Outcome following isolated tricuspid valve replacement.

OBJECTIVES: The clinical outcome of isolated tricuspid valve replacement is not well defined because this procedure is usually performed concomitantly with other valve surgery. METHODS: We retrospectively studied the short and long-term outcome of 15 consecutive patients (six men and nine women, aged 61+/-3 years) undergoing isolated tricuspid valve replacement from 1984 to 1996. The cause of valve dysfunction was rheumatic heart disease in 12 patients, healed endocarditis in two patients, and sarcoidosis in one patient. The tricuspid valve was stenotic in one patient, regurgitant in eight patients, and both stenotic and regurgitant in six patients. A St. Jude Medical prosthesis was placed in eight patients, Carpentier-Edwards in five patients, and Bj?rk-Shiley and Starr-Edwards in one patient each. RESULTS: The median survival was only 1.2 years. Three patients (20%) died < or =30 days after the surgery or before discharge, and six other patients (40%) died within 3 years of surgery. Anasarca was the only predictor of short-term mortality (P=0.03), while the predictors of long-term mortality were anemia (P=0.01), rheumatic heart disease (P=0.04), previous stroke (P=0.04), and previous mitral valve surgery (P=0.04). CONCLUSIONS: Isolated tricuspid valve replacement is characterized by a poor short and long-term outcome.     

Responsiveness to therapy for increased intracranial pressure in traumatic brain injury is associated with neurological outcome

In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome.Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19 mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2 h after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome.We identified 46 patients who received at least 1 dose of HTS for ICP > 19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP 1 h after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by 2 h after HTS administration.In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP 2 h after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.     

Medium to long-term functional outcome of patients after chemonucleolysis

Chemonucleolysis is an established modality in the treatment of lumbar disc prolapse and has been widely used for over 39 years since its introduction by Lyman Smith in 1963. We report the medium to long-term functional outcome of patients who had chemonucleolysis for single level disc prolapse. One hundred and twelve patients were reviewed retrospectively with a mean follow-up of 9.5 years. The Oswestry Disability Index questionnaire was used to estimate the functional outcome of chemonucleolysis. An excellent or good response occurred in 79 patients (70.5%) while 12 patients (10.7%) showed moderate response with minimal disability. Treatment failed in 21 patients (18.5%) who showed poor response and 12 of these 21 patients went for surgery within a mean period of 6 months. One patient had surgery at a different level than chemonucleolysis. There was only one incident of procedure termination because of epidural contrast leak. There was no case of anaphylaxis or discitis. We concluded on the basis of our results that in carefully selected patients, chemonucleolysis is a safe and effective treatment modality for lumbar disc herniation with good medium to long-term functional outcome.     

Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms

Recurrent hemorrhage in the case of incompletely treated aneurysms is well known. The authors present a series of patients in whom rebleeding occurred in spite of totally occluded aneurysms. During a period of 12 years, 1170 patients with intracranial aneurysms were treated using either clipping (n=727) or coiling (n=443). In 11 of them, intracranial rebleeding occurred, in seven of whom routine post-treatment angiography revealed total aneurysm occlusion before the appearance of rehemorrhage. Further analysis focused on these seven patients. Their recurrent aneurysm ruptures happened with a mean latency of 9.5 months (range 21 h–48 months) from initial treatment. All aneurysms belonged to the anterior circulation. Three patients underwent primary clipping, and four experienced coiling first. The intracranial hemorrhages appeared mainly as intracerebral hematomas. The angiographically documented recurrent aneurysm configurations were caused by clip slippage (n=2), coil compaction (n=3), or coil migration/dislocation (n=1). In one case with primary surgery, clip slippage was possible but not confirmed by intraoperative view, because the patient died before therapeutic intervention. Two patients did not undergo therapy because of their poor clinical condition and died. Four of the remaining patients underwent clipping of the recurrent lesions, and one had recoiling. Final outcome was excellent/good in only two patients. The mainly poor outcome after rebleeding was caused by the high incidence of intracerebral hemorrhage.     

Long-term outcome of extratemporal epilepsy surgery among 154 adult patients

OBJECT: The goal of this study was to evaluate the long-term outcome of patients who underwent extratemporal epilepsy surgery and to assess preoperative prognostic factors associated with seizure outcome. METHODS: This retrospective study included 154 consecutive adult patients who underwent epilepsy surgery at Bethel Epilepsy Centre, Bielefeld, Germany between 1991 and 2001. Seizure outcome was categorized based on the modified Engel classification. Survival statistics were calculated using Kaplan-Meier curves, life tables, and Cox regression models to evaluate the risk factors associated with outcomes. RESULTS: Sixty-one patients (39.6%) underwent frontal resections, 68 (44.1%) had posterior cortex resections, 15 (9.7%) multilobar resections, 6 (3.9%) parietal resections, and 4 (2.6%) occipital resections. The probability of an Engel Class I outcome for the overall patient group was 55.8% (95% confidence interval [CI] 52-58% at 0.5 years), 54.5% (95% CI 50-58%) at 1 year, and 51.1% (95% CI 48-54%) at 14 years. If a patient was in Class I at 2 years postoperatively, the probability of remaining in Class I for 14 years postoperatively was 88% (95% CI 78-98%). Factors predictive of poor long-term outcome after surgery were previous surgery (p = 0.04), tonic-clonic seizures (p = 0.02), and the presence of an auditory aura (p = 0.03). Factors predictive of good long-term outcome were surgery within 5 years after onset (p = 0.015) and preoperative invasive monitoring (p = 0.002). CONCLUSIONS: Extratemporal epilepsy surgery is effective according to findings on long-term follow-up. The outcome at the first 2-year follow-up visit is a reliable predictor of long-term Engel Class I postoperative outcome.     

Clinical outcome of aortic valve replacement in the elderly

Since elderly patients are being referred for surgery in increasing numbers, we reviewed the clinical outcome of 459 consecutive patients aged 70 to 89 years, who had aortic valve replacement between 1993 and 2000. We subdivided the study population into three groups: in Group 1 we included patients aged 70-74 years old; in Group 2 patients aged 75-79 years old; and in Group 3 patients aged 80 years old or older. An isolated AVR was performed in 289 patients (63%), concomitant coronary artery bypass graft (CABG) in 168 patients (36.6%), an isolated ventricular septal defect (VSD) closure in one patient (0.2%) and an isolated atrial septal defect (ASD) closure in one patient (0.2%). The overall perioperative mortality rate was 7% (32 patients), without significant differences among the three groups (P=0.88). Our study confirms the good outcome of aortic valve replacement in elderly patients even in octagenarians and only concomitant CABG procedures increase the operative risk, reducing long-term survival (P<0.05).     

Intracranial meningioma in children: Different from adult forms? A series of 21 cases

Objective

Intracranial meningiomas are very rare in children, comprising only 0.4 to 4.1% of pediatric tumors and only 1.5 to 1.8% to all intracranial meningiomas. The goal of this study of pediatric meningiomas was to establish their epidemiological profile as well as their clinical and radiological features, to assess the long-term outcome, and compare this result with adult meningioma.

Patient and methods

We conducted a retrospective study from June 1983 to June 2007; during this period 521 patients underwent surgery for primary meningioma at the Rabat Hospital, Department of Neurosurgery. Twenty-one patients were under 16 years of age (4%). The clinical charts and imaging data were reviewed.

Results

The mean age was 10.3 years (range: 2 to 16 years), with 13 boys and eight girls. In one patient a neurofibromatosis was associated. The mean delay to diagnosis was 4.6 months (range: 1 to 12 months). The most common clinical sign was raised intracranial pressure (90%). Of the meningiomas diagnosed, 47% were convexity meningiomas while 24% were parasagittal and 19% were skull-base meningiomas; in two cases (9.5%) the location was intraventricular. The mean tumor diameter was 6.6 cm (range: 3 to 10 cm). A large cystic component was found in 24% of the cases. Surgery achieved a Simpson grade I resection in 47%; 62% of the tumors were grade I and 24% were grade II based on World Health Organization pathological classification. The mean follow-up period was 33 months (range: 6 to 120 months). The recurrence rate was 33%.

Conclusion

Pediatric meningiomas are larger than those found in the adult population; there is a male predominance with high incidence of a cystic component and high-grade meningiomas, thus explaining the increased recurrence rate despite the multimodal treatment.     

Demographic factors affecting long-term outcome of total hip arthroplasty

We report the outcome of total hip arthroplasty (THA) in a cohort of patients with complete long-term radiographic and clinical followup information from our database of more than 48,000 primary hip replacements. The purpose of the study was to evaluate the influence of various demographic factors and patient comorbidity (Charnley classification) on the long-term outcome of THA. The cohort was comprised of 25,990 total hip replacements (THRs) in 10,243 (46.6%) men and 11,754 (53.4%) women with a median age of 66 years (range, 20-96 years) at the time of arthroplasty. Our study confirmed that THA has an impressive efficiency and reliability in alleviating pain and improving function for almost all of the patients. Furthermore, the results are enduring with more than 90% of patients being satisfied with the outcome at 15 years. Clinical outcome measures reach their maximum at 2 to 5 years after arthroplasty and thereafter they decline gradually. Furthermore, patient age, gender, body mass index, and main diagnosis all have an influence on specific functional parameters. The Charnley classification has the most profound effect on the overall functional status of patients.     

Crescentic proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study

The senior author's (R.C.) first 25 patients (37 feet) treated with a combination proximal crescentic osteotomy and distal soft-tissue reconstruction made up the patient cohort. All 25 patients were reviewed at a minimum of one year post-op (short-term follow-up) and 20/25 (31/37 feet) were reviewed again at a mean 12.2 years (range 11.4 to 13.0 yrs) post-op (long-term follow-up). This allowed for a comparison of short- and long-term results and led to a long-term follow-up rate of 84% (31/37 feet, mean 12.2 yrs). Clinical, radiographic and patient outcome measures were obtained and compared pre-op and at short- and long-term follow-up. The mean preoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were 37degrees and 16 degrees respectively. The mean HVA correction was 24 degrees and IMA correction 10 degrees at long-term follow-up with no tendency toward recurrence. Sesamoid position and first MTP subluxation was markedly improved postoperatively and the correction was maintained at long-term follow-up. Patients were asked about their satisfaction in terms of pain, appearance and motion. At long-term follow-up, more than 90% of patients were completely satisfied with pain and motion and greater than 80% with their appearance. Ninety-four percent of patients said they would have the operation again. The AOFAS clinical rating scale for the hallux was calculated retrospectively for pre-op and short-term follow-up and prospectively for long-term follow-up. The mean pre-op score was 37/100 (16 to 60) which significantly improved to 92/100 (67 to 100) at both follow-up periods, suggesting no evidence of decrease in outcome over time. Complications included two patients (5%) that were over-corrected into varus (one symptomatic, one asymptomatic), and four patients (11%) that were undercorrected, developing asymptomatic recurrences (>10 degrees increase HVA) at long-term follow-up. In addition, two patients (5%) developed new transfer lesions postoperatively, likely related to technical error (one varus overcorrection, one dorsiflexion malunion). In conclusion, the long-term results, with a mean follow-up of 12.2 years, of the resection realignment procedure for moderate to severe hallux valgus are generally excellent and the complication rate is low and acceptable. Attention to detail, avoiding both undercorrection, which can lead to recurrence, and overcorrection, which can cause symptomatic varus, is essential.     

Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up

Background

Literature on long-term outcome after endoscopic management of pediatric pancreatic pseudocyst is not available. The aim of the present study is to report long-term outcome after endoscopic drainage of pancreatic pseudocyst in children.

Methods

Nine patients younger than 15 years, subjected to endoscopic pseudocyst drainage, were included in this study (between 1994 and 2004). Eight patients were subjected to endoscopic cystogastrostomy and stenting, whereas 1 patient was subjected to cystoduodenostomy and stenting. A follow-up of patients was done at 1 month and at 2 to 10 years after drainage. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 2 patients at the time of drainage, and it was repeated in both the patients at the time of final follow-up.

Results

Mean age of the patients was 9.6 years. Trauma was the most common cause (n = 8). Mean follow-up of these patients was 5.7 years (2-10 years). No recurrence was seen in any patient. Endoscopic retrograde cholangiopancreatography revealed complete pancreatic duct block in prevertebral region in 2 posttraumatic patients, and it was persisting on repeat ERCP at final follow-up.

Conclusions

Endoscopic drainage of pancreatic pseudocyst is safe in children with a very good long-term outcome. Pancreatic duct block seen on ERCP may not be clinically important on long-term follow-up.     

Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy

BACKGROUND: Spastic hip subluxation and dislocation are common problems in children with cerebral palsy. Soft-tissue releases have proved to be beneficial in the prevention of spastic hip dislocation. A protocol for treatment based on patient age, hip abduction, and hip migration percentage was established in 1988. The purpose of this study was to assess the outcome in sixty-five children treated according to this protocol and followed for a minimum of eight years. METHODS: The medical records and radiographs of sixty-five children, from an original series of seventy-four patients, who met the inclusion criteria were available for review. Forty-seven children had spastic quadriplegia and were unable to walk; eighteen children had spastic diplegia and were able to walk independently or with assistive devices. The mean age at the time of the surgery was 4.4 years. Open adductor tenotomy and psoas muscle recession or iliopsoas tenotomy were performed on 129 hips, which were followed for a mean of 10.8 years. The mean age at the time of follow-up was fifteen years. Hips were grouped according to the hip migration percentage preoperatively, at one year postoperatively, and at the time of final follow-up. The final outcome for the patient was defined according to the worse hip. An analysis was performed to identify potential factors influencing outcome. RESULTS: Thirty-two patients (49%) had a good result, eleven (17%) had a fair result, three (4%) had a poor result, and nineteen (30%) had a failure. The mean hip migration percentage was 34% preoperatively and 18% at the time of final follow-up. Nineteen patients required subsequent osseous reconstructive procedures, and eleven required repeat soft-tissue releases. The migration percentage at one year postoperatively was the most predictive of the final outcome (p = 0.001). Patients who had been able to walk preoperatively had a better long-term outcome (p = 0.01). Neither the preoperative hip migration percentage nor the age at surgery significantly affected the outcome. CONCLUSIONS: Soft-tissue release was effective for long-term prevention of hip dislocation in 67% (forty-three) of sixty-five children with spastic hip subluxation. Two preoperative factors that were related to a favorable outcome were a spastic diplegic pattern of involvement and the ability to walk. The hip migration percentage at one year postoperatively was a good predictor of final outcome.     

Long-term outcome of hepaticojejunostomy with routine access loop formation following iatrogenic bile duct injury

BACKGROUND: Hepaticojejunostomy is the 'gold standard' procedure for repairing iatrogenic bile duct injuries. The aim of this study was to examine the long-term outcome following hepaticojejunostomy for iatrogenic bile duct injury and the utility of routine construction of an access loop. METHODS: Patients with iatrogenic biliary injuries were treated with hepaticojejunostomy and access loop by a single surgeon. Injuries were classified according to the Bismuth level. An 'excellent' outcome was achieved if the patient never experienced jaundice or cholangitis in the follow-up period, and the outcome was 'good' if the patient developed symptoms but was asymptomatic for more than 12 months. RESULTS: Forty-eight patients underwent such operation. There was one operative death. Thirty-three patients were followed for 3 years or more (mean follow-up 80.4 (range 46-118) months). Thirteen of the 33 injuries were Bismuth level II, 13 were Bismuth level III and seven were Bismuth level IV. Outcome was dependent on the Bismuth level (P < 0.001). It was excellent in all 13 patients with Bismuth level II injuries, excellent in seven and good in six of the 13 patients with Bismuth level III injuries, and excellent in one and good in six of the seven patients with Bismuth level IV injuries. Moreover, the need for access loop intervention was dependent on the Bismuth level (P < 0.001). No patient with Bismuth level II injury required intervention, compared with five of 13 with Bismuth level III and six of seven with Bismuth level IV injuries. CONCLUSION: Biliary reconstruction affords satisfactory long-term outcome. The likelihood of needing the access loop for radiological intervention is dependent on the Bismuth level. The authors recommend that an access loop be constructed in all patients with Bismuth level III and IV injuries.     

Long-Term Survival of Kidneys Transplanted from Live A2 Donors to O and B Recipients

The long-term outcome of kidneys transplanted from blood group A(2) live donors into blood group O or B candidates is not known. From 1986 through 2006, we transplanted eight blood group O patients and one blood group B patient with kidneys from blood group A(2) live donors. Immunosuppression was no different for these patients than for ABO-compatible recipients. All patients received methylprednisolone, cyclosporine or tacrolimus and azathioprine or mycophenolate mofetil with or without antibody induction (monoclonal or polyclonal). Of the nine live-donor A(2) to O and B transplants performed, seven grafts remain functioning. One of those seven was lost to follow-up at 9.2 years with a functioning kidney. Of the remaining six patients, length of follow-up is 10.4, 6.5, 5.3, 4, 2.1 and 1 years. Of the two patients who lost their grafts, one died with a functioning graft (DWFG) at 8.8 years and one lost his graft at 13.2 years due to noncompliance with immunosuppression. These data show that good long-term graft survival can be expected in live-donor A(2) to O and B transplantation despite some of those patients experiencing the type of clinical problems seen with ABO-compatible transplants.     

Basiliximab induction therapy for live donor kidney transplantation: a long-term follow-up of prospective randomized controlled study

Background/Aims  The effect of basiliximab induction therapy on long-term patient and graft survival is not yet clear. We aimed to evaluate if there is any advantage of routine basiliximab induction on the long-term outcome of living related donor kidney transplantation. Methods  One hundred adult recipients with their first kidney allograft were randomized into two treatment groups, one group received basiliximab and the second served as a control. All patients received a maintenance triple immunosuppressive therapy (steroids, cyclosporine (CsA) micro-emulsion and azathioprinep) and were followed up thoroughly for 7 years. Results  Basiliximab significantly reduced the proportion of patients who experienced acute rejection in the first year (18/50) when compared to the control group (31/50), and in 7 years (28/50) when compared to (37/50) in controls. The cumulative steroid dose used throughout the whole study period was significantly lower in the basiliximab group. The overall incidence of post-transplant complications was comparable among the two treatment groups. There was no significant difference in patient or graft survival; 7 years patient and graft survival were 92, 76% for basiliximab and 92, 80% for the control group, respectively. Conclusion  Routine basiliximab induction significantly reduced the incidence of acute rejection without any noticeble beneficial effect on the long-term renal transplantation outcome.     

Posterior elbow dislocation with associated vascular injury after blunt trauma.

BACKGROUND: Injury of the brachial artery is a rare (5-13%) but serious complication after closed elbow dislocation without associated fractures. METHOD: Retrospective analysis of long-term results (mean, 4.1 years) in four patients. RESULTS: All patients underwent emergency repair of the arterial injury within 2.5 hours. In three patients, a reversed saphenous vein graft was used; in one patient the artery was sutured. This latter patient needed another operation with interposition of a reversed saphenous graft, because the primary anastomosis occluded. The capsule and the collateral ligaments were immediately reconstructed in three patients because of instability. No patient showed claudication of the arm. In three patients, a sensory deficiency of median nerve persisted. Average range of motion was 128 degrees of flexion (120-135 degrees) and an extension deficit of 7.5 degrees (15-0 degrees). CONCLUSION: Primary repair of vascular injury after closed elbow dislocation with vein graft and immediate reconstruction of ligamentous injuries results in good long-term functional outcome.     

Evaluation of hypertensive intracerebral hematomas based on the study of long-term outcome--part IV: Prognostic importance of the age of the patient and the laterality of the lesion in putaminal hematoma

The age of the patient and the laterality of the lesion are said to play an important role in determining surgical indications and prognosis of any neurosurgical disease. These two factors have been evaluated in 355 cases of putaminal haematoma, which were seen during the last 10 years after the introduction of the CT scan. Patients have been divided in three age groups; less than 59 years, 60-69 years and greater than 70 years, consisting of 235, 80 and 40 cases in each group respectively. Long-term outcome of three groups has been compared in both surgically and conservatively treated patients. The hematoma was situated on left side in 182 and on right side in 173 cases. 56.6% of left sided and 48.7% of right sided hematoma cases were operated. The long-term outcome of the two sides has also been compared in both surgically and conservatively treated patients. One has to be careful while considering patients of greater than 70 years of age as there is always some natural selection among these patients before they are referred to the hospital or are operated upon thereafter. One tends to be less aggressive for so old patients. Only in moderate type and operated cases the younger patients (less than 59 years) showed a better long-term outcome (ADL) than other surgically treated patients. Otherwise age did not effect the long-term outcome (ADL) in any type of putaminal haematoma. No effect of laterality was found in mild and very severe types of hematoma for the long-term outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arthroscopic partial medial meniscectomy in patients over 40 years old: A 5- to 11-year follow-up study

A retrospective analysi sof 68 knees from 65 patients older than 40 years, who had undergone a partial medial meniscectomy, was carried out. The average age of the patients was 49.7 years (range, 40 to 74), and themean follow-up period was 7.8 years (range, 5 to 11). The patients were divided into two groups based on the degree of articular cartilage degeneration. Group I consisted of 53 knees that did not have any significant articular cartilage damage beyond grade I or II. Group II consisted of 15 knees that had grade III or IV cartilage damage. Overall, excellent results were obtained in 44 patients (47 knees), good results in 10 patients, fair results in six patients, and poor results in five patients. In group I, 46 knees (87%) had an excellent outcome, and only one patient had a poor result. In contrast, patients in group II had significantly worse results, with only one knee (7%) having excellent outcome, and four knees had a poor result. A specific history of trauma did not affect the clinical outcome. Forty-two patiens (64%) were able to resume normal athletic activities without any restrictions. Arthroscopic partial medial meniscectomy in patients older than 40 years is an acceptable and effective long-term treatment, particularly in patients without significant articular cartilage damage.     

Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair.

OBJECTIVE: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches. METHODS: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7+/-8.2 years; mean time interval for development of aneurysm was 3.6+/-4.2 years; mean age at aneurysm surgery was 16.9+/-8.8 years. Residual left to right shunt was detected in 6 (46%) patients. RESULTS: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6+/-5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up. CONCLUSION: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-right-lateral positioning of the patient.     

Indications for and outcomes after combined lung and liver transplantation: a single-center experience on 13 consecutive cases

BACKGROUND: Combined lung and liver transplantation (Lu-LTx) is a therapeutic option for selected patients with coexisting lung and liver disease. For several reasons, Lu-LTx is performed in few centers and information about the technical issues, posttransplant management and long-term outcomes associated with this procedure is limited. METHODS: We analyzed data from 13 consecutive patients who underwent combined Lu-LTx at Hannover Medical School (Hannover, Germany) between April 1999 and December 2003. The main indications were cystic fibrosis, alpha1-proteinase inhibitor deficiency and portopulmonary hypertension. All patients had advanced cirrhosis and severe pulmonary disease manifestation. RESULTS: Ten patients received a sequential double Lu-LTx, one patient received a single Lu-LTx, one received a double lung and split liver transplantation, and one received an en-bloc heart-lung and liver transplantation. Immunosuppression was based on cyclosporine in a triple/quadruple regimen. Postoperative surgical complications occurred in eight patients. There were two perioperative deaths; two patients died during the first year on day 67 and 354, respectively, and one patient died at month 53. The overall patient survival rates at 1, 3, and 5 years were 69%, 62%, and 49%, respectively. CONCLUSION: Combined Lu-LTx is a therapeutic option for highly selected patients with end-stage lung and liver disease with acceptable long-term outcome.