Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?

A best evidence topic was written according to a structured protocol. The question addressed was whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival in patients with an aortic root aneurysm suitable for an aortic valve-sparing operation. In total, 392 papers were found using the reported search criteria, of which 14 papers provided the best evidence to answer the clinical question. A total of 1338 patients (Yacoub technique in 606 and David technique in 732) from 13 centres were included. In most series, cardiopulmonary bypass time and aortic cross-clamp time were longer for the David technique compared to the Yacoub technique. Early mortality was comparable between the two techniques (0-6.9% for the Yacoub technique and 0-6% for the David technique). There is a tendency for a higher freedom from significant long-term aortic insufficiency in the David group than the Yacoub group, which does not necessarily result in a higher reoperation rate in the Yacoub group. In the largest series reported, freedom from a moderate-to-severe aortic insufficiency at 12 years was 82.6 ± 6.2% in the Yacoub and 91.0 ± 3.8% in the David group (P=0.035). Freedom from reoperation at the same time point was 90.4 ± 4.7% in the Yacoub group and 97.4 ± 2.2% in the David group (P=0.09). In another series, freedom from reoperation at a follow-up time of about four years was 89 ± 4% in the Yacoub group and 98 ± 2% in the David group. Although some authors merely preferred the Yacoub technique for a bicuspid aortic valve, the accumulated evidence in the current review indicates comparable results for both techniques in a bicuspid aortic valve. Current evidence is in favour of the David rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity. Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in aortic valve-sparing operations.     

Protecting podocytes: how good do we need to be?

Progression of many glomerular diseases has been firmly tied to a loss of podocytes, followed by a deterioration of glomerular architectural stability eventuating in segmental, and ultimately global, sclerosis. Recent studies have begun to clarify the nature of the autonomous (disease-independent) aspects of this process, as well as to explore mechanistically the 'unreasonable effectiveness' of angiotensin blockade in slowing glomerular disease progression. Quantitative monitoring of podocyte loss (e.g., to assess therapy) remains a challenge.     

Aortic graft infections: is there still a role for axillobifemoral reconstruction?

Infection of an aortic prosthesis is a severe condition with high morbidity and mortality rates. Surgical treatment of an infected aortic graft focuses on treatment of the infection and maintaining or restoring perfusion of the lower limbs. Traditionally, this is done by removing the graft, extensive debridement, and constructing an extra-anatomic bypass, usually an axillobifemoral bypass (AXBF). The disappointing early results of these extra-anatomic bypass reconstructions prompted various surgeons to develop new surgical treatment options to secure lower limb perfusion. With the upcoming role of in situ reconstructions, AXBF is being scrutinized. Patients with an infected aortic graft are often critically ill, and the interplay of patient fitness and seriousness of the disease must lead to a tailor-made treatment strategy. Most in situ reconstructions have surpassed AXBF in almost every aspect. After having held the position of gold standard for years, AXBF is now part of a wide array of treatment options with limited indications.     

Appendix mass: do we know how to treat it?

INTRODUCTION: The traditional management of appendiceal mass has been an initial conservative approach followed by interval appendicectomy. More recently, the necessity of interval appendicectomy has been questioned by a growing amount of evidence in the surgical literature. The aim of this study was to review the available scientific evidence and to determine how appendiceal masses are currently being managed in the Mid-Trent region by general surgeons. PATIENTS & METHODS: A literature search using Medline, Embase, Cinahl, HMIC and Biosis was carried out. A personal or telephonic survey of all consultants and specialist registrars working in general surgery in the Mid-Trent region (n = 67) was conducted recording their management protocol of 3 different clinical scenarios--a 14-year-old boy, a 29-year-old female and a 68-year-old male. Responses of the questionnaire were entered to a database in Microsoft Access 2000 and analysed. RESULTS: The results showed that there was difference of opinion on the management of appendix mass in either scenario. Appendectomy (interval or emergency) is still practised by 75% of general surgeons in the Mid-Trent region and less that 25% manage asymptomatic appendix mass without interval appendectomy. Additionally, specialist registrars appear more likely not to offer patients interval appendicectomy after successful conservative management (P < 0.05). CONCLUSIONS: At present, there is no agreed consensus on the management of appendiceal mass. There is a need to develop a protocol for the management of this common problem.     

Who is responsible for operating room management and how do we measure how well we do it?

BACKGROUND: Managing the surgical process in the operating suite - often the most expensive unit in the hospital - is vital, yet challenging. While sensible management can improve efficiency, unclear managerial structures can hinder the optimal use of resources. Despite that, no previous data exists as to how the operating room management is organized and the performance monitored in our country. METHODS: A survey was sent to chief anesthesiologists and head nurses of 103 surgery units of 60 public hospitals regarding the current structures of daily management, as well as metrics and tools used for monitoring the performance of the operating room. RESULTS: The overall response rate was 87%. Nurses' and anesthesiologists' perceptions differed significantly on which care provider they held responsible for the daily operative management of the operating room. In doctors' opinion, that person was an anesthesiologist - either alone or in combinations - more often than in nurses' opinion (66% vs. 35%, P < 0.001). Anesthesiologists' involvement increased by the type and size of the hospital, being greatest in the university hospitals. Operating room performance was measured most often by number of procedures in a time unit, utilization and turnover time. Monitoring was complicated by old-fashioned information systems, and seldom seemed to lead to organizational changes. CONCLUSION: The structure of the daily operative management of an operating room needs redefining. There should be more focus on collaboration and communication between the care providers.     

Starting dialysis is dangerous: how do we balance the risk?

Recent studies of timing of dialysis initiation have challenged the recent trend to earlier initiation of therapy. The observed outcomes though are a consequence of the balance between the risks of advanced uremia versus the inherent dangers relating to dialysis therapy itself. Many of these risks are inherent in how dialysis treatment is currently carried out, and may indeed be amenable to mitigation, through refinement of clinical practice (and potentially modality choice). This article aims to lay out a discussion relating to patient outcomes being the composite result of this balance, pivoting on the vulnerability of a particular patient to these attendant risks.     

Clinical pig liver xenotransplantation: how far do we have to go?

As pigs are currently the preferred species for organ xenotransplantation, initial experience in liver xenotransplantation with wild-type (WT) pigs, advances in the development of genetically modified pigs, and recent studies using livers from them are reviewed. The xenotransplantation of livers from pigs transgenic for the human complement regulatory protein (CRP) CD55 or from α1,3-galactosyltransferase gene-knockout pigs+/- additionally transgenic for the CRP CD46 (GTKO/CD46 pigs) is associated with the survival of approximately 1 week. Satisfactory hepatic function has been documented, lending support to the concept that the pig liver might provide a bridge to allotransplantation. However, although significant features of rejection have not been documented, the development of an immediate thrombocytopenia after graft reperfusion is problematic and leads to spontaneous hemorrhage within the body cavities, native organs, and graft. Current studies are being directed to understand the factors causing the activation, aggregation, or phagocytosis of platelets, in particular the interaction between platelets and liver sinusoidal endothelial cells, hepatocytes, and Kupffer cells. If this problem can be resolved, a clinical trial of pig liver xenotransplantation as a bridge to allotransplantation may be both feasible and justified.