% were normotensive and 14% were improved. The results support the value of surgery in patients with renal fibromuscular hyperplasia and to the long-term benefits of surgical treatment of patients with atherosclerotic renovascular disease.     

Chondrosarcoma of the pelvis. A review of sixty-four cases.

BACKGROUND: Treatment of pelvic chondrosarcoma is a difficult problem for the musculoskeletal oncologist. Poor rates of survival and high rates of local recurrence after surgical treatment have been reported in previous studies. The present study was designed to review the long-term oncologic and functional outcomes of surgical management in a large series of patients with pelvic chondrosarcoma who were treated at a single institution. METHODS: The cases of sixty-four patients with localized pelvic chondrosarcoma that had been surgically treated between 1975 and 1996 were reviewed retrospectively. The study was limited to patients who had received no previous treatment for chondrosarcoma. There were forty-one male and twenty-three female patients who had a mean age of forty-seven years (range, fifteen to eighty-eight years). The patients were followed for a minimum of three years or until death. The median duration of follow-up of the living patients was 140 months (range, thirty-nine to 295 months). RESULTS: Thirty-three of the sixty-four patients were first seen with grade-1 chondrosarcoma; twenty-three, with grade-2; one, with grade-3; and seven, with grade-4 (dedifferentiated chondrosarcoma). Thirteen patients had a hemipelvectomy to achieve local tumor control, whereas fifty-one patients underwent a limb-salvage procedure. Twelve patients (19%) had local recurrence, and eleven (17%) had distant metastases. At the time of the final follow-up, forty-four patients (69%) were alive without evidence of disease, thirteen (20%) had died of the disease, six (9%) had died of unrelated causes, and one (2%) was alive with disease. Less than a wide surgical margin correlated with local recurrence (p = 0.014). High-grade tumors correlated with poor overall survival (p < 0.001). All patients who had a limb-salvage procedure were able to walk at the time of the final follow-up, and they had a mean functional score of 77%, according to the system of the Musculoskeletal Tumor Society. CONCLUSIONS: Aggressive surgical resection of pelvic chondrosarcoma results in long-term survival of the majority of patients. There is a high correlation between tumor grade and overall or disease-free survival.     

Thromboendarterectomy of the symptomatic occluded internal carotid artery.

A retrospective review of 42 patients (mean age 61.4 years) with surgically managed symptomatic internal carotid artery occlusion is reported. A standardized surgical protocol aimed at restoration of flow in the vessel was used. Presenting symptoms included hemispheric transient ischemic attacks in 68% of patients, new fixed neurological deficits in 28%, amaurosis fugax in 28%, and stroke-in-evolution in 9%. Twenty-four arteries were successfully reopened. A proximal remnant angioplasty (stumpectomy) was performed alone in nine patients or in combination with an external carotid endarterectomy in nine. In four patients with persisting symptoms who failed to achieve primary restoration of flow, a superficial temporal-to-middle cerebral artery bypass procedure was performed. The permanent surgical morbidity rate was 2% and the surgical mortality rate was 0%. Transient postoperative deficits were present in three patients (7%). Follow-up review at a mean of 40 months was obtained in 39 patients (93%). Following surgical intervention, five patients died of unrelated causes, two had neurological events consistent with a transient cerebral ischemic attack, and two had vertebrobasilar insufficiency. No patient suffered from stroke. Of the 24 successfully reopened vessels, follow-up ultrasound evaluations were obtained in 17 (73%) at a mean of 28 months after surgery. In 15 patients (88%) the vessels were widely patent, one (5.8%) had stenosis greater than 70%, and one (5.8%) showed asymptomatic reocclusion. Reopening occluded internal carotid arteries in selected patients is associated with low surgical morbidity and mortality rates. Further studies are necessary to determine the impact of this surgical therapy on the natural history of this condition.     

Surgical treatment of Ebstein's malformation: report of 108 cases

OBJECTIVE: To review retrospectively the experience of surgical treatment of Ebstein's malformation in 108 patients. METHODS: One hundred and eight patients with Ebsteins malformation underwent surgical correction, including tricuspid valve annuloplasty in 83 patients (73.4%) and tricuspid valve replacement in 30 (5 with redo-operation). Concomitant procedure included division of the abnormal accessory conduction pathway in 8 patients. RESULTS: The overall hospital mortality was 8.8%. The hospital mortality rate was 10.4% before 1990 and 5.5% after that time. There was a significant difference between the two periods (P < 0.05). The main causes of death were low cardiac output, arrhythmias and right heart failure. The mean follow-up time was 6.3 years. The heart function improved to be NYHA class I or II in 92% of the patients. CONCLUSIONS: Early surgical intervention is recommended for patients with Ebstein's malformation, especially for those with symptoms and cardiac enlargement. Tricuspid valve repair should be performed if anterior leaflet of the tricuspid valve well developed. However, tricuspid valve replacement is advocated if anterior leaflet is dysplastic or its origin displaced.     

A retrospective analysis of ureteropelvic junction obstructions in patients with horseshoe kidney

BackgroundUreteropelvic junction obstruction (UPJO) is often encountered in patients with a horseshoe kidney (HSK) and may require surgical intervention. This study retrospectively investigated obstruction causes in HSK patients with UPJOs to determine the most suitable surgical method.MethodsTwenty HSK patients with UPJO who underwent pyeloplasty between July 2000 and June 2020 and were followed-up for more than six months in our institution were included in the study. The clinical characteristics, obstruction causes, and surgical outcomes were analyzed.ResultsThe median age at the time of the operation was 4.1 years [interquartile range (IQR): 1.8–10.6]. Hydronephrosis (HN) was found prenatally in 5 patients (25.0%). Pyeloplasty was performed by open, laparoscopic, and robotic techniques in 6, 10, and 4 patients, respectively. Sixteen patients (80.0%) had high ureteral insertion. Twelve patients (60.0%) had crossing vessels, and eight had a high ureteral insertion and crossing vessels. The median follow-up duration was 4.0 years (IQR: 1.8–8.9); no patient required additional surgery. The median differential renal function was 38.0% (IQR: 16.9–43.0%) preoperatively and 38.0% (IQR: 13.3–48.2%) postoperatively.ConclusionsUPJOs in HSKs were primarily caused by a high ureteral insertion and crossing vessels. Dismembered pyeloplasty was successfully performed in all surgical modalities such as the open, laparoscopic, and robotic approaches. Attention must be given to patients with HSKs, even in those without HN, to avoid UPJO development.     

Gastrointestinal stromal tumours: a broad spectrum of clinical presentations

Gastrointestinal stromal tumours, though rare, are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The most frequent sites of origin are the stomach and the small bowel, but they can occur anywhere in the gastrointestinal tract. Mesenteric and retroperitoneal forms have been described. The Authors present their personal experience with the treatment of gastrointestinal stromal tumours, with particular reference to the broad spectrum of clinical presentations and to the consequent therapeutic implications. We report on a retrospective analysis of the clinical presentations and courses, surgical management and pathological features of 27 patients with such tumours treated in our institution from 1993 to 2005. The variables analysed were the morphological and clinical characteristics of the tumours, demographic data, type of surgical treatment and postoperative course. Long-term survival was evaluated on the basis of clinical and/or telephonic follow-up in all patients. One tumour was located in the oesophagus, 14 in the gastric area, 7 in the small bowel, 2 in the colon-rectum, and 3 in the peritoneum. All patients studied received radical surgical treatment. In 7 patients surgical resection was extended to other organs. No postoperative mortality or major postoperative complications were observed. Twenty-two patients are still alive at follow-up. Three patients died as a result of neoplastic relapse and 2 of other causes. The median survival was 36 months. The actuarial 3- and 5-year survival rates were 89.7% and 67.8%, respectively. Our experience indicates that the site of origin of gastrointestinal stromal tumours with their broad spectrum of clinical presentations may influence both the therapeutic choice (neoadjuvant utilisation of imatinib mesylate) and the surgical treatment (wedge resection vs enlarged operations).     

Ten-year survival analysis of the PFC total knee arthroplasty-a surgeon’s first 99 replacements

Ninety-seven patients with 99 total knee arthroplasties were operated on by a surgeon in the first 3 years of his surgical career. Complete survival data were available for all 99 knees. The cases were reviewed at a minimum of 10 years after their initial operation, but as 37 patients had died before reaching 10 years, the average follow-up was 8 years 8 months with a maximum of 12 years 4 months. Ninety-one patients had osteoarthritis, five had rheumatoid arthritis, and three had juvenile chronic arthritis. No patients were lost to follow-up. Four required revision. The 10-year survival rate, using revision for all causes as an end-point, was 94.96%. The survival rate for aseptic loosening was 97.04%. The survival rate for loose joints that had not been revised was 94.13%. Three of the four revisions occurred in the first 6 patients operated upon, suggesting there may be a learning curve for surgeons at this stage in their career.     

Our experience in the transanal excision of tubulovillous adenomas of the rectum]

BACKGROUND: Personal experience on transanal excision of rectal adenomas without affecting sphincteric function is reported. METHODS: From 1985 to 1997, 27 patients suffering from rectal adenomatous polyps underwent surgery; the sites of lesions were within 3 to 10 cm from anal orifice in the whole series; the age of patients ranged from 30 to 81 years. Two different procedures were employed: the Parks' technique and the electroresection by traction flap technique according to Faivre. RESULTS: Any postsurgical complication such as hemorrhage, stenosis or incontinentia occurred; surgical mortality was absent. Histological examination disclosed severe dysplasia as well as in situ carcinoma in 6 patients (22.2%) and malignant polyps in 9 patients (33.3%). Only in a case a palliative excision was performed since the poor general conditions of this patient did not permit a more extended treatment; a local relapse of the tumour associated with liver metastases led the patient to death 22 months after surgery. Three patients were lost to follow-up and 2 patients died because of other causes, 6 and 8 years after surgical excision, respectively. CONCLUSIONS: The conclusions are is drawn that either Park's and Faivre's procedures are useful and safe for the surgical treatment of rectal villous polyps extended up to 8-12 cm from anal orifice, in spite of the presence of malignant foci within their mass. These surgical procedures are simple and relatively poor traumatic; for this reason they are more suitable than other transabdominal or abdomino-perineal approaches for older patients and other at risk-patients. It is underlined that the treated patients require a long-term follow-up aimed at the early diagnosis of possible relapses of adenomatosis.     

Patient-evaluated outcome after surgery for basal meningiomas

OBJECTIVE: To study the outcomes of patients with basal meningiomas treated by one primary surgeon with a philosophy of aggressive surgical management to establish an index of satisfaction and patient-evaluated outcome. METHODS: We collected prospective data for patients with basal meningiomas who were operated on by one primary surgeon (LNS) during a 7-year period from 1993 to 2000. The outcomes in 269 patients were ascertained through follow-up visits, mailed follow-up questionnaires, and telephone interviews by two other surgeons (RA and MN). The mean patient age was 50 +/- 13.6 years. The mean estimated tumor diameter was 3.07 +/- 1.24 cm. There were 62 males and 207 females. Mean follow-up was 49 +/- 26 months. Twenty-seven percent of patients were Levine-Sekhar (LS) Grade 0, 43% were LS Grade I, 24% were LS Grade II, and 6% were LS Grade III. Gross total resection was achieved in 66% of patients. Extent of resection correlated (P < 0.05) with LS grade. Thirty-seven patients received adjuvant treatments, and six patients required reoperations. Perioperative mortality was 1.1%. Eighty percent of patients were discharged home, 17% were discharged to rehabilitation facilities, and 1.5% were discharged to nursing homes. Postoperative complications were observed in 30% of patients. RESULTS: During the follow-up study, of a total of 269 patients, 30 patients could not be contacted, and 11 patients had died of unrelated causes. The mean follow-up Karnofsky Performance Scale score of the patients was 83 +/- 10. Ninety-seven percent of patients were very satisfied/satisfied with their treatments (P < 0.001). Forty-three percent of patients were employed, and 83% of patients were employable. Their expectations of treatment were met in 90% of patients (P < 0.001), 95% thought surgery had been a good treatment choice (P < 0.001), and 95% would recommend the same treatment for a family member (P < 0.001). CONCLUSION: These results demonstrate that patient satisfaction can remain high and satisfactory outcome can be achieved with surgical management in patients with these complex lesions.     

Spinal meningiomas: review of 174 operated cases

The long-term results obtained in a series of 174 patients operated on for spinal meningiomas are critically analyzed. This series was similar to those of other authors with regard to age, sex, location of the tumors, and clinical presentation. Before surgery, about 70% of the patients were included in Groups I and II (mild neurological impairment), and about 30% of the patients were classified in Groups III and IV (significant to severe neurological impairment, up to paraplegia). Complete tumor removal was achieved in 96.5% of the patients, and surgical mortality was about 1%. Microsurgical technique, which was adopted in the last 29 cases, proved to be very effective in reducing undue damage to the spinal cord and in minimizing the postoperative neurological deficits. Of the 174 patients who underwent surgery, 156 underwent late follow-up study for an average of 15 years (2 patients died in the immediate postoperative period, and 16 patients were lost to follow-up). Twenty-nine patients died of causes unrelated to the spinal meningioma; of the remaining 126 patients, 92% were categorized in Groups I and II, and only 8% in Groups III and IV. The rate of recurrence was 6% (9 patients) among the 150 patients who had complete tumor removal, and the rate of regrowth was 17% (1 patient with anaplastic meningioma) among the 6 patients treated by subtotal removal. The early diagnosis of the disease and the use of microsurgical technique appeared as the most relevant factors for further improvement of the surgical results.     

A prospective study of medically treated acute type B aortic dissection.

OBJECTIVE: To study prospectively aneurysm formation, need of surgery, incidence of rupture and mortality in patients with conservatively treated acute type B aortic dissection. METHODS: All patients referred to us with acute type B dissection between January 1990 and December 2001 were candidates for this prospective treatment and follow-up study. Patients deemed not to be in need of acute surgical repair were included after aggressive antihypertensive treatment. The follow-up protocol included close blood pressure control, clinic visits with physical examination, chest x-ray and spiral CT or MRI at 3 and 6 months and annually thereafter. RESULTS: Sixty-six patients were followed for a mean of 79 months (range 22-179). The actuarial survival rate was 82% at 5 years and 69% at 10 years. Eighty-five percent remained free from dissection-related death at 5 years and 82% at 10 years. Ten patients (15%) developed aneurysm (>6 cm) of the dissected aorta. Three of these 10 patients died from aortic rupture and 2 underwent elective surgical repair. Of the 56 patients without aneurysm, one died from rupture and one died suddenly for causes unknown. One patient was treated with endovascular stent-graft. Five patients sustained a new type A aortic dissection which in all but one were fatal. In 26 patients the initial dissection was categorized as intramural hematoma. Twelve of these patients had, in addition to the hematoma, areas with localized dissection/ulcer-like projection. The latter was found to be a predictor of aortic event (dissection-related death, rupture, new type A aortic dissection, aneurysm formation) during follow-up, as was an initial diameter of >4.0 cm at first CT-scan during the acute event. CONCLUSIONS: Conservatively treated acute type B dissection has a low incidence of aneurysm formation and rupture during the chronic phase. These results must be matched or improved upon before endovascular stent-grafting or early aortic surgical repair can be regarded as the primary treatment of choice.     

Endovascular repair versus open surgery in patients with ruptured abdominal aortic aneurysms: clinical outcomes with 1-year follow-up

OBJECTIVE: To compare the clinical outcomes of treatment after endovascular repair and open surgery in patients with ruptured infrarenal abdominal aortic aneurysms (AAAs), including 1-year follow-up. METHODS: All consecutive conscious patients with ruptured infrarenal AAAs who presented to our tertiary care teaching hospital between January 1, 2001, and December 31, 2005, were included in this study (n = 55). Twenty-six patients underwent endovascular repair, and 29 patients underwent open surgery. Patients who were hemodynamically too unstable to undergo a computed tomography angiography scan were excluded. Outcomes evaluated were intraoperative mortality, 30-day mortality, systemic complications, complications necessitating surgical intervention, and mortality and complications during 1-year follow-up. The statistical tests we used were the Student t test, chi2 test, Fisher exact test, and Mann-Whitney U test (two sided; alpha = .05). RESULTS: Thirty-day mortality was 8 (31%) of 26 patients who underwent endovascular repair and 9 (31%) of 29 patients who underwent open surgery (P = .98). Systemic complications and complications necessitating surgical intervention during the initial hospital stay were similar in both treatment groups (8/26 [31%] and 5/26 [19%] for endovascular repair, respectively, and 9/29 [31%] and 8/29 [28%] for open surgery, respectively; P > .40). During 1-year follow-up, two patients initially treated with endovascular repair died as a result of non-aneurysm-related causes; no death occurred in the open surgery group. Complications during 1-year follow-up were 1 (5%) of 20 for endovascular repair and 4 (16%) of 25 for open surgery (P = .36). CONCLUSIONS: On the basis of our study with a highly selected population, the mortality and complication rates after endovascular repair may be similar compared with those after open surgery in patients treated for ruptured infrarenal AAAs.     

Reoperative surgery for postcholecystectomy bile duct injuries

BACKGROUND: Surgical repair for a postcholecystectomy bile duct injury can be complicated by the development of an anastomotic stricture which necessitates re-intervention. The authors reviewed their experience with patients requiring re-operation after unsuccessful surgical repair of the bile duct injury, to analyze the possible causes of the failure of the operative procedure and the long-term outcome following revisional surgery. METHODS: Retrospective analysis of the records of 41 patients referred to a tertiary care center for the management of recurrent stricture following surgical repair performed for a postcholecystectomy bile duct injury. RESULTS: Before referral, 69 operative procedures had been performed on these 41 patients. Factors likely to be associated with increased chances of failure of the biliary reconstructive procedures included presentation with cholangitis after the biliary injury, no cholangiographic study before the surgical repair and surgical intervention within 3 weeks of the injury. Thirty-seven (90%) patients were found to have strictures at or above the level of confluence of right and left hepatic ducts, while at the time of the index repair only 12 (29%) patients had an injury at that level. Revisional surgery in all the patients was a Roux-en-Y hepaticojejunostomy. One patient died, 2 patients with multiple previous operations developed recurrence and needed intervention again. Over a mean follow-up period of 4.2 years, 90% patients had a satisfactory outcome. CONCLUSION: Development of recurrent stricture following surgical repair of a postcholecystectomy biliary injury can be related to the technique and timing of the surgical procedure, the complication may therefore be avoidable in some patients. In experienced hands the results of revisional surgery are good but are adversely affected as the number of previous repairs increases.     

Varicose vein recurrence after surgery of the sapheno-femoral junction: color Doppler ultrasonography study

The aim of this study was to evaluate the accuracy and sensitivity of colour Doppler ultrasonography for the diagnosis of postoperative recurrent varicose veins in patients submitted to surgical ligation of the saphenofemoral junction with a view to classifying the recurrences according to the causes. We studied 401 lower limbs in the orthostatic position with colour Doppler ultrasonography in 318 patients (64 M and 254 F) presenting postoperative varicose vein recurrence during the follow-up (12-60 months). We evaluated the type of reflux at the inguinal level under the Valsalva manoeuvre and divided them into 5 types. We observed an incomplete crossectomy (type 1) in 23.2% of the cases; an incontinent saphenofemoral junction, intact and in an anatomical site in 12.5% (type 2); a major tributary (double saphena) originating from the common femoral vein near to the crossectomy site in 10.2% (type 3); neovascularization in 9.7% (type 4) and the presence of a number of major tributaries from the veins of the perineal and pudendal region or from the abdominal parietal veins in 44.4% (type 5). In all cases it was possible to note and classify the type of recurrence. Colour Doppler ultrasonography is an accurate, reliable tool for the diagnosis and classification of postoperative varicose vein recurrences in patients submitted to surgical obliteration of the saphenofemoral junction. It is decisive in the preoperative evaluation and follow-up of patients. In our experience, more than one half of the cases of recurrence were not due to an error of surgical technique.     

Subintimal recanalization is safe and effective in treating chronic critical limb ischemia in selected patients

Subintimal recanalization is a percutaneous technique that allows revascularization in patients with limb-threatening ischemia. It was first described by Bolia (Cardiovasc Intervent Radiol 13;357-63:1990) but has not gained widespread use in the United States. Twenty-five patients with 32 threatened limbs were referred from a single surgeon's practice over a 23-month period. All patients were either high-risk surgical patients, due to severe medical comorbidities, or not surgical candidates due to poor target vessels, lack of appropriate conduit, or failed previous surgical revascularizations. The average age of patients was 69. There were 15 men and 10 women treated. Subintimal recanalization was immediately successful in 30 limbs. One peri-procedural death occurred, although this patient underwent a surgical bypass graft procedure in the same hospitalization. Three significant complications occurred (myocardial infarction, ventricular arrhythmia, and gastrointestinal hemorrhage). Primary patency is 83 per cent. Secondary patency is 90 per cent. Limb salvage rate is 88 per cent. Mean follow-up period is 10 months. Eight patients died in the follow-up period due to unrelated causes.     

Revision of failed foot surgery: a critical analysis.

The purpose of this study was to consider the causes of patient dissatisfaction following foot surgery and review whether poor outcomes are more commonly associated with particular techniques. Two hundred forty-four patients who had previously undergone foot surgery were referred to a podiatric surgery service because of continued pain, disability, footwear-fitting problems, and cosmetic concerns. The majority of cases had previously undergone first ray surgery to correct hallux valgus. The most common reason for referral was transfer metatarsalgia followed by recurrence of hallux valgus and lesser digit deformity. Thirty-two patients were treated with conservative measures, including orthoses and cortisone injections. Eight patients (25%) were completely satisfied with conservative treatment, 20 patients (63%) were satisfied with reservations, and four patients (12.5%) were dissatisfied. One hundred seventy-six patients underwent revision surgery. High patient satisfaction was achieved with surgical revision with 123 patients (69%) completely satisfied at an average 5.6-month follow-up, 43 patients (24%) were satisfied with reservations, while 10 patients (6%) were dissatisfied. Complications occurred in 23 patients (13%) with nine cases developing a superficial postoperative infection. In reviewing this series of patients, it is apparent that poor surgical outcomes and the need for revision surgery could in many cases be prevented with selection of surgical techniques that avoid joint destruction, excessive shortening of single metatarsals, and digital amputation.     

Infantile nontumoral aqueductal stenosis

A surgical series of 144 infantile triventricular hydrocephalus (from nontumoral aqueductal stenosis) operated on in the period 1957-1982 is presented. The etiological factors, preoperative clinical and anatomical status of the patients are summarized. Their surgical career, the reasons, for revision operations and causes of death are analyzed in relation to each of the four operations performed: ventriculocisternostomies according to Stookey-Scharff or Torkildsen, extrathecal shunts (VA or VP). 46 patients required 72 revision operations, but 23 more patients were lost to follow-up after the first operation. 3 patients (2.0%) died after the first operation, 7 (4.8%) on revision and 18 (12.5%) sometime later. A recent clinical and instrumental review of the physical, neurological and mental status of the remaining 93 patients (64.5% of the total series) has showed that 50 (34.8%) are well or very well; 35 (24.3%) have residual deficits, and 8 (5.4%) are severely handicapped.