Mortality in open abdominal aortic surgery in patients with morbid obesity

BackgroundOpen abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients.ObjectivesThis study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity.SettingA retrospective analysis of 2007–2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.MethodsWe included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses.ResultsA total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50–8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001).ConclusionsMorbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.     

Left flank retroperitoneal exposure: a technical aid to complex aortic reconstruction

Over the last 5 years an extended left flank retroperitoneal approach was used in 85 of 531 (16%) aortic reconstructions deemed technically complex. Abdominal aortic aneurysm repair was performed in 70 patients (82%), bypass of aortoiliac occlusive disease was performed in 11 (13%), and aortic endarterectomy for mesenteric and/or renovascular disease was performed in 4 (5%). Indications for use of this approach included a "hostile" abdomen (43 patients), juxta/suprarenal abdominal aortic aneurysm (35), large (greater than 10 cm) abdominal aortic aneurysm (12), extreme obesity (10), associated renal and/or visceral artery stenosis requiring endarterectomy (9), inflammatory abdominal aortic aneurysm (2), and horseshoe kidney (2). Suprarenal or supraceliac aortic clamping, averaging 31 minutes, was required in 43 patients (50%). Postoperative recovery was rapid (average length of stay, 10.2 days), and morbidity was minimal despite the complex nature of these reconstructions. The perioperative mortality rate in elective operations was 1.2%. This approach facilitated proximal abdominal aortic exposure and anastomosis, especially in large, pararenal aneurysms or in situations unfavorable to a transabdominal approach. Whereas a left flank retroperitoneal approach can be used in most aortic reconstructions, it seems especially suited to those that pose significant technical challenges.     

Analysis of gallbladder bile in morbid obesity

Thirty-seven per cent of our grossly obese patients selected for gastric bypass had cholesterol gallstones. To document the composition of the biliary lipids prior to weight loss, the bile taken from eleven obese patients at the time of gastric bypass was analyzed and the results compared with those in eleven nonobese patients undergoing elective surgery. There was extreme supersaturation of both gallbladder and hepatic bile in all obese patients. The gallbladder bile of all obese patients fell well outside the micellar zone whereas the bile from all but one of the controls fell within the micellar zone. These data provide biochemical support for the clinical association of obesity and cholesterol gallstone formation and are evidence against the possibility that gastric bypass is a lithogenic operation.     

Gastric bypass in the surgical treatment of extreme adiposity

The gastric bypass is an effective surgical procedure for the treatment of extreme obesity. A small gastric reservoir and a narrow anastomosis are combined (to limit the possibility of food intake). In patients with a mean weight of 94% above the Broca value the normal weight is reached 18 months after the operation. Failure to lose weight can be caused by technical errors during the procedure or by a continuous food intake by the patients. Surgical complications are rare. The operative lethality is less than 1%, and anastomotic ulcers occur in 2% of cases. There is no reason to expect metabolic derangements as after jejunoileal bypass.     

Hemostasis after open-heart surgery with extreme or moderate hemodilution

Patients who received aortic disc valves during cardiopulmonary bypass (CPB) with extreme hemodilution, obtained with preoperative blood withdrawal, infusion of acetate solution and use of blood-free priming fluid, bled less than patients operated with moderate dilution. One hour after CPB with extreme dilution when the autologous blood had been reinfused, platelet adhesiveness was twice as high as in the moderate dilution group. Other parameters of platelet function, coagulation and fibrinolysis did not differ between the groups. The higher number of reactive platelets may therefore have contributed to the improved hemostasis after extreme dilution. Later, thrombocytosis with hyperreactive platelets and hyperfibrinogenemia developed in all patients. This might predispose for thrombosis.     

A successful surgical case of DeBakey IIIb dissecting aortic aneurysm in association with right aortic arch

A case of chronic DeBakey IIIb dissecting aneurysm in association with right aortic arch is reported. A 49-year-old man having encountered an aortic dissecting episode two years ago, was examined more closely because the aneurysm became larger recently. Digital subtraction angiography (intra-venous and intra-aortic) showed DeBakey IIIb dissecting aneurysm associated with a right aortic arch with aberrant subclavian artery. The entry of the aneurysm was in the right descending aorta passing from left thorax to right. The operative indication was for enlarged false lumen in this case. Graft replacement of the aneurysm and closure of the false lumen in the right thorax was performed under partial cardiopulmonary bypass through right thoracotomy. Postoperative digital subtraction angiography showed that dissection was in the abdominal aorta but false lumen in the thorax was completely closed. The patient has made a comeback working. A case of dissecting aortic aneurysm associated with right aortic arch is extremely rare. To our knowledge, this is the third such case reported in Japan, but the first case of a successful graft replacement for dissecting aortic aneurysm associated with right aortic arch.     

Severe obesity does not adversely affect perioperative mortality and morbidity in coronary artery bypass surgery.

OBJECTIVE: Obese patients are usually thought to have an increased risk for complications in coronary artery bypass surgery. METHODS: Therefore, the data of 500 consecutive patients undergoing coronary artery bypass grafting at our department in 1998 by use of cardiopulmonary bypass were analyzed. Severe obesity was defined as body mass index (BMI) > or = 30.0 kg/m(2). Obese patients (n=100; group O) were compared to the remaining 400 patients (group C). Both groups were comparable with respect to sex, history of prior myocardial infarction, chronic obstructive pulmonary disease, previous stroke, duration of cardiopulmonary bypass, aortic cross-clamp time and number of distal anastomoses performed. Obese patients were slightly younger and diabetes and hypertension were more common in these patients. RESULTS: Survival and potential complications including perioperative myocardial infarction, sternal wound infection, wound infection at the leg, renal failure, stroke, prolonged mechanical ventilation, pneumonia, reexploration for bleeding, and atrial arrhythmias were analyzed. No significant differences between obese and non-obese patients were detected. CONCLUSION: Severe obesity does not necessarily adversely affect perioperative mortality and morbidity in patients undergoing coronary artery bypass grafting in this study.     

Hat der jejunoileale Bypass noch eine Daseinsberechtigung?

Zusammenfassung Der jejunoileale Bypass zur Behandlung der therapierefraktären, extremen Adipositas ist wegen seiner schweren metabolischen Komplikationen zunehmend unter Kritik geraten. Mit dem 1967 von Mason entwickelten Gastric (gastrojejunalen) Bypass steht eine operative Alternative zur Verfügung, die hinsichtlich der Gewichtsreduktion gleichwertig ist, jedoch nicht derart unphysiologische Resorptionsverhältnisse schafft und deshalb nicht mit den schweren metabolischen Störungen belastet ist. Der jejunoileale Bypass muß deshalb heute als nicht mehr gerechtfertigte Therapieform angesehen werden.

---

Is the jejunoileal bypass still justified?

Summary The jejunoileal bypass for the treatment of extreme obesity is being increasingly critiziced because of its severe metabolic complications. With the gastric bypass, developed by Mason in 1967, there now exists an operative alternative that is equivalent concerning weight reduction, but does not create such non-physiologic conditions of absorption, and therefore is not burdened with the severe metabolic disturbances of the jejunoileal bypass. Therefore the jejunoileal bypass should not be used any longer for the treatment of obesity.

Vortrag gehalten auf der 96. Tagung der Deutschen Gesellschaft für Chirurgie     

Aortic dissection with potential origin from a mechanical bypass anastomosis

Ascending aortic dissection is a known complication of cardiac surgery. Off-pump coronary artery bypass surgery seems to be associated with a higher risk for this event as compared with on-pump bypass surgery. This increased risk may result from aortic side-clamping under pulsatile flow as opposed to continuous flow in conventional bypass surgery. Mechanical devices allowing performance of proximal bypass anastomoses without aortic side-clamping are supposed to reduce the risk for aortic dissection. We report a case in which ascending aortic dissection occurred 8 days after off-pump bypass surgery, most likely arising from a mechanically performed proximal bypass anastomosis.     

Postpneumonectomy syndrome: diagnosis, management, and results.

Airway obstruction may be caused by extreme mediastinal shift and rotation after right pneumonectomy or after left pneumonectomy in the presence of a right aortic arch. Eleven adults (aged 18 to 58 years) with severe symptoms were treated surgically between 5 months to 17 years after pneumonectomy (7 right, 4 left). An initial patient with only one functional lobe was treated unsuccessfully by aortic division and bypass graft. Ten underwent mediastinal repositioning. After two recurrences prostheses were used to maintain mediastinal position. Five patients who underwent such repositioning are doing well from 5 months to more than 5 years later. One died 1 month after operation probably of pulmonary embolism. One who showed residual airway collapse after operation has some recurrent obstruction. Three other patients who showed severe malacic obstruction of the airway after mediastinal repositioning variously underwent aortic division with bypass graft and tracheal and bronchial resection. One is well almost 6 years later. Two died postoperatively. Occurrence of the syndrome is unpredictable. Where malacic changes have not occurred, mediastinal repositioning may reasonably be expected to correct obstruction. Optimal treatment for concurrent severely malacic airways is unclear.     

Disseminated intravascular coagulopathy associated with thromboexclusion for dissecting aortic aneurysm

Disseminated intravascular coagulopathy (DIC) was demonstrated in a patient who underwent surgical thromboexclusion by blood flow reversal for dissecting aortic aneurysm. Large clots in the descending thoracic aorta and extra-anatomic bypass grafting might have been causative factors of the consumption coagulopathy. Low-dose heparin together with fresh-frozen plasma was effective; however, extreme caution should be adopted with such patients to minimize the development of DIC, because the factors responsible for the coagulation abnormalities are not removed in patients who undergo the surgical treatment of thromboexclusion.     

Hepatorenal artery bypass in the management of renovascular hypertension.

Infrequently, when the aorta cannot be used for a standard renal bypass operation because of a previous aortic operation, severe degenerative atherosclerosis or complete aortic thrombosis, a unilateral (hepatic) or bilateral (hepatic and splenic) visceral bypass should be contemplated. Patients with abdominal aortic aneurysms extending above the renal arteries might benefit from concomitant bilateral visceral bypass procedures followed by aortic replacement during the same operative session. The hepatic circulation with its common anatomic variations, indications, surgical technique and effects of hepatorenal artery bypass on the renal and hepatic circulation are discussed.     

Initial (1-year) weight loss after gastric banding, gastroplasty or gastric bypass

Inadequate weight loss after gastric stapling operations for extreme obesity was found in an earlier study to be mainly due to dilatation of the outlet from the upper gastric pouch or rupture of the staple line. To avoid such failure we performed gastric banding with a Marlex mesh as originally suggested by Wilkinson. One year after surgery the criterion for acceptable weight loss (Broca's body weight index less than 1.20) was attained significantly more often after gastric banding than after gastric bypass or gastroplasty.     

Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal

OBJECTIVE: The purpose of this study was to determine long-term outcome in patients with infected prosthetic aortic grafts who were treated with extra-anatomic bypass grafting and aortic graft removal. METHODS: Between January 1989 and July 1999, 36 patients were treated for aortic graft infection with extra-anatomic bypass grafting and aortic graft removal. Extra-anatomic bypass graft types were axillofemoral femoral (5), axillofemoral (26; bilateral in 20), axillopopliteal (3; bilateral in 1) and axillofemoral/axillopopliteal (2). The mean follow-up was 32.3 +/- 4. 8 months. RESULTS: Four patients (11%) died in the postoperative period, and two patients died during follow-up as a direct consequence of extra-anatomic bypass grafting and aortic graft removal (one died 7 months after extra-anatomic bypass graft failure, one died 36 months after aortic stump disruption). One additional patient died 72 months after failure of a subsequent aortic reconstruction, so that the overall treatment-related mortality was 19%, whereas overall survival by means of life table analysis was 56% at 5 years. No amputations were required in the postoperative period, but four patients (11%) required amputation during follow-up. Twelve patients (35%) had extra-anatomic bypass graft failure during follow-up, and six patients underwent secondary aortic reconstruction (thoracobifemoral [2], iliofemoral [2], femorofemoral [2]). However, with the exclusion of patients undergoing axillopopliteal grafts (primary patency 0% at 7 months), only seven patients (25%) had extra-anatomic bypass graft failure, and only two patients required amputation (one after extra-anatomic bypass graft removal for infection, one after failure of a secondary aortic reconstruction). Furthermore, primary and secondary patency rates by means of life table analysis were 75% and 100% at 41 months for axillofemoral femoral grafts and 64% and 100% at 60 months for axillofemoral grafts. Only one patient required extra-anatomic bypass graft removal for recurrent infection, and only one late aortic stump disruption occurred. CONCLUSIONS: Staged extra-anatomic bypass grafting (with axillofemoral bypass graft) and aortic graft removal for treatment of aortic graft infection are associated with acceptable early and long-term outcomes and should remain a primary approach in selected patients with this grave problem.     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Selective Delayed Management of Blunt Traumatic Left Common Carotid Artery Injury Using Hypothermic Circulatory Arrest

Most traumatic carotid artery aneurysms occur at or close to its bifurcation, and traumatic aneurysm of the intrathoracic carotid arteries are rare. We describe a case of false aneurysm at the origin of the left common carotid artery (LCCA) after blunt trauma. A 53-year-old man suffered a blow from a broken steel plate, which flew from a working concrete crusher over his neck when he looked down the machine. Chest computed tomography revealed aneurysm of the LCCA, and aortic arch arteriography demonstrated a false aneurysm of about 3 × 5 cm at the origin of the LCCA, with loss of arterial continuity and abnormal tortuosity above the aneurysm. An ascending aorta to LCCA bypass graft was placed during the cooling period of cardiopulmonary bypass, and mattress sutures were placed in the normal aorta to close the origin of the LCCA under hypothermic circulatory arrest because of the extreme danger of dissection. The LCCA was transected partially at its origin from the aorta. We speculated that the direct lifting force which caused the carotid artery to move upward might produce a tear at the junction of the LCCA and the aortic arch.     

A novel technique of coronary revascularization in porcelain aorta: Report of two cases

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.     

Successful combined minimally invasive direct coronary artery bypass and transapical aortic valve implantation

Transapical aortic valve implantation is indicated in high-risk patients with aortic stenosis and peripheral vascular disease requiring aortic valve replacement. Minimally invasive direct coronary artery bypass grafting is also a valid, minimally invasive option for myocardial revascularization in patients with critical stenosis on the anterior descending coronary artery. Both procedures are performed through a left minithoracotomy, without cardiopulmonary bypass, aortic cross-clamping, and cardioplegic arrest. We describe a successful combined transapical aortic valve implantation and minimally invasive direct coronary bypass in a high-risk patient with left anterior descending coronary artery occlusion and severe aortic valve stenosis.     

The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons' database

BACKGROUND: Obesity is epidemic in the United States and afflicts 97 million adults. Prior single center studies have been contradictory as to obese patients having higher risks with coronary artery bypass operations. Our objective was to assess the independent effect of both moderate (body mass index [BMI], 35 to 39.9) and extreme (BMI > or = 40) obesity on bypass operation outcomes using the Society of Thoracic Surgeons National Cardiac Database. METHODS: The study population consisted of 559,004 patients from the Society of Thoracic Surgeons database who underwent first-time, isolated coronary artery bypass grafting between January 1997 and December 2000. We compared 42,060 moderately obese patients (BMI, 35 to 39.9) and 18,735 extremely obese patients (BMI > or = 40) with 498,209 normal or mildly obese patients (BMI, 18.5 to 34.9). Multivariable logistic regression was used to determine whether BMI subgroups were independent predictors of operative risk after adjusting for other preoperative factors. RESULTS: Compared with normal or mildly obese patients (BMI, 18.5 to 34.9), moderate and severely obese patients were younger and more likely to be diabetic and hypertensive. After adjusting for these and other known preoperative risk factors, moderate obesity slightly elevated patients' operative risk (adjusted odds ratio, 1.21; confidence interval, 1.13 to 1.29). In contrast, extremely obese patients had marked higher risk for operative mortality (adjusted odds ratio, 1.58; confidence interval, 1.45 to 1.73). Major perioperative complications, particularly deep sternal wound infection, renal failure, and prolonged postoperative hospital stay also increased for extremely obese patients. CONCLUSIONS: Extreme obesity (body mass index > or = 40) is a significant independent predictor for adverse outcomes and prolonged hospitalization after coronary artery bypass operation.     

Extra-anatomic ascending-to-descending aortic bypass via right thoracotomy for complex re-coarctation of the aorta. An alternative surgical approach for complex re-coarctation

Ascending-to-descending aortic bypass may be the best approach for complex re-coarctation of the aorta because of adhesions around the coarctation area, risk of spinal cord ischaemia due to aortic cross-clamping and laceration of the recurrent laryngeal nerve. We report a patient with complex re-coarctation of the aorta successfully treated by extra-anatomic ascending-to-descending aortic bypass via right thoracotomy without cardiopulmonary bypass.