Reconstructive valve surgery.

Despite continued refinement of heart valve prostheses, valve replacement carries risks of thromboembolic, mechanical, and infectious complications, and long-term success is further limited by the eventual wear of prosthetic parts. In many patients with congenital or acquired valve diseases, valve function may be improved, if not restored, by reconstructive techniques, prosthetic replacement being thereby avoided or delayed. This review examines the current status of reconstructive procedures for management of diseased valves, with emphasis on long-term results and post-operative hemodynamic studies. In many instances the choice between reconstruction and replacement of a diseased valve remains controversial. The documented success of selectively applied reconstructive techniques, however, weighs against expedient decisions for prosthetic replacement and supports a continuing search for new techniques.     

Reconstructive venous surgery.

Experience with 60 reconstructions of large peripheral veins is summarized. No deaths occurred and complications were minimal. Most patients had excellent or good results.     

Reconstructive surgery on the venous system

1. The progress of reconstructive venous surgery in recent years has been mainly based on the use of changed operative techniques (atraumatic preparation and suture technique; intraoperative vascular endoscopy or venography; temporary arteriovenous fistula). As a result, the clinical indications could be remarkably increased (acute phlebothrombosis; some types of post-thrombotic syndrome; venous substitution in tumor surgery; vascular lesions). 2. A peripheral temporary arteriovenous-fistula proves the most effective protective method both in venous thrombectomy and in graft reconstruction (full lumen restoration also in cases with incomplete disobliteration due to increase of flow velocity and flow volume; improvement of graft patency). 3. In long-standing axillar or subclavian venous thrombosis, a distal arteriovenous fistula (similar to a Cimino shunt) has a curative effect (without venous thrombectomy) via stimulation of rapid recanalisation and formation of collateral pathways. 4. Persisting central venous blocks may be corrected by a bypass procedure (great saphenous vein graft for the shoulder region; expanded PTFE grafts (Gore-Tex) for the ilio-caval segment).     

Reconstructive surgery in chronic venous obstruction of the lower limbs

Forty-one patients with chronic venous insufficiency due to venous trunk obstruction of the lower limbs underwent 43 flow reconstruction procedures consisting of either free veno-venous bypass or venous transposition. The indicating symptoms for these procedures were (1) progressive chronic edema, (2) claudication while walking, or (3) trophic lesions. Doppler ultrasound and plethysmographic techniques were employed in the diagnosis while phlebography was considered the most useful and most essential technique. Iliac vein obstruction was the most common venous obstruction, followed by superficial femoral vein obstruction. Two patients were operated on for combined obstruction at both levels. Free veno-venous bypass was the most frequently used procedure. In two cases of cavo-iliac obstruction, an original technique of femoro-axillary veno-venous bypass yielded good results. Temporary arteriovenous fistulas to improve patency at sites distal to venous bypass were used in the most complex cases. Good results were obtained in 80% of the operated cases. Postoperative follow-up phlebograms were obtained in 30 of 43 operations.     

Reconstructive surgery of the thorax and breast]

Various possibilities of breast plasty after tumor surgery or for the correction of combined anomalies of the thorax and the breasts are discussed. In the augmentive procedures either local flaps or mammary prostheses as well as silicone rubber were used. The authors show a personal method where the remaining healthy breast is used for reconstruction.     

Reconstructive surgery of the mitral valve using a soft synthetic half-ring

A soft synthetic semi-ring was used in reconstructive-plastic operations on 36 patients with rheumatic mitral insufficiency; it was sutured in the projection of the posterior cusp. The operative techniques and the immediate results are described. Lethality was 5.5%.     

Reconstructive aortic valve surgery in the elderly: Techniques and outcomes

Objectives

The aim of the study was to evaluate operative techniques and long-term results after aortic valve or root repair in patients aged 75 years or more.

Reconstructive surgery for deep venous reflux: a report on 144 cases

This retrospective study was conducted on 144 lower extremities (133 patients) with deep venous reflux treated with surgery to restore venous valvular function. Clinically, 51% of patients were in class C5-C6, and based on etiology, patients were equally divided into primary and secondary venous disease. Four surgical procedures were used: valvuloplasty (n=85), transposition (n=18), transplantation (n=32), or Psathakis' technique II (n=9). The procedure chosen was determined mainly by the feasibility of the technique in the above-mentioned preferred order. Thus, 76% of valvuloplasties were performed for primary venous insufficiency. A postoperative venography routinely performed soon after surgery demonstrated a large number of segmental thromboses (20.3%). Their number was statistically different in primary and secondary (PTS) venous disease, respectively 8.8 vs 32.3%. Clinical and hemodynamic results were evaluated (duration of follow-up: 12-168 months) based on etiology and type of procedure. A correlation was established between clinical result (venous ulcer) and efficacy of valvular reconstruction. The latter was satisfactory in valvuloplasties (P=0.005) but not in venous transfer (P=0.35). Overall results were better for primary venous insufficiency than in postthrombotic syndromes (P=0.03).     

Reconstructive septal surgery

To attain without compromise the surgical goal, a straight and concurrently solid septum, especially in cases of marked deviations or severe post-traumatic deformities (sometimes combined with external deformities), an excellent proven and well-known technique is extracorporal or external septoplasty. Surgery consists of excision of the quadrilateral cartilage and its division into straight fragments. To avoid postoperative sequelae such as saddling, the pieces of cartilage must be reconnected meticulously to form a straight and at the same time solid plate. This difficult and time-consuming procedure can be assisted by the use of a connecting material. Since 1996 we have been using a polydioxanone foil (PDS, Ethicon Norderstedt Germany) as the supporting material for this purpose. The PDS as well as the suture material is completely resorbed within 5 months, excluding long-term complications of other artificial implants.     

Reconstructive surgery of the soft tissue in hemifacial microsomia]

Hypoplasia of soft tissues constitutes one of the major elements of hemifacial microsomia. Despite the fact that it occurs in 95% of cases of microsomia, hypoplasia is one aspect of the syndrome that is often neglected. The authors, by a general review of the relevant literature, describe the quantitative and qualitative importance of hypoplasia, as well as its statistical rapport with other elements of the syndrome. In studying the different treatments available for hypoplasia of soft tissues, several factors stand out. New techniques of bone distraction have transformed surgical indications by allowing an extension of soft tissues, particularly of skin. The treatment of hypoplasia follows two major axes; firstly, the use of grafts by injection of adiposal tissue for cases in which the deficit is only moderate, and secondly, microsurgical flaps, mainly of the fasciocutaneous type, for the relatively small portion of cases (9%) in which the deficit is more severe. By first analysing any constraints due to the treatment of bone and ear malformations, the schedule of the different stages of necessary surgery can be effectively planned.