机械瓣膜置换术后再手术的抗凝治疗

目的探讨机械瓣膜置换术后再手术的抗凝治疗。方法回顾并随访1997年3月-2010年1月在我科行心脏机械瓣膜置换术后并再次行其他外科手术患者96例,术前2～3d停用华法林,检测凝血酶原国际标准化比值（INR）,术后2-3d恢复服用华法林,并依据INR调整用量。结果全组再手术患者均安全渡过围手术期,未出现血栓、颅内出血及胃肠道等异常出血。结论机械瓣膜置换术后再手术必须合理调整华法林的使用;依据INR值维持一个有效的抗凝强度,可以安全地进行手术,也可以安全地妊娠、分娩。     

Redo off-pump coronary artery bypass grafting via a left thoracotomy

Re-operative coronary artery bypass graft (CABG) surgery is more complicated than the initial CABG and it may also be more hazardous because of risk factors related to median resternotomy, such as cardiac injury and damage to the patent grafts due to sternal adhesion.1 Deciding on the appropriate treatment for recurrent coronary artery disease (CAD), especially conditions such as non-left anterior descending coronary artery (LAD) ischaemic lesions during the existence of patent left internal thoracic artery-to-left anterior descending coronary artery (LITA–LAD) anastomosis is a dilemma.2If the patient is unresponsive to medical therapy, and percutaneous transluminal coronary angioplasty (PTCA) and/or stenting is not appropriate for revascularisation, alternative surgical strategies, excluding resternotomy and cardiopulmonary bypass (CPB), may be the most appropriate way of revascularising the branches of the circumflex artery (Cx) or right coronary arteries (RCA) (non-LAD territories).3-5 In selected patients, off-pump redo CABG for the branches of the Cx via a posterolateral thoracotomy may reduce the risks due to median resternotomy and dissection of the heart.This procedure to avoid resternotomy and CPB has become an established and popular way of revascularising recurrent coronary artery disease in the lateral aspect of the heart. In this article, we share our experience of 32 patients who underwent redo CABG for the Cx and its branches via a left posterolateral thoracotomy.     

Laparoscopic re-operation for failed Heller myotomy

Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require re-operation to control persistent or recurrent symptoms. We report follow-up of 15 patients who underwent laparoscopic re-operation for failed Heller myotomy. Between 1993 and 2004, 15 patients underwent laparoscopic re-operation for failed Heller myotomy at our center. The mean duration between procedures was 23 months. Follow-up was completed at a mean duration of 30 months in 14 patients (93%) via a telephone questionnaire. Our overall failure rate for primary surgery (n = 106) was 5.6%. The mechanisms of failure were incomplete myotomy (33%), myotomy fibrosis (27%), fundoplication disruption (13%), too tight fundoplication (7%) and a combination of myotomy fibrosis and incomplete myotomy (20%). Significant symptom improvement was observed with postoperative symptom resolution seen in 71% of patients with dysphagia, 89% for regurgitation, 58% for heartburn and 40% for chest pain. Fifty percent reported excellent results and 79% would recommend the procedure to a friend. Subsequent dilations were performed in four patients (29%). Two patients required conversion to open surgery (13%). Three patients (20%) failed the re-operation and required further revisional surgery. Complications included intraoperative perforation in three (none of which resulted in postoperative morbidity) and a pneumothorax in one patient. Prior endoscopic therapies (pneumatic dilation or Botulinum toxin) were not associated with poor results. Laparoscopic re-operation for failed Heller myotomy is feasible and results are encouraging.