Open versus laparoscopic right hemicolectomy in the elderly population

AIM:To compare short term outcomes of elective laparoscopic and open right hemicolectomy(RH) in an elderly population.METHODS:All patients over the age of 70 undergoing elective RH at Ninewells Hospital and Perth Royal Infirmary between January 2006 and May 2011 were included in our analysis.Operative details,hospital length of stay,morbidity and mortality was collected by way of proforma from a dedicated prospective database.An extracorporeal anastomosis was performed routinely in the laparoscopic group.The primary endpoints for analysis were morbidity and mortality.Our secondary endpoints were operative duration,length of hospital stay and discharge destination.RESULTS:Two hundred and six patients were included in our analysis.One hundred and twenty-five patients underwent an open resection and 81 patients had a laparoscopic resection.The mean operating time was significantly longer in the laparoscopic group(139 ± 36 min vs 197 ± 53 min,P = 0.001).The mean length of hospital stay was similar in both groups(11.2 ± 7.8 d vs 9.6 ± 10.7 d,P = 0.28).The incidence of postoperative morbidities was 27% in the open group and 38% in the laparoscopic group(P = 0.12).Overall inhospital mortality was 0.8% in open procedures vs 1% in laparoscopic.CONCLUSION:Laparoscopic RH was associated with a significantly longer operative time compared to open RH.In our study,laparoscopic RH was not associated with reduced post-operative morbidity or significantly shorter length of hospital stay.     

Surgical treatment of complicated traumatic aneurysm and arteriovenous fistula

Objective: To evaluate the surgical methods and the outcome of management for traumatic arterial aneurysm(TAA) and traumatic arteriovenous fistula (TAVF). Methods : A total of 121 patients with TAA or TAVF were treated by surgery. Clinical, operative and postoperative data were collected and analyzed retrospectively. Results : The surgical techniques included aneurysmectomy and arterial end-to-end anastomosis or vascular grafting or artery ligation, aneurysm ligation and bypass, vascular repair, fistula excision and vascular ligation or vascular grafting or repair and so on. One patient died (0.83%). The follow-up rates of TAA and TAVF were 65.7% and 60% respectively. Conclusions: Complicated TAA and TAVF in different sites should be treated with different methods.     

Bowel anastomoses: The theory, the practice and the evidence base

Since the introduction of stapling instruments in the 1970s various studies have compared the results of sutured and stapled bowel anastomoses. A literature search was performed from 1960 to 2010 and articles relating to small bowel, colonic and colorectal anastomotic techniques were reviewed. ?eferences from these articles were also reviewed, and relevant articles obtained. Either a stapled or sutured gastrointestinal tract anastomosis is acceptable in most situations. The available evidence suggests that in the following situations, however, particular anastomotic techniques may result in fewer complications: A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. A stapled side-to-side anastomosis is likely also preferable after an ileocolic resection for Crohn’s disease. Colorectal anastomoses can be sutured or stapled with similar results, although the incidence of strictures is higher following stapled anas-tomoses. Following reversal of loop ileostomy there is some evidence to suggest that a stapled side-to-side anastomosis or sutured enterotomy closure (rather than spout resection and sutured anastomosis) results in fewer complications. Non-randomised data has indi-cated that small bowel anastomoses are best sutured in the trauma patient. This article reviews the theory,practice and evidence base behind the various gastro-intestinal anastomoses to help the practising general surgeon make evidence based operative decisions.     

心脏右侧径路纠治心下型肺静脉异位回流

目的 评估经心脏右侧径路纠治心下型完全性肺静脉异位回流方法的价值.方法 2005年9月至2007年12月,采用经心脏右侧进路方法纠治心下型完全性肺静脉异位回流7例.平均年龄(70.57 -44.67)天;平均体重(4.07±0.87)kg.其中3例肺静脉回流梗阻,2例卵圆孔未闭较小.结果 无手术死亡.术后并发症包括:低心排5例,发生肺动脉高压危象3例,呼吸机辅助7天以上2例,肺部感染2例.术后随访6个月至2年,超声检查心房内无残余分流,吻合口无明显梗阻,流速1.20～1.47m/s;心功能:射血分数0.70～0.79,短轴缩短率0.32～0.44;1例出现肺静脉回流的流速增快,其右上肺静脉2.60m/s,右下肺静脉2.12m/s,继续随访中.结论 采用经心脏右侧径路方法纠治心下型完全性肺静脉异位回流,取得了较好效果.手术成功取决于左房与垂直静脉的吻合口大小,保证肺静脉回流无梗阻.

Abstract：

Objective Infracardiac total anomalous pulmonary venous connection, a rare congenital cardiac defect, is associated with high mortality. A modification was designed for the procedure to reduce the post-operative obstruction in the pulmonary venous. Methods From September 2005 to December 2007, seven patients with infracardiac total anomalous pulmonary venous connection were treated with repair surgery through right side approach. The patients' age at operation was (70.57 ±44.67) days , the weight was (4.07 ±0.87) kg. Three patients had pulmonary venous obstruction, and 2 with small PFO. A modified right - side approach for repairing this defect was used. Results No death occurred after the operation. The postoperative complications included low cardiac output in 5 patients (71.43%), pulmonary hypertension crisis in 3patients ( 42.86% ) , mechanical ventilation for more than 7 days, which happened in 2 patients (28.58%) and pulmonary infection. All of the patients received follow-up. No residual shunt and pulmonary venous return obstruction were identified on echocardiogram(with a velocity from 1.2 m/s to 1.47 m/s). The heart function of patients was within the normal range(EF 0.70 -0.79, FS 0.32 -0.44). Conclusion The modified surgical procedure for the correction of infracardiac total anomalous pulmonary venous connection by right side approach was associated with favorite clinical outcomes, The post-operative outcomes depended on the size of anastomosis between the common vein and left atrium and the patency of the pulmonary venous return. Adequate size of anastomosis and maintenance of the spatial structures in adjacent regions were helpful in decreasing the adverse effect of postoperative obstruction.     

Risk factors associated with the progression of extra-axial hematoma in the original frontotemporoparietal site after contralateral decompressive surgery in traumatic brain injury patients

Purpose:To introduced our experience with progressive extra-axial hematoma(EAH)in the original frontotemporoparietal(FTP)site after contralateral decompressive surgery(CDS)in traumatic brain injury patients and discuss the risk factors associated with this dangerous situation.Methods:This retrospective study was conducted on 941 patients with moderate or severe TBI treated in Daping Hospital,Army Medical University,Chongqing,China in a period over 5 years(2013e2017).Only patients with bilateral lesion,the contralateral side being the dominant lesion,and decompressive surgery on the contralateral side conducted firstly were included.Patients were exclude if(1)they underwent bilateral decompression or neurosurgery at the original location firstly;(2)although surgery was performed first on the contralateral side,surgery was done again at the contralateral side due to rebleeding or complications;(3)patients younger than 18 years or older than 80 years;and(4)patients with other significant organ injury or severe disorder or those with abnormal coagulation profiles.Clinical and radiographic variables reviewed were demographic data,trauma mechanisms,neurological condition assessed by Glasgow coma scale(GCS)score at admission,pupil size and reactivity,use of mannitol,time interval from trauma to surgery,Rotterdam CT classification,type and volume of EAH,presence of a skull fracture overlying the EAH,status of basal cistern,size of midline shift,associated brain lesions and types,etc.Patients were followed-up for at least 6 months and the outcome was graded by Glasgow outcome scale(GOS)score as favorable(scores of 4e5)and unfavorable(scores of 1e3).Student's t-test was adopted for quantitative variables while Pearson Chi-squared test or Fisher's exact test for categorical variables.Multivariate logistic regression analysis was also applied to estimate the significance of risk factors.Results:Initially 186 patients(19.8%)with original impact locations at the FTP site and underwent surgery were selected.Among them,66 met the inclusion and exclusion criteria.But only 50 patients were included because the data of the other 16 patients were incomplete.Progressive EAH developed at the original FTP site in 11 patients after the treatment of,with an incidence of 22%.Therefore the other 39 patients were classified as the control group.Multivariate logistic regression analysis showed that both the volume of the original hematoma and the absence of an apparent midline shift were significant predictors of hematoma progression after decompressive surgery.Patients with fracture at the original impact site had a higher incidence of progressive EAH after CDS,however this factor was not an important predictor in the multivariate model.We also found that patients with progressive EAH had a similar favorable outcome with control group.Conclusion:Progressive EAH is correlated with several variables,such as hematoma volumes
10 mL at the original impact location and the absence of an apparent midline shift(<5 mm).Although progressive EAH is devastating,timely diagnosis with computed tomography scans and immediate evacuation of the progressive hematoma can yield a favorable result.     

Operative treatment for cervical fracture and dislocation with blunt unilateral vertebral artery injury

Objective： To investigate risks and clinical effects of operative treatment for cervical vertebral fracture and dislocation associated with unilateral vertebral artery injury. Methods： This group consisted of 76 cases of closed cervical spine trauma combined with unilateral vertebral artery injury （23 cases of bilateral facet dislocation, 28 unilateral facet dislocation and 25 fracture）. All patients underwent prospective examination of cervical spine MRI and vertebral artery two-dimensional time-of-flight （2D TOF） magnetic resonance angiography （MRA）, and anterior cervical decompression. The healthy vertebral artery paths were evaluated before the surgery, and were protected during the surgery according to the anatomical signs. Results： There were no acute or chronic clinical dam- age symptoms in 76 cases after surgery. No neural damage symptoms were observed in patients with normal neural functions. The neural functions of incomplete paralyzed patients were improved in different grades. Conclusions： Reliable anterior operation can produce good results for cervical fracture and dislocation with unilateral vertebral artery injury. Detecting the course of uninjured vertebral artery before operation and locating the anatomical site during operation are effective to avoid damaging vertebral artery of uninjured side.     

Diabetes patients and non-diabetic patients intensive care unit and hospital mortality risks associated with sepsis

AIM:To compare mortality risks associated with known diabetic patients to hyperglycemic non-diabetic patients.METHODS:PubMed data base was searched for patients with sepsis,bacteremia,mortality and diabetes.Articles that also identified new onset hyperglycemia (NOH) (fasting blood glucose125 mg/dL or random blood glucose199 mg/dL) were identified and reviewed.Nine studies were evaluated with regards to hyperglycemia and hospital mortality and five of the nine were summarized with regards to intensive care unit (ICU) mortality.RESULTS:Historically hyperglycemia has been believed to be equally harmful in known diabetic patients and non-diabetics patients admitted to the hospital.Unexpectedly,having a history of diabetes when admitted to the hospital was associated with a reduced risk of hospital mortality.Approximately 17% of patients admitted to hospital have NOH and 24% have diabetes mellitus.Hospital mortality was significantly increased in all nine studies of patients with NOH as compared to known diabetic patients (26.7%±3.4% vs 12.5% ±3.4%,P0.05;analysis of variance).Unadjusted ICU mortality was evaluated in five studies and was more than doubled for those patients with NOH as compared to known diabetic patients (25.3%±3.3% vs 12.8%±2.6%,P0.05) despite having similar blood glucose concentrations.Most importantly,having NOH was associated with an increased ICU and a 2.7-fold increase in hospital mortality when compared to hyperglycemic diabetic patients.The mortality benefit of being diabetic is unclear but may have to do with adaptation to hyperglycemia over time.Having a history of diabetes mellitus and prior episodes of hyperglycemia may provide time for the immune system to adapt to hyperglycemia and result in a reduced mortality risk.Understanding why diabetic patients have a lower than expected hospital mortality rate even with bacteremia or acute respiratory distress syndrome needs further study.CONCLUSION:Having hyperglycemia without a history of previous diabetes mellitus is a major independent risk factor for ICU and hospital mortality.     

Surgical treatment of post—traumatic pseudoaneurysms and arteriovenous fistulas

Objective:To report the experience in the diagnosis and treatment of post-traumatic pseudoaneurysms and arteriovenous fistulas.Methods:A series of 30 patients(11 women and 19 men) with posttraumatic pseudoaneurysms were reviewed retrospectively.Among them 7 patients (5 women and 2 men) were associated with arteriovenous fistula.Results:The causes included sharp penetration trauma(18 cases),blunt trauma (6 cases) and iatrogenic arterial injury (6 cases).The main clinical manifestations consisted of local pulsatile mass (26 cases),vascular bruits (19 cases),thrill (13 cases),ischemia of distal limb (9 cases),neuropathy (5 cases) and pseudoaneurysm rupture (2 cases).All patients underwent surgery.The operations included:ligation of the vessels (12 cases),surgical resection and primary suture repain of the vascular defect or anastomosis (11 cases),vascular reconstruction with autogenous saphenous vein (3 cases) and synthetic vascular graft (4 cases).Conclusions:Because of the imminent clinical course,early operation is usually indicated.The operative treatment is effective and safe for most of the patients with post-traumatic pseudoaneurysms and arteriovenous fistulas.     

Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience

Purpose:To analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair(TEVAR)in patients with traumatic blunt aortic injury in our single-center.Methods:From January 2014 to December 2018,a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center.Their clinical data such as demographics,operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software.Continuous variables were expressed as mean and standard deviation or median and interquartile range.Categorical variables are expressed as the numbers and percentages of patients.Results:The median age of the patients was 37 years,and 76(85.4%)were males.All the patients were involved in violent accidents and combined with associated injuries.Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR,with a 100%technique success.The mean time interval from admission to operating room was(90.1±18.7)min,and the mean procedure time was(54.6±11.9)min.Eighty(92.0%)patients were operated on under local anesthesia,while other 7(8.0%)patients were under general anesthesia.Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels.A total of 98 aortic covered stent grafts were deployed,of which 11 patients used two stent grafts(all in dissection cases).The length of the stent was(177.5±24.6)mm.The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was(24.9±2.4)mm,the proximal diameter of the covered stent was(30.5±2.6)mm,and the oversize rate of proximal site was(22.7±4.0)%.The proximal landing zone length was(14.1±5.5)mm.The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients.No blood flow reconstruction was performed.The overall aortic-related mortality was 2.25%(2/89).Among 87 patients,the median follow-up time was 24 months.Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm,hematoma or endoleak.One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion.Neither late death,nor neurological or other complications occurred.Conclusion:Emergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries.Long-term results remain to be further followed.     

双侧肾输尿管结石同期或分期经皮肾镜取石术的选择

目的 探讨双侧肾输尿管结石同期或分期经皮肾镜取石术的选择.方法 2008年1-12月收治双侧肾输尿管结石患者60例.其中双侧肾结石30例、一侧肾结石合并对侧输尿管结石12例、双侧输尿管结石8例、双侧肾结石并一侧输尿管上段结石10例.结石直径1.0～6.5 cm,平均2.0 cm.根据手术时间、血红蛋白及血压变化、血气分析结果 和患者耐受程度等判定是否同期行双侧手术.根据手术完成情况分为同期组51例和分期组9例,分期组二期手术在3～6周后进行.比较2组患者一般情况、结石特征及手术情况.结果 手术分期原因:首侧手术时间＞3 h 4例,血红蛋白＜100 g/L或下降＞30 g/L 3例,收缩压＜90 mm Hg或下降＞30 mm Hg 2例,动脉血pH值＜7.35或动脉氧饱和度＜95% 2例,患者不耐受3例.同期组首侧结石负荷、总结石负荷分别为(480.4±375.3)mm2及(858.8±426.0)mm2,分期组分别为(1271.7±928.1)mm2及(1667.0±811.2)mm2,2组比较差异有统计学意义(P＜0.05).同期组首侧平均手术时间、总手术时间分别为(119.3±25.1)min及(212.7±25.5)min,分期组分别为(153.7±42.4)min及(254.8±44.9)min,2组比较差异有统计学意义(P＜0.05).2组患者性别、年龄、体质指数、术前血红蛋白、总血红蛋白降低值、手术开始侧别、结石数量、第二侧结石负荷等差异均无统计性意义(P＞0.05).2组总结石清除率分别为87.3%与88.9%,并发症发生率分别为17.6%与16.7%,2组差异均无统计性意义(P＞0.05).同期组术后出现发热(体温＞38.5 ℃)4例、迟发出血4例、肾盂穿孔1例;分期组术后发热1例、迟发出血1例、尿外渗1例.结论 首侧手术时间过长、术中出血及患者不耐受是双侧结石经皮肾镜取石分期手术的主要因素.

Abstract：

Objective To evaluate the of the decision process to perform staged or synchronous bilateral percutaneous nephrolithotripsy (PCNL) in the treatment of bilateral upper urinary tract calculi. Methods Patients with an indication for bilateral PCNL were enrolled in the study from Jan. 2008 to Dec. 2008. The decision to perform staged or synchronous bilateral PCNL was based on the initial side operative time, the changes of hemoglobin level and systolic arterial pressure, the results of blood gas analysis and the patient′s tolerance at the end of initial side operation. The patients were divided into two groups, patients who underwent synchronous bilateral PCNL were in group one. Patients where the PCNL procedure was stopped after the initial side and subsequently underwent staged bilateral PCNL three to six weeks later were placed in group two. The success and complication rates of two groups were compared and analyzed. Results Of 60 planned simultaneous bilateral PCNLs, nine were stopped after the initial side, due to prolonged operative time in four cases, a hemoglobin level ＜100 g/L or the decrease of more than 30 g/L in three cases, a systolic arterial pressure lower than 90 mm Hg or the decrease more than 30 mm Hg in two cases, an arterial blood pH lower than 7.35 or the arterial oxygen saturation lower than 95% in two cases or the patients were intolerant to the surgery in three cases. Between the two groups, the differences of patient gender, age, BMI, preoperative hemoglobin level, the total hemoglobin decrease, the side initiated operation, stone number and second side stone burden were insignificant. However, there were significant differences in the first operative side stone burden, total stone burden, the first operative side operative time and total operative time. The stone-clearance rate was 87.3% in group one and 88.9% in group two. There was no difference in complication rate of two groups. Conclusions Prolonged operative time, large blood loss during the first operation side and patient intolerance are the main causes of staged bilateral PCNL.     

End-to-side anastomosis for coarctation of the aorta and type a aortic arch interruption with hypoplastic aortic arch

Objective: We investigated the advantages of reconstructing the aortic arch in neonates and infants by end-to-side anastomosis (ESA) in aortic coarctation and type A aortic arch interruption. Subjects and Methods: The patients were 28 neonates and infants who underwent median full sternotomy for correction of aortic coarctation (CoA) and type A interrupted aortic arch (IAA), at our institute, from October 1997 to September 2002. The cases were divided into two groups: ESA was performed in 16 cases (group A) and extended end to end anastomosis in 12 cases (group B). All repairs were made using simple clamping of the descending aorta under cardiac arrest. We compared groups A and B with regard to duration of simple clamping, postoperative blood pressure in the upper and lower extremities, echocardiographic pressure gradient, and the presence or absence of tracheal stenosis as diagnosed by postoperative clinical symptoms and chest radiography. Results: No significant difference between the groups was found in age, gender, body weight, or the ratio of CoA to IAA. In addition, there was no defference between the two groups in the duration of simple clamping or the difference in blood pressure between the lower and upper extremities. However, the echocardiographic pressure gradient at the site of anastomosis in group A was significantly lower than that in group B. There were no cases with symptoms of bronchial stenosis in either group. Conclusion: ESA is a relatively simple method for treating CoA or IAA with hypoplastic aortic arch, and was found to be effective for the elimination of residual stenosis.     

End-to-side anastomosis for coarctation of the aorta and type a aortic arch interruption with hypoplastic aortic arch

Objective: We investigated the advantages of reconstructing the aortic arch in neonates and infants by end-to-side anastomosis (ESA) in aortic coarctation and type A aortic arch interruption. Subjects and Methods: The patients were 28 neonates and infants who underwent median full sternotomy for correction of aortic coarctation (CoA) and type A interrupted aortic arch (IAA), at our institute, from October 1997 to September 2002. The cases were divided into two groups: ESA was performed in 16 cases (group A) and extended end to end anastomosis in 12 cases (group B). All repairs were made using simple clamping of the descending aorta under cardiac arrest. We compared groups A and B with regard to duration of simple clamping, postoperative blood pressure in the upper and lower extremities, echocardiographic pressure gradient, and the presence or absence of tracheal stenosis as diagnosed by postoperative clinical symptoms and chest radiography. Results: No significant difference between the groups was found in age, gender, body weight, or the ratio of CoA to IAA. In addition, there was no defference between the two groups in the duration of simple clamping or the difference in blood pressure between the lower and upper extremities. However, the echocardiographic pressure gradient at the site of anastomosis in group A was significantly lower than that in group B. There were no cases with symptoms of bronchial stenosis in either group. Conclusion: ESA is a relatively simple method for treating CoA or IAA with hypoplastic aortic arch, and was found to be effective for the elimination of residual stenosis.     

主动脉弓中断的外科治疗

目的 总结主动脉弓中断及合并心脏畸形的外科治疗经验.方法 1997年1月至2008年1月,36例主动脉弓中断患者进行了外科手术治疗,其中男性22例,女性14例.儿童患者36例,年龄2个月～7岁,平均年龄2.8岁.成人患者1例,年龄31岁.33例合并心内畸形,其中31例正中开胸同时矫治主动脉弓中断和心内畸形;1例左侧切口矫治主动脉弓中断,正中开胸修补心内畸形;1例采用姑息手术.3例无心内畸形的患者2例采用左后外侧切口,1例采用正中胸部加上腹部切口.术式包括16例管道连接,9例直接吻合,9例直接吻合并补片成形,1例应用左锁骨下动脉翻转.在31例正中切口一期手术中,17例应用选择性脑灌注加下半身停循环,8例采用深低温低流量灌注,6例采用全身停循环.结果 住院死亡5例,3例死于肺部感染,1例死于肺动脉高压危象,1例死于术后低心排血量.术后早期有其他重要并发症7例.31例存活患者随访3个月～5年,无远期死亡,无需要再次手术的病例.结论 合并心内畸形的主动脉弓中断患者可采取选择性脑灌注加下半身停循环或深低温全身低流量下正中一期手术同时矫治.     

Off pump repair of aortic arch anomalies with concomitant intracardiac defects via anterior approach

BACKGROUND: The authors evaluated the surgical treatment of aortic arch anomalies associated with intracardiac pathologies, through median sternotomy on beating heart without using cardiopulmonary bypass (CPB). METHODS: A consecutive series of 10 patients with aortic coarctation were operated upon. Median age at repair was 3.5 months (range, 5 days to 72 months), median weight was 4 kg (range, 2.2 to 30 kg). All aortic obstruction repairs were done via midsternotomy without using CPB and it is used only for repair of intracardiac defects. The aortic reconstruction included resection and end-to-side anastomosis in six patients and pulmonary autograft patch aortoplasty in four patients. RESULTS: There was no operative mortality. Mean follow-up value was 17.6 +/- 8.07 months. There was no restenosis. CONCLUSION: Most of the aortic coarctation and interrupted aorta type A can be well-treated surgically through median sternotomy without using CPB. Thus, the need for profound hypothermia and circulatory arrest and its potential neurological and other side effects are removed and CPB is reserved only for associated intracardiac defects, if present.     

Total anatomic correction of interrupted aortic arch complex. Experience in 4 infants

In two cases of interrupted aortic arch (IAA) of type A, one associated with a ventricular septal defect (VSD) and one with an aortopulmonary window, and two of type B, both associated with a VSD, total anatomic repair was performed at respective ages of 6 months and 24, 8 and 3 days. All four operations were performed through a median sternotomy, using profound hypothermia and circulatory arrest. The repair included resection of the patent ductus arteriosus, direct end-to-side anastomosis of the descending to the ascending aorta and closure of the VSD or, in one case, of the aortopulmonary window. The two oldest infants (with type A IAA) survived. Reexamination two years postoperatively demonstrated good width of the aortic anastomosis with no gradient. In the child who had had an aortopulmonary window there was a proximal tight stenosis of the right pulmonary artery, which was corrected at reoperation. Total anatomic correction of IAA through an anterior approach is technically feasible and the aortic anastomosis seems to grow satisfactorily. The management of very sick neonates with IAA remains a great challenge.     

婴儿主动脉缩窄合并心内畸形的一期矫治

目的总结婴儿主动脉缩窄（CoA）合并心内畸形一期矫治的手术方法和临床经验。方法2001年1月至2006年1月，对28例CoA合并心内畸形患者行一期手术矫治。CoA为导管前型18例，邻近或正对导管处10例；伴主动脉弓发育不良6例，动脉导管未闭22例。合并的心内畸形包括：室间隔缺损16例、室间隔缺损＋房间隔缺损5例、完全性房室间隔缺损3例，完全型大动脉错位伴室间隔缺损（D—TGA／VSD）2例，右心室双出口2例。采用左胸后外侧联合胸骨正中切口（双切口）径路手术12例，胸骨正中切口径路（单一切口）手术16例。采用缩窄段切除端端吻合术20例，Gore—Tex补片扩大成形术4例，左锁骨下动脉翻转扩大成形术4例。结果全组无手术死亡，术后呼吸机辅助呼吸时间7h～13d，住ICU时间3～18d。因术后心脏扩大延迟48～72h关胸4例，术后发生急性肾功能衰竭行腹膜透析3例，吸入一氧化氮（NO）治疗重度肺动脉高压3例。术后下肢收缩压高于上肢10～20mmHg18例（64．3％），收缩压上、下肢相差不大8例（28．6％），上肢分别高于下肢15mmHg和20mmHg2例（7．1％）。所有患者均得到随访，随访时间3～50个月，1例D—TGA／VSD患者因重度三尖瓣反流、肺部严重感染和呼吸功能衰竭于术后3个月死亡；其余27例患者恢复顺利。心脏超声心动图提示：1例采用端端吻合法、1例采用Gore～Tex补片扩大成形术的患者在CoA纠治处仍存在压差，分别为25mmHg、28mmHg，均未再次手术。结论一期手术矫治CoA合并心内畸形可以缩短疗程，有利于患者术后心、肺功能的恢复，避免二次手术的痛苦，降低治疗费用。可采用单一胸骨正中切口或胸骨正中联合左胸后外侧切口完成手术。     

One stage repair of aortic arch anomalies and intracardiac defects

Between August 1985 and May 1990, 27 neonates and infants underwent combined correction of intracardiac and aortic arch anomalies through a median sternotomy. Coarctation (CoA) was combined with VSD (6), AVSD (2), Taussig-Bing (TB) heart (5), transposition of the great arteries (TGA) (1), TGA + VSD (2), congenitally corrected TGA + VSD (1) and VSD + myxoid stenotic outlet valves (1). Interrupted aortic arch (IAA) was combined with VSD (10) and TB heart (1). Two patients had IAA type B as well as CoA. Age at operation varied from 2 to 243 days with a mean age of 51 days. Twenty patients (70%) were younger than 30 days. One TGA + VSD and all TB hearts had maligned outlet septum and right ventricular outflow tract obstruction (RVOTO). Posterior outlet septum deviation and left ventricular outflow tract obstruction (LVOTO) occurred in 8 patients with malalignment VSD and IAA (7) or CoA (1). Aortic arch reconstruction was performed using extended end-to-end anastomoses. In 3 patients, arch hypoplasia necessitated patch implantation. VSDs were closed through the right atrium unless the anatomy dictated otherwise. One TB heart was reconstructed with a Kawashima procedure. All other TB hearts and all TGAs were corrected with arterial switch operation. Obstructing outlet septum was resected whenever necessary. Follow-up was complete and included echo-Doppler control. Eleven patients had postoperative heart catheterisation. Early mortality was 18.5% (5 patients). Persisting LVOTO or RVOTO was responsible. There was no late mortality. Five patients were reoperated upon: 3 for stenotic anastomoses and 2 for a subaortic membranous stenosis. Successful balloon dilatation of recoarctation was performed four times.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coarctation of the aorta in complex congenital heart disease: simultaneous repair via sternotomy

Coarctation of the aorta (CoA) is often associated with complex congenital heart disease. Patients with such a combination may not benefit from coarctectomy alone. Eight children who presented with complex malformations of the heart underwent simultaneous repair of CoA and intracardiac surgery via sternotomy. After extensive mobilization of the aortic arch, cardiopulmonary bypass was established. During the cooling phase for deep hypothermic circulatory arrest (six cases), a persistent temperature gradient between the upper and lower half of the body confirmed the significance of CoA. One child was operated upon in deep hypothermia with low flow and one underwent valve repair on cardiopulmonary bypass. Mobilization of the descending aorta enabled CoA resection and end-to-end anastomosis with a running absorbable suture. The average descending aortic cross-clamping time was 15 min. By this time, the patient had been cooled sufficiently for the intracardiac procedure. There were two operative deaths not related to coarctectomy. The remaining children showed no arm-to-leg pressure gradient. Five were discharged from hospital and one patient died late from septicaemia. In our hands, this technique has served to accomplish simultaneous relief of CoA and repair of the intracardiac lesion thus sparing critically ill infants the hazards of repeated procedures.     

主动脉缩窄或主动脉弓中断合并心内畸形一期修复

目的 探讨采用经胸骨正中切口一期修复主动脉缩窄(CoA)或主动脉弓中断(IAA)合并心内畸形的治疗效果.方法 2002年7月至2009年6月,经胸骨正中切口行降主动脉远端和主动脉弓下缘端侧吻合术一期修复CoA或IAA合并心内畸形病儿43例,其中CoA 34例,IAA 9例(A型6例、B型3例),合并心内畸形包括室间隔缺损42例、动脉导管未闭34例、房间隔缺损12例、主动脉瓣下隔膜狭窄5例、二尖瓣关闭不全2例,右心室双出口1例.结果 手术死亡1例,为术后肺动脉高压和严重低心排血量综合征者.术后并发症包括严重低心排血量综合征3例,低氧血症6例,肺部炎症11例,肺不张14例,声音嘶哑19例,室上性心动过速23例.8例失访.34例随访3个月～5年,生活质量明显改善,心脏超声心动图和CT检查显示吻合口无明显再缩窄发生.结论 经胸骨正中切口,采用主动脉远端和主动脉弓下缘端侧吻合技术一期修复CoA或IAA合并心内畸形的手术早、中期效果良好,能明显减少术后再狭窄.     

Extended direct anastomosis for coarctation of the aorta and interruption of the aortic arch

Between March, 1986 and May, 1988, extended direct anastomosis was performed for coarctation of the aorta (CoA) (5 infants) and interruption of the aortic arch (IAA) (3 infants). The aortic arch was hypoplastic in 3 patients. The incision was made in the inferior aspect of the aortic arch proximal to the origin of the carotid or brachiocephalic artery, which was then anastomosed to the descending aorta. Pulmonary artery banding was placed in 4 patients with associated complex cardiac anomalies. Aortic cross-clamp time was 19-54 minutes (mean 41 minutes). Pressure gradient between upper and lower extremity was 0-10 mmHg (mean 4 mmHg). There were no operative deaths and no neurologic complications. The peak flow velocity at the site of aortic reconstruction measured by Doppler echocardiographic study after surgery was 1.2-2.5 m/sec (mean 1.7 m/sec). This procedure has the advantages of leaving the subclavian artery intact and no aortic shelf tissue. And it can be applied in IAA or CoA with hypoplastic aortic arch.