Long-term evaluation of direct repair of traumatic isthmic aortic transection

Direct repair of traumatic aortic isthmic transection eliminates the late complications of prosthetic graft repair. This study evaluates the long-term fate of direct aortic repair to which little attention has been paid. Among 32 patients operated upon from 1965 to 1987, 27 (84%) underwent direct repair. The tear was circumferential in 15 patients and partial in 12. Multiple traumatic lesions were present in 26 patients, including intracranial injury in 19. Partial cardiopulmonary bypass was used in 15 patients and simple aortic cross-clamping in 12. No paraplegia was observed. There were 4 deaths from associated lesions among the 14 patients operated upon for acute traumatic isthmic transection and no deaths in the others. Among the 23 survivors, 4 were lost to follow-up; the other 19 patients have excellent clinical results. Intravenous digital aortic angiography performed in 14 patients at a mean delay of 5 years 3 months showed excellent aortic reconstruction in all cases. Technically more demanding and faster than a graft interposition, direct repair is recommended as the procedure of choice in the surgical treatment of traumatic isthmic transection, particularly in young patients, the group most at risk from this lesion.     

Selective instrumentation,reduction and repair in low-grade isthmic spondylolisthesis

We treated 32 patients with low-grade (<30%) isthmic spondylolisthesis at L5–S1 with selective instrumentation, reduction of the slip, resection of the pseudoarthrosis adding autologous bone grafting and decompressing the root canal. The ages ranged from 18 to 54 years. After a mean of 3.4 (1–7) years, we found good radiological and clinical results in 27 patients. Five patients lost correction, of whom three were asymptomatic whereas two required fusion of L5–S1. We think this technique is a useful surgical option for select patients.

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Résumé Nous avons traité 32 malades avec un spondylolisthésis isthmique L5-S1 de bas degré (<30%) avec décompression radiculaire, réduction du glissement, résection de la pseudarthrose et greffe osseuse autologue. Lâge des patients variait de 18 à 54 ans. Après une moyenne de 3,4 (1–7) années nous avons trouvé de bons résultats radiologiques et cliniques pour 27 malades. Cinq malades avaient perdu la correction, trois étaient asymptomatiques alors que deux ont nécessité une fusion L5-S1. Nous pensons que cette technique est une option chirurgicale utile pour des malades sélectionnés.

     

Correlation between correction of pelvic balance and clinical outcomes in mid- and low-grade adult isthmic spondylolisthesis

Background

Pelvic balance is a version of the pelvis defined by pelvic orientation parameters of PT and SS. Two distinct versions of pelvis are defined: (1) balanced characterized by a relatively low PT and high SS, and (2) unbalanced with relatively high PT and low SS meaning excessive retroversion of the pelvis. It was proved for patients with a high-grade spondylolisthesis that rebalancing of the pelvis can positively affect clinical outcomes. Little is known about the impact of such rebalancing in low-grade isthmic spondylolisthesis.

Purpose

To determine whether clinical outcomes correlated with rebalancing of the pelvis after surgical correction of mid- and low-grade adult isthmic spondylolisthesis.

Methods

One hundred and three adult patients with a mid- and low-grade isthmic slip were the participants. Clinical outcomes were assessed at least 2 years after the surgery with the use of the Oswestry Disability Index (ODI) and a back pain visual analogue scale. Statistical analysis was used to identify differences in clinical outcomes between patients (1) with a balanced and unbalanced pelvis postoperatively, (2) who regained and did not regain pelvic balance postoperatively, (3) who maintained and lost pelvic balance postoperatively, and (4) with reduced and increased postoperative PT.

Results

There were no significant differences in clinical outcomes between patients with a balanced and unbalanced pelvis postoperatively regardless of whether they lost, maintained, or regained pelvic balance after the surgery (Student’s t test for independent variables or the non-parametric Mann–Whitney U, p value = 0.05). No correlation (Spearman’s rank correlation) was found between postoperative reduction of PT and postoperative: (1) level of back pain (r = ?0.10, p = 0.3063), (2) degree of reduction in back pain (r = 0.03, p = 0.7927), (3) ODI scores (r = ?0.18, p = 0.0696), and (4) degree of reduction in ODI scores (r = 0.13, p = 0.1893).

Conclusions

Radiological improvement of pelvic balance after surgical correction of mid- and low-grade isthmic spondylolisthesis did not correlate with clinical outcomes.

     

Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature

The objective of this study was to evaluate which fusion technique provides the best clinical and radiological outcome for adult low-grade lumbar isthmic spondylolisthesis, and to assess the overall clinical and radiological outcome of each fusion technique. A systematic review was performed. Medline, Embase, Current Contents, and Cochrane databases as well as reference lists of selected articles were searched. Randomised controlled trials (RCTs) were used to evaluate the best treatment; controlled studies and non-controlled studies were used to determine the outcomes after surgery. Two independent reviewers evaluated the studies with the methodological checklists of van Tulder and Jadad for the randomised studies and of Cowley for the non-randomised studies. The search resulted in 684 references and eventually 29 studies met the inclusion criteria, of which eight were RCTs, four were prospective, and 17 were retrospective case series. Ten of the case series did not clearly identify consecutive patient selection. All the eight RCTs evaluated the effect of different techniques of posterolateral fusion (PLF). Evidence was found that the PLF was superior to non-operative treatment (exercise). Circumferential fusion was compared to PLF, but no difference could be found. PLF with or without instrumentation was evaluated in three studies, but no benefits from additional instrumentation were found. Other comparisons within PLF showed no effect of decompression, alternative instrumentation, or bone graft substitute. The 21 case series included 24 patient groups. PLF was used in 15 groups, good or excellent clinical outcome varied from 60 to 98% and fusion rate varied from 81 to 100%. Anterior interbody fusion was used in five groups, good or excellent clinical outcome varied from 85 to 94% and fusion rate varied from 47 to 90%. Posterior interbody fusion was used in two groups, good or excellent clinical outcome was 45% and fusion rate was 80 and 95%, respectively. Reduction, loss of reduction, and lordotic angles before and after the treatment was reported in only four studies. Average reduction achieved was 12.3%, average loss of reduction at follow-up was 5.9%. Preoperative lordotic angles were too heterogeneous to pool the results. Adjacent segment degeneration was not reported in any of the publications. A wide variety of complications were reported in 18 studies and included neurological complications, instrument failure, and infections. Fusion for low-grade isthmic spondylolisthesis has better outcomes than non-operative treatment. The current study could not identify the best surgical technique (PLF, PLIF, ALIF, instrumentation) to perform the fusion. However, instrumentation and/or decompression may play a beneficial role in the modern practice of reduction and fusion for low-grade isthmic spondylolisthesis, but there are no studies yet available to confirm this. The outcomes of fusion are generally good, but reports vary widely.     

Preoperative evaluation of adult isthmic spondylolisthesis with diskography

Fourteen consecutive patients with a diagnosis of isthmic spondylolisthesis (grade I and II) underwent provocative lumbar diskography (L2-S1) to evaluate the disk adjacent to the spondylolisthesis. Seven (50%) of 14 patients had concordant pain at the disk above the slip and 2 patients had no pain at the slip level. Surgical treatment included anteroposterior fusion of the slip level and any adjacent concordant levels. Clinical results included 3 excellent, 7 good, 2 fair, and 1 poor outcome. This data supports the hypothesis that the disk adjacent to an isthmic slip is predisposed to symptomatic degeneration in the adult patient with axial pain. It does not prove that a fusion is indicated or that clinical outcomes would be improved with this approach.     

Correlation of ventricular septal defect height and outcomes after complete atrioventricular septal defect repair

 Open in a separate windowOBJECTIVESThere are limited data available on the height of the ventricular component of the septal deficiency (VSD) in patients undergoing complete atrioventricular septal defect (CAVSD) repair. VSD height may influence optimal choice of repair strategy with potential consequences for long-term outcomes. We aimed to measure VSD height using 2-dimensional echocardiography and review its association with postoperative outcomes.METHODSWe retrospectively reviewed the preoperative echocardiograms of 45 consecutive patients who underwent CAVSD repair between May 2010 and December 2015 at a single centre. VSD height and left ventricular length on the four-chamber view were measured. Demographic details and early and late outcomes including reoperation and long-term survival were studied.RESULTSTwenty patients underwent modified single-patch repair and 25 patients underwent double-patch repair of CAVSD. VSD height in the modified single-patch group ranged from 4.2 to 11.7 mm and in the double-patch group ranged from 5.1 to 14.9 mm. Nine patients had a deep ‘scoop’ with a VSD height of >10 mm, (7 double patch, 2 modified single patch). VSD height did not correlate with a specific Rastelli classification. There was no significant difference in the VSD height (P = 0.51) or the VSD height-to-left ventricular length ratio (P = 0.43) between the 2 repair groups. There was no 30-day mortality. Eight patients required reoperation; however, VSD height was not a significant predictor of reoperation (hazard ratio 0.95, 95% confidence interval 0.69–1.33; P = 0.08).CONCLUSIONSThere was no correlation between VSD height and risk of reoperation after CAVSD repair. A deep ventricular scoop is uncommon in CAVSD patients.     

Long-term outcome after spinal fusion for isthmic spondylolisthesis in adults

BACKGROUND CONTEXT

Data on the long-term outcome after fusion for isthmic spondylolisthesis are scarce.

节段内修复手术治疗腰椎峡部裂及轻度峡部裂性滑脱的疗效分析

目的探讨节段内直接修复手术对于腰椎峡部裂及轻度峡部裂性滑脱的疗效。方法回顾2010-01-2015-06收治并手术治疗的55例腰椎峡部裂及小于Meyerding I°峡部裂性滑脱病例。按术式分为修复组(15例)及融合组(40例),统计各组术前及末次随访时的VAS评分、ODI指数以及腰椎活动度,同时统计各组手术时间及术中出血量以及并发症情况,结果以SPSS 19.0进行相关数据统计分析。结果两组患者一般资料无显著性差异(P0.05),末次随访两组VAS评分及ODI指数均较术前显著改善(P0.05),末次随访两组间VAS评分及ODI指数无显著差异(P0.05),但修复组腰椎活动度大于融合组(P0.05),修复组翻修率明显高于融合组(P0.05)。结论对于单纯腰椎峡部裂及伴轻度滑脱的患者,修复手术与融合手术疗效相当,且其有利于保留腰椎的活动度,但其手术翻修率相对较高。     

A systematic review of clinical outcomes in surgical treatment of adult isthmic spondylolisthesis

Background Context

A variety of surgical methods are available for the treatment of adult isthmic spondylolisthesis, but there is no consensus regarding their relative effects on clinical outcomes.

Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade

OBJECTIVE: The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes. METHODS: During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis. RESULTS: Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87 (10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years. CONCLUSIONS: EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.     

Long-term outcomes after native tissue vs. biological graft-augmented repair in the posterior compartment

Introduction and hypothesis  

We aimed to compare the outcomes of native tissue vs. biological graft-augmented repair in the posterior compartment. We hypothesized that the addition of graft would result in superior anatomic and functional outcomes.     

腰椎椎弓峡部裂伴I°滑脱单纯峡部植骨与椎弓根钉内固定的疗效对比研究

目的对腰椎椎弓峡部裂伴Ⅰ°滑脱行嵌入式单纯峡部植骨与植骨加用椎弓根钉内固定的临床疗效进行比较.方法对43例腰椎椎弓峡部裂伴I°滑脱患者随机行嵌入式单纯峡部植骨20例、植骨加用椎弓根钉内固定23例,随访22～115个月,平均47个月.根据随访X线片和症状改善情况,统计植骨融合率和疗效优良率,并进行比较.结果嵌入式单纯峡部植骨和植骨加用椎弓根钉内固定的融合率分别为85%和91.3%,优良率分别为85%和91.3%,统计学分析无显著差异,但前者并发症少于后者.结论对于腰椎椎弓峡部裂伴I°滑脱患者两种治疗方法均能取得满意疗效,单纯嵌入式植骨的术式简单、并发症少,但卧床时间较长.     

Long-term results of mitral valve regurgitation after surgical repair of incomplete atrioventricular septal defect

Although the postoperative outcome in patients with incomplete atrioventricular septal defect (iAVSD) is excellent, deterioration of mitral valve regurgitation (MR) is still remained to be resolved. Therefore, this study was undertaken to compare surgical procedures for mitral cleft repair with their long-term results of MR. From 1991 to 1996, 52 patients underwent surgical repair of iAVSD. Age at operation ranged from 2 months to 62 years old with mean age of 14.2 years. Mean follow-up period was 8.6 +/- 4.4 years. All patients underwent patch closure of ostium primum defect. Two patients did not have cleft (Group A). Seven patients did not close the cleft at all (Group B), while 40 patients had the repair of valve by closing cleft near septal attachment only (Group C). The latest 3 patients had the complete closure of cleft from annulus to margin of leaflet where chorda is attached. MR was evaluated by echocardiography grading 0 to IV and regurgitation more than grade II was considered to be significant. In Group A, MR remained grade I. In Group B, MR was deteriorated in 5 patients (71%). Consequently, 6 patients (86%) had grade II or more regurgitation and 4 patients (57%) revealed grade III/IV regurgitation including one (14%) reoperation. In Group C, MR was deteriorated in 10 patients (55%). Consequently, 22 patients (86%) had grade II or more regurgitation and 5 patients (13%) had grade III/IV regurgitation including 3 (7.5%) reoperations. In Group D, no deterioration of MR was noted and all had grade I or less regurgitation. These results suggest that the closure of cleft near septal attachment is not sufficient to prevent MR in late phase and the complete closure of cleft from annulus to margin of leaflet, where chorda is attached, would be useful to prevent the deterioration of MR in late phase.     

Long-term outcomes in laparoscopic vs open ventral hernia repair

OBJECTIVE: To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair. DESIGN AND SETTING: Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Statistical analysis was performed by Fisher exact test and analysis of variance. PATIENTS: Between October 1995 and December 2005, data from 360 consecutive patients who had undergone open or laparoscopic intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected in a database and were supplemented by record review. MAIN OUTCOME MEASURES: Morbidity, hernia recurrence, and length of hospital stay. Postoperative complications of Clavien grade II or greater were considered major complications. RESULTS: Intraperitoneal onlay mesh repair was performed in 233 patients by the open approach and in 127 patients using the laparoscopic approach. The groups were similar for sex and body mass index (calculated as the weight in kilograms divided by the height in meters squared); the mean age of the laparoscopic group was 3 years younger; and the mesh was larger in the laparoscopic group. Mean follow-up was 30 and 36 months for the laparoscopic and open groups, respectively; the conversion rate was 4%. Major morbidities were 15% in the open group vs 7% in the laparoscopic group (P = .01). Recurrence rates were 9% in the open group vs 12% in the laparoscopic group (P = .36). Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% vs 16%, respectively; P<.05). CONCLUSIONS: Outcomes did not differ with respect to recurrence rates after long-term follow-up; however, the lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.