Reoperations for chronic infections following prosthetic hernia repair

Summary The growing popularity of prosthetic hernia repair has resulted in a larger number of complications such as a chronically discharging sinus; in such cases, the infected mesh may have to be removed. Five reoperations were performed in the past five years, all in male patients aged 52 to 73 years. A cylinder plug was removed in two cases, and in the other three a partial or complete removal of the mesh was required. Four of the prostheses were made of polypropylene and one of dacron. Recovery was satisfactory in all patients; infection recurred in one case six months later, and one patient developed a new hernia. Alloplasty was performed in 1,190 hernias: 16 wound infections occurred, although no meshes had to be removed due to the onset of a chronically discharging sinus. The importance of monitoring the patients' condition and offering early treatment to avoid complications is highlighted. In conclusion, inexperience in prosthetic surgery appears to be the main risk factor. Cylinder plugs are most at risk, especially the larger or tightly rolled up ones. Inguinal hernia mesh-plug repair (cone-shaped plugs) appears to be a safe and reliable operation when correctly performed and followed up.     

Treatment with daptomycin for Corynebacterium Jeikeium left-sided prosthetic valve endocarditis

Prosthetic valve endocarditis (PVE) is a serious complication with potential fatal consequences, classified as early or late PVE, depending on whether typical symptoms occur within or later than 12 months from surgery. The incidence of early PVE is under 1%, but it carries high morbidity and mortality rates. There are few reported cases in literature of PVE due to Corynebacterium Jeikeium even though it is present in normal skin flora particularly in hospitalized patients. Corynebacterium species are, in fact, recognized as uncommon agents of endocarditis and little is known regarding species-specific risk factors and the outcome in this kind of endocarditis. Described is an unusual case report of a 57-year-old man who had early aortic PVE due to Corynebacterium Jeikeium infection complicated by dehiscence of the prosthesis, complete atrio-ventricular block, perforation of the interventricular septum and septic shock. Prompt diagnosis, choice of daptomycin as antibiotic therapy although it has only been approved by the European Medicine Agency (EMEA) for right-sided endocarditis and timely open heart surgery, resulted in a successful outcome.     

再次瓣膜替换术64例报告

作者报告１９８８年２月至１９９６年５月间，行再次瓣膜替换术病例６４例，其中生物瓣衰坏４６例，机械瓣功能障碍９例，瓣周漏９例。按照术前的心功能状态，９例因机械瓣急性功能障碍，引起急性充血性心力衰竭或心源性休克，施行急症手术，其余５５例行择期手术。早期死亡８例（１２．５０％），其中择期手术后死亡３例（５．５０％），急症手术后死亡３例（３３．３％）。长期生存者５６例，随访时间３个月至７年（平均２．１年），晚期死亡３例（５．３％）。生存１年以上的４８例中，心功能恢复至Ⅰ级者４２例，Ⅱ级５例，Ⅲ级１例。作者对再次瓣膜替换术的手术时机与手术操作的重点作了讨论。     

Reoperations for acute prosthetic thrombosis and pannus: an assessment of rates, relationship and risk.

OBJECTIVE: Mechanical valvular prostheses have the advantage of longevity but carry a risk of thrombosis which is dependant on valve design, materials and host-related interface. While pannus is common to both biologic and mechanical valves, acute prosthetic thrombosis is mostly a complication of mechanical valves; therefore we investigated to find rates and risk of these obstructive complications. METHODS: Between 1/1/70 and 31/12/97, 2680 patients received at least one mechanical prosthesis in the aortic or mitral or tricuspid position and a total of 3014 operations were performed. Follow-up included 18523 years and was 98% complete. Incidence rates, Kaplan-Meier estimates, modeling of the hazard and multivariate analysis in the hazard domain were used in the analysis. RESULTS: Overall survival was 76%, 64%, 51%, 38.5% and 29% at 5, 10, 15, 20 and 25 years, respectively. It was significantly better in aortic than in mitral than in double prosthesis. 290 patients received a single reoperation, 37 a second, six a third and one a fourth reoperation. Two-hundred and fifty-one of these reoperations were exclusively due to malfunction of mechanical prosthesis, nine to malfunction of both mechanic and biologic prostheses. Most frequent reoperative indications was dehiscence (133), pannus (48) and thrombosis (29). The linearized rate of reoperations for pannus was 0.24%/patient per year, for valvular thrombosis 0.15%/patient per year. The shape of the thrombotic hazard was constant (at random) and the relative risk 12 times higher for tricuspid prosthesis, seven times higher for mitral prosthesis. Multivariate analysis controlling for prosthetic position, age, sex and prosthetic size, showed a 67% risk reduction with larger prosthesis (>27 mm), a 69% risk reduction with the Sorin tilting disk prosthesis and an 83% risk reduction with the bileaflet prosthesis. Pannus hazard shows a delayed exponential rise and was two times higher in tricuspid and three times higher in mitral position. Multivariate analysis showed a 50% risk reduction with larger prosthesis, an 11 times higher hazard of old (caged-disk, caged ball) prosthesis and a three times higher hazard of Lillehei-Kaster prosthesis. Reoperation for thrombosis has a 62% perioperative (30 days) survival compared to 92% survival of pannus reoperation. CONCLUSIONS: Mechanical valves have a low incidence of reoperation, mostly for prosthetic dehiscence. Pannus development is the next frequent complication increasing with time since implant, therefore in this series it was related to old valvular models and tilting disk prosthesis, with longer follow-up. Acute thrombosis occurs significantly earlier than pannus formation. Despite shorter follow-up we are therefore confident that bileaflet prostheses are less prone to this complication and pannus is a rare early etiologic factor. Thrombosis has very high operative risk as compared to pannus, justifying the present trend to thrombolysate selected cases.     

A simplified operative technique for single-staged resection of left-sided colon obstructions: report of a 9-year experience

Purpose: The operative strategy for left-sided large bowel obstruction remains controversial. Because a safe and definitive single-staged operation that avoided a colostomy would clearly be in the patients' best interest, we conducted a prospective study to compare the efficacy of single-staged surgery (SSS) supplemented by the milking and swabbing technique (MST), with the conventional Hartmann's procedure (HP). Methods: In group 1 (n = 37) we performed traditional HP by resecting the site of obstruction and constructing an end colostomy. In group 2 (n = 33), after resecting the site of obstruction, instead of on-table lavage, we cleaned out the fecal content from the proximal and distal parts of the obstruction by milking the colon with the fingers, then swabbing the proximal and distal 10 cm of lumen of the colonic anastomosis with povidone iodinized stick sponges. Finally, we performed a primary one-layer anastomosis without fecal diversion. Results: The mortality, morbidity, and postoperative hospital stay after emergency left-side colonic resection and primary anastomosis by MST was comparable with those after HP (P > 0.05). Conclusions: We believe that SSS with MST is a viable choice in the surgical management of selected patients with obstructing lesions of the left colon. The advantages of SSS with MST lie in its good long-term results, and short-term reduced surgical intervention and hospital stay. Received: November 12, 2001 / Accepted: May 7, 2002 Reprint requests to: M. Turan, Inonu Muzesi Yani, K. Kazancilar Sok. No 1/4, 58070 Sivas, Turkey     

Reoperations for esophageal achalasia

Purpose

To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia.

Methods

We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5?±?11.0?years), who underwent reoperations for achalasia between August 1994 and August 2010.

Results

The primary surgical procedures were Heller–Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n?=?2), recurrent adhesion after myotomy (n?=?2), reflux esophagitis (n?=?2), difficulty in passage caused by tortuosity of the esophagus (n?=?2), difficulty in passage through the thoracic esophagus (n?=?1), and severe chest pain (n?=?1). The reoperations included repeated HD procedures (n?=?4), repair of an esophageal hiatal hernia (n?=?2), thoracic esophageal myotomy (n?=?2), straightening of the lower esophagus with gastropexy (n?=?1), and subtotal esophagectomy (n?=?1). The success rate of the reoperations for resolving symptoms was 90?% (9 patients).

Conclusion

Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.     

Reoperations for myocardial revascularization.

Reoperations solely for myocardial revascularization were performed in 219 consecutive patients (1967 to 1975). Indications were (1) graft failure, 46 (21 per cent); (2) progressive atherosclerosis, 42 (19 per cent); (3) incomplete revascularization, 39 (18 per cent); and (4) combinations, 92 (42 per cent). Primary operations included bypass grafts in 100 patients; mammary artery implants, 87; and combinations of direct and indirect procedures, 32. Reoperations performed were single bypass, 141 patients; double, 61; and triple or other coronary artery operations, 17. Eight patients died within 30 days of operation (3.7 per cent). Major postoperative complications included hepatitis, 24 (11 per cent); myocardial infarction, 19 (9 per cent); bleeding, 21 (10 per cent); and respiratory insufficiency, 12 (5 per cent). Follow-up for 202 long-term survivors was complete (mean 29 months). In patients who originally underwent direct revascularization, Class I or II (N.Y.H.A.) was attained in 35 of 43 (81 per cent) of those reoperated upon for primary graft failure, in 14 of 15 (93 per cent) of those with progressive atherosclerosis, and in 27 of 33 (82 per cent) of patients with combined indications. Arteriography was performed after the reoperation in 55 patients (mean interval 17 months), and 65 of 77 (84 per cent) grafts were patent. Nineteen of 22 grafts performed for primary graft failure were patent. We have made the following conclusions: (1) Reoperation for direct myocardial revascularization can be accomplished with low mortality rates although morbidity is high; (2) complete relief of symptoms was achieved in 65 per cent of survivors; (3) results in patients reoperated upon for graft failure alone were similar to results in those operated upon for progressive atherosclerosis or combined indications; and (4) high graft patency was found in secondary grafts constructed to arteries involved with primary graft failure.     

Reoperations for fractures of the proximal femur

The number and type of reoperations after fractures of the proximal femur was studied in Jokilaakso Regional Hospital, Finland, from 1970 to 1981. Reoperations after fractures of the femoral neck occurred in 32% (24/74), in trochanteric fractures in 13% (6/48). In fractures of the femoral neck 38% (9/24) of the reoperations were performed during the first postoperative year, in trochanteric fractures half of the cases. The average time of hospital stay for reoperation was 19 days.     

心脏瓣膜置换术后低强度抗凝研究

目的　研究我国南方地区人工机械瓣膜置换术后行低强度抗凝的可行性及安全强度。方法　75例置换人工机械瓣膜的患者按国际标准化比值(INR)分为A、B、C 3组。术后定时分别检测其凝血酶原时间(PT)及INR、D 二聚体浓度、抗凝血酶Ⅲ活性(AT Ⅲ:C) ,并定时监测术后出血及血栓形成的发生率。结果　机械瓣膜置换术后,INR控制于1.6～2 .5范围,可保持D 二聚体浓度、AT Ⅲ:C与对照组差异无统计学意义(P >0 .0 5 )。2 5 5人次INR控制1.6～2 .5之间,3组均未出现血栓形成,有16人次轻微出血,其中A组有4人次(4 /15 5 ,2 .5 % ) ;B组有5人次(5 /70 ,7.1% ) ;C组有7人次(7/3 0 ,2 3 .3 % ) ,明显高于A、B两组(P <0 .0 1)。结论　我国南方地区人工机械瓣膜置换术后低强度抗凝是可行的,INR控制在1.6～2 .5范围较安全。     

Aortic valve replacement for aortic stenosis with a small mechanical prosthetic valve

BACKGROUND: Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is recognized that the use of small prosthetic valves due to a small aortic root often affects postoperative course after AVR. The aim of this study was to determine whether the use of small prosthetic valves was a risk factor of AVR for AS. METHODS: We compared various perioperative factors and operative outcomes between patients with a small mechanical prosthetic valve (small group) and patients with a large mechanical prosthetic valve (large group). RESULTS: Early mortality was 0% in each group and the 5-year mortality was 25% in the small group and 10% in the large group. There were no significant differences in perioperative factors between the two groups. The small group patients were significantly older and smaller compared to the large group patients. The valve size was significantly correlated with age and BSA. CONCLUSIONS: The use of small mechanical prostheses was not a risk factor of AVR for AS when it was proportionate to the BSA even for elderly patients. AVR using a small mechanical prosthetic valve may be performed with good results in the short- and long-term.     

Long-term Outcome of Reoperations for Medullary Thyroid Carcinoma

Background Most patients with medullary thyroid carcinoma (MTC) have persistent disease after primary surgery, as evidenced by calcitonin elevation. Previous reports showed that reoperation on selected patients yields immediate calcitonin normalization in one-third of patients. Long-term follow-up data are needed to assess the outcome in such patients. This report aims to provide 8– to 10–year follow-up on reoperations for persistent or recurrent MTC. Methods An Internal Review Board (IRB) approved database on patients treated for MTC has been prospectively maintained. This database was reviewed to report follow-up data on calcitonin levels and survival. Results Between 1992 and 2006, 148 patients underwent reoperations for recurrent or persistent MTC (55 patients had 59 reoperations for palliation, and 93 patients had 105 reoperations for cure). Of the 93 patients operated on for cure (44 with hereditary MTC, 49 with the sporadic form), 8–10-year follow-up data were available on 56. Four patients died of disease (4.3% of 93). Two died of unrelated causes, and were excluded from calcitonin outcome analysis. Fourteen patients of 54 (26.0%) have unstimulated calcitonin levels of < 10 pg/ml at 8–10 years. Eleven additional patients (20.4%) have levels < 100 pg/ml. None of these 25 patients (46.4%) have radiologic recurrence. Conclusions Previous reports demonstrated the low morbidity of reoperation for MTC in experienced hands, and success was determined by lowering of calcitonin levels. Follow-up data demonstrate that at least one third of such patients have long-term eradication of their disease following reoperation, as evidenced by biochemical and imaging studies.     

Reoperations for persistent and recurrent secondary hyperparathyroidism.

Forty-nine reoperations for persistent or recurrent secondary hyperparathyroidism (HPT) in 30 patients are reported. The patients are part of a total of 184 patients operated on for secondary HPT; 28 reoperations in 18 patients were performed in the neck or in the upper mediastinum for remaining glands. Eleven reoperations at the forearm autograft revealed hyperplasia of the grafted tissue as the reason for recurrent disease in seven patients; they were treated by excision of all grossly enlarged particles. Ten patients received autologous cryopreserved tissue because of permanent postoperative hypoparathyroidism. The rate of graft-dependent recurrent HPT was 7%, and inadequate graft function was found in 6% of the patients.