Short‐ and long‐term outcomes following redo valvular surgery

Aim

We reviewed our experience in redo valvular surgery to evaluate trends in short‐ and long‐term outcomes.

Methods

We reviewed 414 patients (mean age, 62.8 ± 13.6 years) who underwent redo valvular surgery in the past 25 years. A total of 301 patients (54.2%) underwent first‐time redo valvular surgeries; 178 (32.1%) were second redos, 60 (10.8%) were third redos, and 16 were fourth redos (2.9%). The mean follow‐up period was 6.8 ± 6.3 years.

Results

Hospital mortality was 5.8%. New York Heart Association (NYHA) class III/IV (P = 0.0007, odds ratio = 4.403) and hemodialysis (P = 0.0383, odds ratio = 7.196) were risk factors for hospital death. Long‐term survival rates at 15 and 20 years were 64.7% ± 4.3% and 59.1% ± 5.0%, respectively. Predictors of late death were first time redo (P = 0.0076, hazard ratio = 0.422) and age younger than 61 years (P = 0.0005, hazard ratio = 0.229). There were significant differences in long‐term survival between NYHA classes I/II and III/IV (log‐rank test, P = 0.0419) and between the time from redo surgery (log‐rank test, P = 0.0189) and age (log‐rank test, P = 0.0001).

Conclusions

The hospital mortality rate for redo valve surgery has improved. Early referral for redo surgery can contribute to improving early and late outcomes.     

Comparison of efficacy between uncovered and covered self‐expanding metallic stents in malignant large bowel obstruction: a systematic review and meta‐analysis

Aim Insertion of a self‐expandable metallic stent (SEMS) can rapidly relieve colorectal obstruction. This study aimed to compare the efficacy between uncovered and covered SEMSs in the treatment of malignant colorectal obstruction. Method A systematic search in Medline, Embase, the Cochrane controlled trials register and bibliographies of retrieved articles was performed. Randomized controlled trials and other comparative studies comparing uncovered and covered SEMSs for treatment of malignant colorectal obstruction were selected for this systematic review and meta‐analysis. The main outcome measures were technical success, clinical success, tumour ingrowth, tumour overgrowth, early migration (≤ 7 days), late migration (> 7 days), overall complications and the duration of stent patency. Results Compared with covered SEMSs, uncovered SEMSs were associated with a lower late migration rate (relative risk 0.25; 95% CI 0.08, 0.80; P = 0.02), a higher tumour ingrowth rate (relative risk 5.99; 95% CI 2.23, 16.10; P = 0.0004) and a prolonged stent patency (weighted mean difference 15.34 days; 95% CI 4.31, 26.37; P = 0.006). There was no significant difference in technical success, clinical success, tumour overgrowth, early migration, perforation or overall complications between the two groups. Conclusion Tumour ingrowth occurred more frequently in the uncovered SEMS group, while late migration was more common in the covered SEMS group.     

Abdominal sonography for the diagnosis of large bowel obstruction

To evaluate the clinical usefulness of abdominal sonography in the diagnosis of large bowel obstruction, the sonography findings of 39 patients with a large bowel obstruction, in the form of a simple obstruction in 36 patients and a sigmoid volvulus in 3, were reviewed in comparison with their plain X-ray findings. Abdominal sonography showed a large bowel obstruction in 33 patients, and an obstructing lesion in 14 of these patients. However, in the other 6 patients, including the 3 with a sigmoid volvulus, the image was disturbed by extensive colonic gas. Although the plain abdominal X-ray films showed no gaseous colonic dilatation, isolated small bowel dilatation was seen in six patients with a large bowel obstruction proximal to the splenic flexure. In five of these six patients, abdominal sonography revealed a dilated colon filled with fluid and feculent contents which was difficult to evaluate on the plain X-ray films. Consequently, abdominal sonography was proven to be useful, especially for detecting X-ray-negative colonic dilatation.     

Management of malignant left-sided large bowel obstruction: a comparison between colonic stents and surgery

Background: Management of distal malignant large bowel obstruction (LBO) remains challenging. Acute surgical intervention is often associated with poorer clinical outcome compared to an elective procedure. Self‐expandable metallic stents (SEMS) as a bridge to surgery (BTS) or palliation remain controversial and are not yet widely available. Methods: From 1998 to 2008, a retrospective analysis of the patients presenting with an acute malignant LBO to The Tweed Public and John Flynn Private Hospitals was performed. Results: Fifty‐six admissions with malignant distal colonic obstruction were reviewed. On an intention to treat, patients underwent either stent 30 or surgery 26. American Association of Anaesthetists (ASA) scores, obesity rates and palliative procedures were all higher in the stent group. Inpatient deaths numbered four (two stent group, two surgery group). The technical success of inserted stents was 29/30, while clinical success was 27/30. Complications both medical, surgical and intensive care unit admissions were more common in the surgical group. Length of stay was 8.5 days for stent and 17.7 days for surgery. Of the 25 successful stent survivors, 14 were palliative and 11 were BTS. Conclusions: SEMS are effective in treatment of LBO either as palliation or BTS. They are associated with an overall better outcome and improved quality of life of patients. Surgery is indicated where SEMS are unavailable or have failed.     

Short‐term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians

Aim The 30‐day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied. Method An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded. Results In all, 173 patients (80 men) of median age 84 (80–93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14–45) kg/m². Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty‐three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1–37) days. Three (1.7%) patients died within 30 days of surgery. Conclusion This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.     

Short‐term kidney transplant outcomes among African American recipients do not predict long‐term outcomes: donor pair analysis

Keith D, Patrie JT. Short‐term kidney transplant outcomes among African‐American recipients do not predict long‐term outcomes: donor pair analysis.
Clin Transplant 2011: 25: 69–76. © 2010 John Wiley & Sons A/S. Abstract: African American (AA) renal transplant recipients have poorer graft survival compared to other racial and ethic groups. This study was undertaken to determine whether pre‐transplant factors and events occurring in the first six months post‐transplant were predictive of the poorer long‐term outcomes in AA recipients. To control for kidney quality, a paired analysis of deceased donor kidneys in which one donor kidney was transplanted into an adult AA recipient and the other was transplanted into an adult Caucasian was undertaken. Cox proportional hazard modeling was used to determine the impact of outcome variables at six months. Outcomes at six months among the paired recipients were very similar for graft and patient survival, and estimated glomerular filtration rate (GFR). Less than 10% of difference in long‐term outcomes was explained by differences in the pre‐transplant covariates and events in the first six months. Causes of graft failure after six months revealed a two to three times higher rate of chronic allograft nephropathy (CAN) and late acute rejection among AA. In conclusion, early outcomes after kidney transplant did not predict the poor long‐term graft survival among AA, and AA recipients appear to be more prone to graft loss because of CAN and late acute rejection.     

恶性肠梗阻的处理与治疗

恶性肠梗阻常见于肠管肿瘤或妇科肿瘤患者.手术治疗对于大部分患者是首选,但对于预后极差的患者并不适用.鼻胃管减压仅用于短期治疗,自膨胀金属支架适用于胃出口梗阻及近端小肠梗阻.